Inspection Reports for Ashley Manor – Mountain Home
940 West 8th South, Mountain Home, ID, 83647
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 28, 2025, found a deficiency related to toxic chemicals being stored in an unlocked laundry room accessible to cognitively impaired residents. Earlier inspections showed a pattern of similar issues with chemical storage and fire safety, as well as deficiencies in updating resident care agreements and medication management. Inspectors cited concerns primarily involving safety hazards with chemical storage, fire and life safety equipment, and incomplete or inaccurate resident care documentation. Complaint investigations mostly found issues with medication administration and service agreement updates, though substantiation status was often not stated. The facility has shown some ongoing challenges with safety and care documentation, with repeated citations in these areas over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The visit was a health care licensure and follow-up inspection to verify correction of previously cited deficiencies.
Findings
The inspection found that toxic chemicals, including disinfectants and cleaning agents, were stored in an unlocked laundry room accessible to cognitively impaired residents on multiple occasions. This issue had been previously cited on 2025-04-03.
Deficiencies (1)
Toxic chemicals were stored in an unlocked laundry room accessible to cognitively impaired residents.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 17, 2025
Visit Reason
The inspection was conducted as a health care complaint investigation to assess compliance with negotiated service agreement requirements for residents.
Complaint Details
The visit was complaint-related as a health care complaint investigation. Substantiation status is not stated.
Findings
The facility failed to update Negotiated Service Agreements (NSAs) to accurately reflect residents' current needs, including care instructions for wounds, use of braces, fall prevention measures, medication management, and emergency evacuation. The facility nurse stated they are in the process of updating the NSAs.
Deficiencies (1)
Negotiated Service Agreements (NSAs) were not updated to accurately reflect residents' current needs, including wound care, medication management, fall prevention, and emergency evacuation.
Inspection Report
Life Safety
Deficiencies: 5
Date: Apr 3, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Ashley Manor - Mountain Home.
Findings
The inspection identified multiple deficiencies including missing monthly inspections of fire suppression system pressure gauges, sprinkler pendants with non-factory applied paint, prohibited use of multi-plug adapters and relocatable power tabs for medical devices, and unsecured toxic chemicals accessible to cognitively impaired residents.
Deficiencies (5)
Missing monthly checks documentation for fire suppression wet system pressure gauges at riser locations H1, H2, and H3.
Sprinkler pendants in room #10 of H1 had non-factory applied paint covering the frangible bulb and pin and require replacement.
Mini fridge in room #8 of H1 was powered by a prohibited 6-2 multi-plug adapter.
Oxygen concentrator in room #8 of H2 was powered by a prohibited relocatable power tab (RPT).
Toxic cleaning chemicals in the laundry room of Building #3 (memory care) were unsecured and accessible to cognitively impaired residents; the laundry room door was unlocked and open with a female resident present.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 11, 2023
Visit Reason
The inspection was conducted as a health care complaint investigation to assess compliance with medication administration, medication availability, scheduling documentation, and menu adherence.
Complaint Details
The visit was triggered by a health care complaint investigation related to medication administration and facility practices.
Findings
The facility failed to ensure residents received medications as ordered, lacked availability of PRN medications, did not document actual nurse schedules, and did not consistently serve dietitian-approved menus, with repeated substitutions and food shortages leading to residents receiving leftovers or ordering pizza.
Deficiencies (4)
Residents did not receive medications as ordered, including missed doses and unavailable scheduled medications.
Not all residents' as-needed (PRN) medications were available at the facility.
The facility's as-worked schedule did not document the actual times nurses were present.
Dietitian-approved menus were not served consistently, with routine substitutions and food shortages.
Report Facts
Missed medication doses: 22
Medication unavailability period (days): 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Giltner | Administrator | Stated the house manager was not properly trained to purchase groceries to meet the menu. |
| Megan Rideout | Survey Team Leader | Led the health care complaint investigation. |
Inspection Report
Life Safety
Deficiencies: 7
Date: Mar 13, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for Ashley Manor - Mountain Home.
Findings
Multiple fire and life safety deficiencies were identified including non-functioning emergency lighting, outdated fire suppression heads, insufficient clearance around sprinkler heads, prohibited transfer grilles, duct-taped main breaker panel, use of extension cords and multiple plug adapters, and lack of policy for elimination of ignition sources related to medical gases.
Deficiencies (7)
Emergency lighting over door to room 6 in House 3 is dead.
Fire suppression quick response heads over 20 years old in House 1 and 2 are past-due for replacement or sampling.
