Inspection Reports for
Family Life Memory Care
422 11th Ave S, Nampa, ID 83651, United States, ID, 83651
Back to Facility Profile12 Reports
Inspection Report — Sep 18, 2025
Annual Inspection
Date: Sep 18, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with medication management and labeling regulations at Wellspring Health & Rehabilitation of Cascadia.
Findings
The facility failed to ensure medications were properly labeled with open and discard dates, individual insulin syringes were labeled with the resident's name, expired medications were disposed of, and unknown pills were not properly identified on medication carts. These deficiencies posed potential risks for medication errors and adverse reactions.
Deficiencies (1)
F 0761: Medications were not labeled with open and discard dates, insulin pens lacked resident names, expired medications were not discarded, and unknown pills were found on medication carts. This posed risks for medication errors and suboptimal therapeutic outcomes.
Report Facts
Date of survey completion: Sep 18, 2025
Date of observations: Sep 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN19 | Licensed Practical Nurse | Observed and confirmed medication labeling issues on 200 hall medication cart |
| LPN20 | Licensed Practical Nurse | Observed and confirmed medication labeling issues on 300/500 hall medication cart |
| Director of Nursing | Director of Nursing | Provided policy and procedural expectations regarding insulin pen labeling and medication administration |
Inspection Report — Jul 26, 2024
Routine
Date: Jul 26, 2024
Visit Reason
Routine inspection of Wellspring Health & Rehabilitation of Cascadia to assess compliance with healthcare regulations, including resident care, infection control, and facility operations.
Findings
The facility had multiple deficiencies including failure to promptly resolve resident grievances, inadequate physician notification of significant weight loss, incomplete investigations of abuse allegations, incomplete care plans, inadequate incontinence care, improper feeding tube management, respiratory care deficiencies, unsanitary kitchen conditions, infection control failures including COVID-19 outbreak management, incomplete vaccination administration, and failure to calibrate glucometers properly.
Deficiencies (11)
F 0565: The facility failed to ensure grievances about call lights voiced by residents were documented, investigated, resolved, and followed up on, risking ongoing resident frustration and unmet care needs.
F 0580: The facility failed to notify the physician of a significant 9.2% weight loss in one resident, placing the resident at risk of complications.
F 0610: The facility failed to thoroughly investigate allegations of verbal abuse and medication errors for two residents, risking harm due to lack of investigation.
F 0656: The facility failed to develop and implement comprehensive resident-centered care plans for two residents, risking negative outcomes due to lack of information.
F 0690: The facility failed to provide timely incontinence care to a resident, resulting in a 25-minute delay and risk of embarrassment and skin impairment.
F 0693: The facility failed to prevent complications from a displaced nasogastric feeding tube, resulting in aspiration pneumonia and pneumothorax in one resident.
F 0695: The facility failed to follow physician orders for respiratory care and did not document treatment outcomes for two residents, risking respiratory infections.
F 0812: The facility failed to maintain kitchen equipment and environment in a sanitary manner, including dirt buildup on a refrigerator fan and residue on shelves, risking food contamination.
F 0880: The facility failed to implement an effective infection prevention and control program during a COVID-19 outbreak, including inadequate cohorting, improper PPE use, incomplete hand hygiene, and failure to vaccinate residents, placing many residents at immediate jeopardy.
F 0883: The facility failed to ensure residents who consented to pneumococcal and influenza vaccines received them, increasing risk of infection for three residents.
F 0908: The facility failed to ensure glucometers were calibrated as required, risking inaccurate blood glucose monitoring for residents on two halls.
Report Facts
Residents positive for COVID-19: 33
Staff positive for COVID-19: 16
Weight loss percentage: 9.2
Residents with roommates positive for COVID-19: 11
Empty private rooms: 6
Empty double occupancy rooms: 4
Dates with missing respiratory treatment documentation: 15
Glucometer calibration missing months: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Noted displaced NG tube and contacted physician on 5/31/23 |
| CNO | Chief Nursing Officer | Interviewed regarding multiple deficiencies including grievance follow-up, weight loss notification, investigations, care plans, infection control, and vaccination documentation |
| CEO | Chief Executive Officer | Provided outbreak timeline and infection control responses during COVID-19 outbreak |
| RN #1 | Registered Nurse | Reported night shift nurses conduct glucometer calibration |
| LPN #3 | Licensed Practical Nurse | Provided care to Resident #81 and stated lack of knowledge on PPE donning/doffing |
| Clinical Resource Nurse #3 | Clinical Resource Nurse | Commented on NG tube incident and nursing practice |
| RT 2 | Respiratory Therapist | Verified missing respiratory treatment documentation |
| CNA #1 | Certified Nursing Assistant | Provided delayed incontinence care to Resident #4 |
| CNA #2 | Certified Nursing Assistant | Observed failing to perform hand hygiene after incontinence care |
| CNA #4 | Certified Nursing Assistant | Observed failing to perform hand hygiene after incontinence care |
| ACNO #1 | Assistant Chief Nursing Officer | Observed improper PPE use and hand hygiene |
Inspection Report — Jul 26, 2024
Annual Inspection
Date: Jul 26, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with healthcare regulations and standards at Wellspring Health & Rehabilitation of Cascadia.
