Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Follow-Up
Deficiencies: 2
Jun 5, 2025
Visit Reason
The inspection visit was a health care licensure and follow-up survey to assess compliance with facility maintenance and behavior documentation requirements.
Findings
The facility was found to be poorly maintained with multiple housekeeping and maintenance issues including dirty and damaged areas, fire safety hazards, and deteriorated furnishings. Additionally, staff failed to document ongoing behavior tracking and interventions for residents exhibiting challenging behaviors, indicating a need for additional staff training.
Deficiencies (2)
| Description |
|---|
| Facility was not maintained in a clean, safe and orderly manner with multiple areas showing spiderwebs, dead bugs, dirty windows, damaged door jambs, missing trim, yard debris, loose siding, scratched and gouged walls and door jambs, discolored toilets and linoleum, separating rubber baseboards, frayed carpet strips, scratched dining furniture, uneven paint patches, and a fire safety hazard due to a brick placed against an exterior door. |
| Facility staff did not document ongoing tracking of resident behaviors, including interventions used and their effectiveness, despite residents exhibiting behaviors such as masturbating in common areas, hitting attempts, yelling, and delusions interfering with care. |
Inspection Report
Life Safety
Deficiencies: 6
Dec 3, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire and life safety standards and licensure requirements.
Findings
The facility failed to maintain required fire and life safety records, including smoke detector sensitivity testing documentation. Multiple deficiencies were found including inoperable emergency lighting, missing smoke detector components, prohibited use of multi-plug adapters and relocatable power taps, and improper storage of medical oxygen cylinders.
Deficiencies (6)
| Description |
|---|
| Facility failed to provide records of smoke detector sensitivity testing within the past five years. |
| Facility failed to maintain emergency lighting in accordance with NFPA 101; emergency lighting in Memory Care entrance corridor and 100 Hall was inoperable. |
| Facility failed to maintain smoke detection initiating devices; smoke detector initiating device in 300 Hall was missing the smoke head. |
| Use of multi-plug adapters prohibited; identified in room #302 a lamp, clock, and phone charger powered by a multi-plug adapter. |
| Use of relocatable power tap to power medical equipment prohibited; identified in room #102 an oxygen concentrator powered by a relocatable power tap. |
| Improper storage of medical gases; an E-sized oxygen cylinder was sitting directly on carpeted floor in room #102 instead of being stored in an appropriate cart or rack. |
Report Facts
Facility License Number: RC-772
Survey Date: Dec 3, 2024
Response Due Date: Jan 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mitchell Wach | Administrator | Named as facility administrator |
| Jeremy Wilson | Survey Team Leader | Named as survey team leader |
Inspection Report
Follow-Up
Deficiencies: 11
Jun 7, 2024
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
The facility was found to have multiple deficiencies including incomplete background checks for employees, failure to follow abuse and neglect investigation policies, inconsistent written responses to complaints, inadequate corrective actions for resident falls, medication administration errors, incomplete resident health assessments, unavailable PRN medications, outdated resident service agreements, incomplete personnel records, deficient as-worked schedules, and insufficient staff certifications for first aid and CPR.
Deficiencies (11)
| Description |
|---|
| One employee did not have Idaho State Police background check completed prior to working alone with residents. |
| Administrator did not ensure the facility's Abuse, Neglect & Exploitation Policy was followed during an investigation of missing money. |
| Administrator did not consistently provide written responses to complaints within 30 days. |
| Facility did not ensure effective corrective actions were implemented to prevent recurrence of resident falls. |
| Residents did not consistently receive medications and specialized diets as ordered by their providers. |
| Facility nurses did not consistently complete change of condition assessments for residents after incidents. |
| Facility did not ensure all ordered as-needed (PRN) medications were available to residents at all times. |
| Residents' Negotiated Service Agreements were not consistently updated to reflect significant changes in health status. |
| Facility failed to obtain results of Criminal History and Background Checks for three of ten employees. |
| As-worked schedules did not include job titles for managers and did not record times for salaried management staff. |
| Eight of eight sampled direct care staff lacked current first aid certifications, and seven of eight lacked CPR certification. |
Report Facts
Missed medication doses: 14
Missed medication doses: 36
Falls: 3
Direct care staff without first aid certification: 8
Direct care staff without CPR certification: 7
Employees missing background check results: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mitchell Wach | Administrator | Named in findings related to failure to follow abuse investigation policy and inconsistent complaint responses. |
| Stacey Brown | Survey Team Leader | Led the health care licensure and follow-up survey. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's compliance with healthcare regulations.