Sprinkler head in storage closet of House 2 had approximately 12 inches clearance, less than required 18 inches.
Transfer grille cut into header above door at room 8 of House 2, which is prohibited.
Main breaker panel of House 1 was duct-taped closed instead of having approved covers.
Extension cords and multiple plug adapters are prohibited but were used in Room 8 House 2.
No policy or procedure for elimination of sources of ignition and misuse of flammable substances related to medical gases.
Report Facts
Facility License Number: RC-688
Survey Date: 03/13/2023
Response Due Date: 04/12/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Giltner | Administrator | Named as facility administrator |
| Sam Burbank | Survey Team Leader | Conducted fire life safety and sanitation licensure survey |
Inspection Report
Follow-Up
Deficiencies: 13
Date: Jul 21, 2022
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to assess compliance with regulatory requirements and verify correction of previously cited deficiencies.
Findings
The facility was found to have multiple deficiencies including lack of consistent activities for residents, failure to investigate and prevent resident falls, inadequate housekeeping and maintenance, inconsistent resident health assessments, medication management issues, incomplete behavior documentation and plans, insufficient staff training documentation, failure to follow dietitian-approved menus, inadequate food supply, and improper delegation of medication passing staff.
Deficiencies (13)
No activities were offered to residents in Buildings #1 and #2, with multiple resident complaints.
Failure to investigate all incidents and accidents for 5 out of 7 sampled residents.
Lack of appropriate corrective actions to prevent recurrence of residents' falls.
Facility not maintained in a clean, safe, and orderly manner with dirty windows, decaying screens, dirty furniture, and trip hazards.
Residents were not consistently assessed after changes in condition or falls.
Medication refrigerator temperatures were not properly documented or maintained within range.
Not all residents' as-needed medications were available at all times.
Psychotropic medication reviews lacked behavior updates for 6 out of 7 sampled residents.
Facility did not evaluate certain residents' behaviors or develop behavior plans with specific interventions.
Two of seven staff members lacked documentation of required orientation and specialized training.
Dietitian-approved menus were not consistently followed.
Perishable food supply was inadequate to meet planned menus on observed days.
Three of seven medication-passing staff were not delegated by the current facility nurse.
Report Facts
Falls documented: 16
Falls documented: 10
Falls documented: 5
Medication refrigerator temperature documentation missing: 17
Medication refrigerator temperature documentation missing: 12
Medication refrigerator temperature out of range: 5
Medication refrigerator temperature documentation missing: 4
Staff missing training documentation: 2
Staff not delegated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Giltner | Administrator | Acknowledged lack of consistent activities and failure to implement corrective actions. |
| Stacey Brown | Survey Team Leader | Led the health care licensure and follow-up survey. |
Inspection Report
Life Safety
Deficiencies: 8
Date: Jan 3, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire and life safety standards for existing residential board and care occupancies.
Findings
The facility did not maintain compliance with the 2018 edition of NFPA 101 Life Safety Code, including non-operational emergency lighting, improper use of multi-plug adapters and power cords, non-compliant exit door locks, incomplete emergency drill documentation, lack of annual fuel-fired heating inspections, unsecured oxygen cylinders, insufficient relocation agreements, and resident room door latch issues.
Deficiencies (8)
Non-operational emergency light in building #3 and missing documentation for monthly emergency lighting tests from July to December 2021.
Use of Multi-Plug Adapter in kitchen of building #1; zip cord and daisy chained power taps in building #2; refrigerator plugged into relocatable power tap in building #3.
Exit doors in buildings #1 and #2 had non-single operational locks requiring knob unlocking before exit.
Incomplete records for emergency egress and relocation drills; missing bi-monthly drills documentation for third and fourth quarters of 2021; no evidence of resident evacuation or assembly point documentation.
Missing annual inspection documentation for fuel-fired heating systems in buildings #1 and #3; last inspection of gas fireplace in building #3 was 8/19/20.
Unsecured oxygen cylinder found in resident room #3 in building #2 bathroom.
Facility had only one relocation agreement instead of the required two; last update was on 2/27/2017.
Resident room #1 in building #2 door would not latch due to an over-the-door hanging shelf unit.
Report Facts
Facility License Number: RC-688
Survey Date: 01/03/2022
Response Due Date: 02/02/2022
Last known inspection date of gas fireplace: Aug 19, 2020
Last known relocation agreement update: Feb 27, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Giltner | Administrator | Named as facility administrator |
| Linda Chaney | Survey Team Leader | Led the fire life safety and sanitation licensure survey |
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