Findings
The facility was found deficient in multiple areas including grievance resolution, physician notification of significant changes, investigation of abuse allegations, comprehensive care planning, incontinence care, feeding tube management, respiratory care, kitchen sanitation, infection control including COVID-19 outbreak management, vaccination administration, and equipment calibration.
Deficiencies (11)
F 0565: Facility failed to ensure grievances about call lights voiced by residents were documented, investigated, resolved, and followed up on, risking resident frustration and unmet care needs.
F 0580: Facility failed to notify the physician of a significant weight loss (9.2%) for Resident #50, risking complications related to unexpected weight changes.
F 0610: Facility failed to thoroughly investigate allegations of verbal abuse and medication errors for Residents #44 and #81, risking harm due to lack of investigation.
F 0656: Facility failed to develop and implement comprehensive resident-centered care plans for Residents #26 and #74, risking negative outcomes due to lack of care plan information.
F 0690: Facility failed to provide timely incontinence care to Resident #4, resulting in a 25-minute delay and risk of embarrassment, skin impairment, and psychosocial harm.
F 0693: Facility failed to ensure proper care and verification of nasogastric tube placement for Resident #85, resulting in aspiration pneumonia and pneumothorax.
F 0695: Facility failed to follow physician orders and document respiratory care and equipment maintenance for Residents #48 and #231, risking respiratory infections.
F 0812: Facility failed to maintain kitchen equipment and environment in a sanitary manner, including dirt buildup on refrigerator fan and residue on steam table shelf, risking food contamination.
F 0880: Facility failed to implement infection prevention and control measures during a COVID-19 outbreak, including cohorting, hand hygiene, PPE use, and vaccination administration, placing 84 residents at immediate jeopardy.
F 0883: Facility failed to ensure residents #52, #64, and #73 received pneumococcal and influenza vaccinations as offered and consented, increasing risk of respiratory infections.
F 0908: Facility failed to ensure glucometers on 100 and 200 Halls were calibrated consistently, risking inaccurate blood glucose monitoring.
Report Facts
Residents positive for COVID-19: 33
Staff positive for COVID-19: 16
Weight loss percentage: 9.2
Number of residents with roommates positive for COVID-19: 11
Number of residents positive for COVID-19 in single rooms: 5
Dates with missing respiratory treatment documentation: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Nurse providing care to Resident #81 on 1/7/23 and discussed fentanyl patch incident | |
| CNO | Chief Nursing Officer | Interviewed multiple times regarding grievances, investigations, care plans, infection control, and vaccination documentation |
| CEO | Chief Executive Officer | Provided information on COVID-19 outbreak and infection control measures |
| Clinical Resource Nurse #3 | Commented on NG tube incident with Resident #85 | |
| RT 2 | Respiratory Therapist | Verified missing respiratory treatment documentation |
| CDM | Certified Dietary Manager | Confirmed kitchen cleaning issues |
| RD | Registered Dietitian | Commented on kitchen cleaning and audits |
Inspection Report — Apr 3, 2024
Routine
Date: Apr 3, 2024
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state regulations.
Findings
Three deficiencies were found related to medication distribution, psychotropic medication reviews, and staff training for traumatic brain injury.
Deficiencies (3)
.310.01.c. Medication Distribution System: the facility's medication refrigerator temperatures were not monitored and documented daily for at least the last few months, and the refrigerator contained insulin. The administrator stated the facility had not been documenting the temperatures.
.310.04.e. Psychotropic or Behavior Modifying Medication: four of four residents taking psychotropic medications for at least six months did not have six month psychotropic medication reviews completed. The facility nurse and administrator stated they had completed the reviews in the past but had not been completing the reviews for about a year.