Findings
The facility's Registered Nurse failed to perform required quarterly assessments for five of seven sampled residents, and the residents' Negotiated Service Agreements did not accurately reflect their current health status or care needs.
Complaint Details
The visit was triggered by a healthcare complaint investigation as stated in the survey type.
Deficiencies (2)
| Description |
|---|
| The facility's Registered Nurse did not perform the quarterly assessments for five of seven sampled residents who required them. |
| Residents' Negotiated Service Agreements did not accurately reflect the residents' health status or care needs. |
Report Facts
Residents requiring quarterly assessments: 7
Residents with incomplete quarterly assessments: 5
Inspection Report
Follow-Up
Census: 74
Deficiencies: 24
Oct 24, 2022
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to protect a resident from sexual abuse, retaining a resident with a non-healing wound requiring skilled nursing care, failure to provide locked storage for residents' personal property, incomplete nursing assessments, inadequate medication temperature monitoring, insufficient staff training, and failure to implement behavior plans and corrective actions. The administrator was cited for multiple failures in oversight and reporting.
Severity Breakdown
Immediate Danger: 1
Deficiencies (24)
| Description | Severity |
|---|---|
| One of ten employees did not have a Department Criminal history and background check. | — |
| Three of six employees who required a state police background check did not have one completed. | — |
| Administrator failed to protect Resident #11 from sexual abuse and did not implement required policies. | — |
| Facility did not have a licensed administrator for 19 days in 2021. | — |
| Administrator failed to report allegations of abuse to Adult Protection. | — |
| Administrator did not conduct investigations within 30 days for abuse and falls. | — |
| Facility did not ensure corrective actions to prevent recurrence of sexual abuse and falls. | — |
| Facility did not notify Licensing and Certification within one business day of falls requiring treatment. | — |
| Administrator did not monitor patterns of incidents or develop interventions to prevent recurrences. | — |
| Memory care unit lacked a call system. | — |
| Facility was not maintained in a clean, safe, and orderly manner; trip hazards and stains observed. | — |
| Licensed nurse did not complete all required nursing assessments; quarterly assessments overdue. | — |
| Medication refrigerator temperatures were not monitored or maintained within required range. | — |
| Psychotropic medication reviews were not completed within the previous six months for several residents. | — |
| Facility did not evaluate maladaptive behaviors for residents exhibiting sexual abuse and wound picking. | — |
| Negotiated Service Agreements were not updated or completed timely to reflect residents' current needs. | — |
| Resident care assessments were not consistently documented after changes in condition or falls. | — |
| Facility did not develop behavior plans for residents exhibiting sexual abuse and wound picking behaviors. | — |
| Facility lacked a Certified Food Protection Manager. | — |
| Medication administration was delayed due to insufficient staffing. | — |
| Staff files lacked evidence of specialized training for care of residents with dementia, mental illness, developmental disability, or traumatic brain injury. | — |
| Facility failed to protect Resident #11 from repeated sexual abuse by Resident #8. | Immediate Danger |
| Facility retained Resident #6 with a non-healing wound requiring skilled nursing care, violating admission/retention policies. | — |
| Facility failed to provide locked drawers or cabinets for personal property to all 74 residents. | — |
Report Facts
Residents: 74
Days without licensed administrator: 19
Medication refrigerator temperature log completion: 7
Medication refrigerator temperature log completion: 3
Medication refrigerator temperature log completion: 2
Falls: 8
Falls: 2
Wound measurements: 0.5
Wound measurements: 0.6
Wound measurements: 0.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Rodgers | Administrator | Named in multiple findings related to failure to protect residents and implement policies |
| Bradley Perry | Survey Team Leader | Lead surveyor conducting the inspection |
| Jenny Walker | Health Facility Surveyor | Surveyor conducting the inspection |
| Torrey Bollinger | QIDP Health Facility Surveyor | Surveyor conducting the inspection |
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