Inspection Reports for Brookdale Lewiston
2975 Juniper Dr, Lewiston, ID 83501, United States, ID, 83501
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 24, 2025, found multiple deficiencies including incomplete employee background checks, medication administration errors, incomplete resident assessments, documentation issues, and maintenance problems. Earlier inspections showed a pattern of similar issues with medication management, resident assessments, housekeeping, and life safety code compliance. Complaint investigations previously substantiated concerns about missed medication doses, inadequate resident assessments after health changes, and inconsistent personal care services. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates ongoing challenges with regulatory compliance and no clear improvement trend over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Follow-Up
Deficiencies: 13
Date: Oct 24, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey to verify compliance with previous deficiencies and regulatory requirements.
Findings
The facility had multiple deficiencies including incomplete background checks for employees, lack of designated smoking area signage, poor housekeeping and maintenance issues, medication administration errors, incomplete resident assessments, and documentation deficiencies. Several issues were previously cited and remain uncorrected.
Deficiencies (13)
Three of seven employees did not have Idaho State Police background checks completed.
Facility did not have designated smoking areas clearly marked with signs.
Facility was not maintained in a clean, safe, and orderly manner with plumbing leaks, missing window screens, carpet stains, and foul odors.
Residents' medications were not available or given as ordered, including discrepancies in Morphine dosing.
Facility nurse did not assess residents prior to allowing self-administration of medications or reassess every 90 days.
Medication refrigerator temperatures were not monitored and documented daily for multiple days.
Four of eleven sampled residents did not have PRN medications available in the facility.
Facility did not keep records of all drug disposals with required documentation.
Four of ten residents reviewed for psychotropic medications did not have six-month medication reviews completed.
Two residents did not have comprehensive assessments completed prior to admission.
Resident care records were not consistently dated or signed by staff.
Facility nurse did not conduct quarterly nursing assessments every 90 days for nine of ten residents sampled.
Facility nurse did not implement all residents' orders; discrepancies found in PRN medication labeling and dosing.
Report Facts
Employees missing background checks: 3
Days medication refrigerator temperatures not documented: 15
Residents without quarterly nursing assessments: 9
Residents without psychotropic medication reviews: 4
Residents without comprehensive assessments prior to admission: 2
Residents without PRN medications available: 4
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 8, 2025
Visit Reason
The inspection was conducted as a health care complaint investigation to assess compliance with medication administration and resident health status protocols.
Complaint Details
The investigation was triggered by complaints regarding medication administration errors and failure to assess residents after health status changes. Specific incidents involved Resident #6, Resident #7, Resident #1, and Resident #5.
Findings
The facility failed to ensure residents received medications as ordered, with specific residents missing multiple medications. Additionally, the facility nurse did not assess residents after changes in their mental and health status, including falls and surgery.
Deficiencies (2)
Residents did not receive medications as ordered, including fluticasone nasal spray and multiple supplements.
Facility nurse did not assess residents after changes in mental and health status following falls and surgery.
Report Facts
Survey Date: Jan 8, 2025
Response Due Date: Feb 7, 2025
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 23, 2024
Visit Reason
The inspection was conducted as a health care complaint investigation to assess compliance with negotiated service agreements and facility maintenance standards.
Complaint Details
The investigation was triggered by complaints regarding missed personal care services, medication administration, and housekeeping. The facility acknowledged staffing issues contributing to inconsistent care. The deficiencies were previously cited on 01/13/23.
Findings
The facility failed to provide residents with a complete breakdown of personal care charges at admission and did not consistently deliver care as outlined in residents' Negotiated Service Agreements, including bathing, medication administration, housekeeping, and laundry services. The facility was also found to be unclean and poorly maintained, with multiple rooms showing stains, debris, soiled linens, and odors.
Deficiencies (3)
The facility did not provide residents with a complete breakdown of charges, including personal care, prior to or on the date of admission.
Residents did not consistently receive cares as outlined in their Negotiated Service Agreements, including missed showers and medication doses.
The facility was not maintained in a clean, safe, and orderly manner, with stained carpets, piles of laundry, trash in hallways, soiled sheets, and urine odor.
Report Facts
Showers received: 10
Showers expected: 28
Missed medication doses: 3
Inspection date: Apr 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hope Brackett | Administrator | Acknowledged the admission agreement did not include a breakdown of personal care fees. |
| Bradley Perry | Survey Team Leader | Led the health care complaint investigation. |
Inspection Report
Life Safety
Deficiencies: 5
Date: Mar 13, 2024
Visit Reason
The inspection was a fire life safety and sanitation licensure survey conducted to assess compliance with fire and life safety codes and sanitation standards at the facility.
Findings
The facility had multiple deficiencies including damaged vinyl tile flooring exposing sub-flooring, an unserviced fire extinguisher, lack of required testing documentation for smoke detectors, sprinkler pendants, and emergency lighting, an unsecured oxygen cylinder in a resident room, and incomplete emergency drill documentation.
Deficiencies (5)
Vinyl tile floor at the 2nd floor utility mop sink/housekeeping closet is badly damaged, exposing the plywood sub-flooring below.
The fire extinguisher at the designated smoking area had not been serviced since February 2022.
Facility did not maintain compliance with NFPA 101 Life Safety Code including missing sensitivity testing of smoke detectors, missing documentation of sprinkler pendant testing, and missing emergency lighting testing documentation.
One unsecured oxygen cylinder found in resident room #220.