.630.04. Traumatic Brain Injury: five of five staff members reviewed did not have specialized training for traumatic brain injury. The facility had one resident diagnosed with a traumatic brain injury and the staff had not received the specialized training.
Inspection Report — Dec 12, 2022
Life Safety
Date: Dec 12, 2022
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable safety and health regulations.
Findings
The facility failed to maintain compliance with fire and life safety standards including emergency plan training, oxygen safety training, ignition source policies, and wet suppression system inspections. Additional deficiencies included a resident room door that would not latch, unsecured exterior gates, and hot water temperature exceeding the allowed maximum.
Deficiencies (4)
.403. Fire and life safety standards for existing buildings: the facility lacked documentation for emergency plan training, oxygen safety training, ignition source policies, and monthly inspections of wet suppression system gauges and control valves.
.250.12.j. Resident sleeping rooms: operational testing revealed the door to resident room #2 would not latch when fully closed.
.250.13. Secure environment: the facility's exterior yard gates were not secured by locks, relying only on latching mechanisms released by levers, despite residents having cognitive impairments.
.250.09. Plumbing: hot water temperature at resident plumbing fixtures was 125°F, exceeding the allowed maximum of 120°F.
Report Facts
temperature: 125
temperature_range: Array
fence_height: 6
gate_count: 2
Inspection Report — Jun 4, 2021
Life Safety
Date: Jun 4, 2021
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable safety and sanitation standards.
Findings
Four deficiencies were identified related to relocation agreements, emergency plan assembly point, and improper use of relocatable power taps.
Deficiencies (4)
.155.01 Relocation agreements: facility has one relocation agreement dated 2017; facility shall have two relocation agreements with two separate locations, reviewed not less than annually.
.403 Fire and life safety standards: facility emergency plan does not show point of assembly; drills must be conducted at designated point of assembly. Facility has automatic Alcohol Based Hand Rub dispensers which must be installed, maintained, and tested per NFPA 101 standards.
.405.02.b Prohibited applications: relocatable power taps shall not be daisy-chained; RPTs were daisy-chained together at main living room (corrected on site 6/4/21).
.405.02.c Prohibited applications: RPTs shall not be used for appliances; RPT used to supply power to an air purifier in main living room (corrected on site 6/4/21).
Inspection Report — Dec 10, 2020
Routine
Date: Dec 10, 2020
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state regulations.
Findings
The facility was found deficient in nursing assessments, maintenance of as-worked schedules, and having a certified food protection manager. Some issues were previously cited in 2017.
Deficiencies (3)
.300.02 Licensed Nurse: the facility nurse did not consistently conduct nursing assessments when residents experienced changes in physical or mental health status, including incomplete wound assessments and delayed evaluations.
.330.14.a As Worked Schedules: the facility did not maintain as-worked schedules documenting personnel on duty at any given time; the administrator stated staff arrival and extended hours were not documented (previously cited 3/16/2017).
.450 Requirements for Food and Nutritional Care Services: the facility did not have an employee with certified food protection manager certification at the time of survey; technical assistance had been provided during the 3/16/2017 survey.
Report Facts
: previous citation
: technical assistance provided
Inspection Report — Nov 15, 2019
Annual Inspection
Date: Nov 15, 2019
Visit Reason
The inspection was conducted as a comprehensive annual survey of Wellspring Health & Rehabilitation of Cascadia to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to respect residents' dignity by not dressing them in personal clothing, failure to revise and update care plans, inadequate provision of activities meeting residents' needs, insufficient pressure ulcer prevention care, ineffective pain management, inaccurate nurse staffing postings, and failure to perform proper infection control hand hygiene.
Deficiencies (7)
F 0550: The facility failed to respect a resident's dignity by not dressing Resident #39 in her personal clothing, instead using hospital-type gowns.
F 0657: The facility failed to revise and update care plans for Residents #18 and #44, risking inappropriate care due to inaccurate information.
F 0679: The facility failed to provide activities meeting Resident #39's individual needs, resulting in potential boredom and lack of stimulation.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevention for Residents #10 and #39, including failure to apply prescribed boots and pillows.
F 0697: The facility failed to ensure effective pain management for Resident #44, including failure to notify the physician of ineffective pain medication.
F 0732: The facility failed to post daily nurse staffing information per shift accurately and failed to maintain records for a minimum of 18 months.
F 0880: The facility failed to ensure appropriate hand hygiene was performed by staff, risking cross contamination and infection.
Report Facts
Residents reviewed for dignity: 15
Residents reviewed for care plans: 15
Residents reviewed for activities: 3
Residents reviewed for skin breakdown: 4
Residents reviewed for pain management: 4
Residents reviewed for infection control: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in pain management deficiency related to use of warm towel and failure to revise care plan. |
| LPN #1 | Licensed Practical Nurse | Named in pain management deficiency for failing to notify physician effectively. |
| CNA #9 | Certified Nursing Assistant | Named in dignity and pressure ulcer prevention deficiencies regarding Resident #39's clothing and boot application. |
| CNA #10 | Certified Nursing Assistant | Named in dignity and pressure ulcer prevention deficiencies regarding Resident #39's clothing and boot application. |
| DON | Director of Nursing | Named in pain management and infection control deficiencies. |
| RT #1 | Respiratory Therapist | Named in infection control deficiency for failure to perform hand hygiene. |
| CNA #2 | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene after pericare. |
| Scheduler | Named in nurse staffing deficiency regarding posting and record keeping. | |
| Activities Director | Activities Director | Named in activities deficiency regarding Resident #39. |
| UM #1 | Utilization Manager | Named in care plan deficiency regarding Resident #18. |
| UM #2 | Utilization Manager | Named in dignity, pressure ulcer, activities, pain management, and infection control deficiencies. |
| Wound Nurse | Wound Nurse | Named in pressure ulcer prevention deficiency. |
Inspection Report — Jul 27, 2018
Life Safety
Date: Jul 27, 2018
Visit Reason
A Fire Life Safety Survey was conducted at Family Life to assess compliance with fire safety and sanitation licensure requirements.
Findings
Two non-core deficiencies were found related to resident room door latching and fire alarm system sensitivity testing.
Deficiencies (2)
.250.13.j Resident sleeping rooms: resident room #4 door is missing internal latching mechanism, which does not provide a door that will latch, limit the transfer of smoke during a fire event, or provide for resident privacy (previously cited during the 2017 FLS survey).
.415.04 Fire alarm smoke detection system service and testing: fire alarm system is a zoned system with no records on site indicating the last sensitivity testing performed for all smoke and heat detectors; sensitivity testing is required per NFPA 72, 7-3.2.1.
Inspection Report — Mar 16, 2017
Routine
Date: Mar 16, 2017
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with applicable regulations.
Findings
Five non-core deficiencies were identified related to monitoring incidents, negotiated service agreements, staff training, care notes documentation, and work records.
Deficiencies (5)
.215.09 Identify and monitor patterns of incidents and accidents: the administrator did not have a method for monitoring patterns of incidents and accidents to develop interventions to prevent recurrences.
.320.01 Use of negotiated service agreement: NSAs did not clearly describe care needs and services for 3 of 4 sampled residents, lacking specification of assistance levels for ADLs such as toileting, dressing, grooming, bathing and transferring.
.600.06.b Sufficient personnel: one of two staff members who worked alone did not have evidence of completing First Aid training.
.711.08 Care notes: signed and dated care notes by direct care staff, such as notifications to the facility nurse of resident changes and unusual events, were not maintained in ongoing resident care records.
.730.02 Work records: the facility did not maintain an as-worked schedule documenting personnel on duty, including first and last names and positions.
Inspection Report — Feb 15, 2017
Life Safety
Date: Feb 15, 2017
Visit Reason
A Fire Life Safety Survey was conducted to assess the safety environment of the facility.
Findings
Two non-core deficiencies were identified related to blocked electrical panels and issues with resident sleeping room doors not opening or latching properly.
Deficiencies (2)
.405.01 Medical Gases: blocked electrical panels in the riser room.
.250.13.j Resident Sleeping Rooms: resident room #1 door would not open once closed and latched, and resident room #11 door would not latch.
Inspection Report — Jan 5, 2016
Life Safety
Date: Jan 5, 2016
Visit Reason
Fire Life Safety and Sanitation Licensure survey conducted to assess compliance with fire safety and sanitation regulations.
Findings
Four non-core deficiencies were found related to medical gases, fuel-fired heating, fire alarm system inspection, and sprinkler system inspection.
Deficiencies (4)
.405.01 Medical Gases: Room #1 oxygen concentrator was plugged into a six to two multiple plug adapter.
.415.02 Fuel-Fired Heating: no record of annual fuel-fired heating inspection.
.415.04.a Fire Alarm Smoke Detection System Service and Testing: no record of annual fire alarm inspection.
.415.05 Automatic Fire Extinguishing System Service and Testing: no record of 5-year internal inspection of sprinkler system.
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