Emergency egress and relocation drill records lacked required details such as drill description, personnel and resident response, problems encountered, and recommendations for improvement.
Report Facts
Facility License Number: RC-595
Survey Date: 03/13/2024
Response Due Date: 04/12/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Chaney | Survey Team Leader | Lead inspector for fire life safety and sanitation licensure survey |
| Hope Brackett | Administrator | Facility administrator named in report header |
Inspection Report
Life Safety
Deficiencies: 4
Date: Jun 29, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Brookdale Lewiston.
Findings
The facility failed to provide documentation for annual inspection of fuel-fired heating systems and did not maintain compliance with the 2018 NFPA 101 Life Safety Code, including lack of documentation for testing Alcohol Based Hand Rub dispensers and emergency lighting, and a door that was chocked open and failed to self-close and latch properly.
Deficiencies (4)
Facility could not produce documentation showing fuel-fired heating systems had been inspected in the past 12 months.
Facility did not produce documentation for testing/inspecting Alcohol Based Hand Rub dispensers each time they are refilled.
Facility was unable to produce documentation for a 90-minute test of the emergency lighting.
Door from corridor to kitchen/kitchen storage room was chocked open and would not self-close and latch when the door chock was removed.
Report Facts
Response Due Date: Jul 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Chaney | Survey Team Leader | Named as survey team leader for the fire life safety and sanitation licensure survey |
| Hope Brackett | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Deficiencies: 14
Date: Jan 13, 2023
Visit Reason
The inspection was conducted as a health care licensure and follow-up visit combined with a complaint investigation.
Complaint Details
The visit was complaint-related and included follow-up; specific substantiation status is not stated.
Findings
The facility was found to have multiple deficiencies including failure to complete investigations for resident falls, inadequate housekeeping and maintenance, incomplete quarterly assessments by the Registered Nurse, missing current medication orders, lack of self-administration medication assessments, inconsistent medication refrigerator temperature monitoring, accumulation of expired medications, missing psychotropic medication reviews, outdated Negotiated Service Agreements, incomplete resident care records documentation, missing CPR and first aid certifications in personnel records, incomplete as-worked schedules, failure to offer snacks between meals, and lack of delegation for staff passing medications.
Deficiencies (14)
Facility administrator did not complete investigations for incidents or accidents involving resident falls.
Facility was not maintained in a clean, safe, and orderly manner with stained carpets, odors, and soiled laundry in multiple rooms.
Registered Nurse did not perform quarterly assessments for 10 of 10 sampled residents.
Facility did not have current, signed medication orders in three of ten sampled residents' records.
Facility nurse did not assess residents for self-administration of medications and prescription creams.
Medication refrigerator temperatures were not monitored and documented daily for November and December 2022, and inconsistently for January 2023.
Accumulation of unused, discontinued, or expired medications for more than 30 days was observed.
Psychotropic medication reviews were not completed for residents taking such medications longer than six months.
Residents' Negotiated Service Agreements did not clearly reflect needs or services and were not updated to reflect changes.
Resident care assessments were performed but not consistently documented.
Personnel records for nine staff members lacked evidence of current CPR or first aid certifications.
As-worked schedules did not document dates and times for various staff roles.
Facility did not offer snacks between meals as confirmed by residents and administrator.
Six staff who passed medications were not delegated by the facility nurse.
Report Facts
Falls incidents: 8
Sampled residents with incomplete quarterly assessments: 10
Sampled residents with missing medication orders: 3
Staff without CPR or first aid certification documentation: 9
Staff passing medications without delegation: 6
Sampled residents with NSA deficiencies: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hope Brackett | Administrator | Named as facility administrator responsible for oversight. |
| Jenny Walker | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey. |
Inspection Report
Life Safety
Deficiencies: 9
Date: Apr 21, 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 and sanitation regulations.
Findings
The facility failed to maintain compliance with multiple fire and life safety standards including deficiencies in smoke detector functionality, lack of documentation for waterflow alarm testing, suppression system inspections, staff training on oxygen safety, and inspection/testing of alcohol-based hand rub dispensers. Additional issues included failure to self-close and latch of a rated door, lack of annual inspection documentation for fuel-fired heating systems, damaged vinyl flooring in utility closets, and unsafe electrical installations such as daisy-chained extension cords and prohibited multi-plug adapters.
Deficiencies (9)
Two smoke detectors in the corridor near the wellness center failed and no documentation of correction was provided.
No documentation for quarterly waterflow alarm testing during second and fourth quarters 2021/2022.
No documentation for weekly visual inspections of dry suppression system gauges and monthly inspections of wet suppression system gauges and secured control valves.
No documentation showing staff are periodically trained on safety guidelines and risks associated with handling and use of oxygen.
No documentation of testing/inspection of Alcohol Based Hand Rub dispensers each time they are refilled.
Operational testing revealed the rated door between dining room and kitchen did not self-close and latch.
No documentation showing fuel-fired heating devices and systems were inspected in the past 12 months.
Vinyl floors in utility closets on upper and lower levels were badly damaged, exposing non-washable sub-flooring.
Electrical violations including daisy-chained extension cords and prohibited multi-plug adapters in nurse's station, admin office, and storage room.
Report Facts
Number of smoke detectors failed: 2
Survey date: Apr 21, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hope Brackett | Administrator | Facility administrator named in report header |
| Linda Chaney | Survey Team Leader | Survey team leader conducting fire life safety and sanitation licensure survey |
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