Inspection Reports for Brookdale Pocatello
1501 Baldy Ave, Pocatello, ID 83201, United States, ID, 83201
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 24, 2025, found multiple deficiencies related to housekeeping, resident assessments, medication management, behavior plans, and fire and life safety compliance. Earlier inspections showed similar issues with medication safety, resident fall investigations, and fire safety documentation, indicating ongoing challenges in these areas. Inspectors cited problems with incomplete documentation, failure to implement corrective actions, and lapses in required safety inspections and drills. Complaint investigations mostly found unsubstantiated issues, though some concerns about resident falls and medication handling were noted without explicit substantiation. The facility’s inspection history shows persistent deficiencies without clear improvement over time, and no fines or enforcement actions were listed in the available reports.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Follow-Up
Deficiencies: 19
Date: Jul 24, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
The facility was found to have multiple deficiencies including inadequate housekeeping and maintenance, failure to assess residents after changes in health status, incomplete medication destruction documentation, improper use of psychotropic medications, incomplete comprehensive assessments prior to admission, deficient resident care records, lack of behavior plans and tracking, failure to maintain fire and life safety records, missed fire extinguisher inspections, and failure to conduct required fire drills. Additionally, nursing assessments and implementation of new orders were not completed as required, and the administrator failed to conduct timely investigations and corrective actions related to resident falls.
Deficiencies (19)
Facility was not maintained in a clean, safe, and orderly manner with trip hazards and unclean furniture.
Facility nurse did not assess residents after changes in mental and health status.
Residents self-administering medications were not evaluated every 90 days.
Incomplete documentation for medication destruction including method of disposal.
Psychotropic medications were used as first resort without attempting non-drug interventions.
Four of five residents did not have required six-month psychotropic medication reviews completed.
Comprehensive assessments were not completed prior to admission for several residents.
Resident care records were not maintained with current and complete entries by caregivers.
Behavior plans were not developed with specific interventions for maladaptive behaviors.
Behavior tracking documentation was not maintained prior to 7/3/25.
Facility failed to maintain fire and life safety records including sprinkler dry system gauge documentation.
Monthly inspections of portable fire extinguishers were not completed.
Life Safety Code standards were not met due to failed dry system pressure gauge inspections without documentation of repairs.
Fuel-fired heating devices including gas fireplace were not inspected annually.
Fire drills were not conducted as required, missing bi-monthly and night drills.
Quarterly nursing assessments were not conducted for sample residents.
New physician orders were not reviewed or implemented correctly.
Administrator did not complete investigations and written reports within 30 days of accidents/incidents.
Administrator did not implement immediate corrective actions to prevent recurrence of problems related to resident falls.
Report Facts
Fire drills completed: 4
Residents sample for quarterly nursing assessments: 10
Residents without six-month psychotropic medication reviews: 4
Residents without comprehensive assessments prior to admission: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nichole Borden | Administrator | Named in relation to failure to complete investigations, corrective actions, and confirming incomplete assessments. |
| Torrey Bollinger | Survey Team Leader | Led the health care licensure and follow-up survey. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 7, 2024
Visit Reason
The inspection was conducted as a health care complaint investigation to evaluate concerns related to resident falls, medication distribution, and updating of residents' service agreements.
Complaint Details
The visit was complaint-related, investigating issues including resident falls, medication safety, and documentation updates. No substantiation status was explicitly stated.
Findings
The investigation found ineffective corrective actions for resident falls, medications left unattended on carts and in the nurse's office, outdated residents' Negotiated Service Agreements not reflecting health status changes, and lack of delegation for staff passing medications.
Deficiencies (4)
The administrator did not ensure effective corrective actions were put into place to prevent recurrence of resident falls.
Medications were observed left unattended on medication carts and in the nurse's office with the door left open.
Residents' Negotiated Service Agreements were not updated to reflect significant changes in health status.
Eight of eight staff members who passed medications were not delegated by the current facility nurse.
Report Facts
Resident falls: 3
Resident falls: 3
Staff not delegated: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanene Lindsey | Administrator | Named as responsible for ensuring corrective actions and updating residents' NSAs |
| Stacey Brown | Survey Team Leader | Led the health care complaint investigation |
Inspection Report
Life Safety
Deficiencies: 11
Date: Dec 8, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey of the facility.
Findings
Multiple fire and life safety deficiencies were identified including unsealed holes compromising compartmentation, missing smoke detectors with no replacement documentation, undocumented emergency lighting tests, exposed electrical wiring, improper use of relocatable power taps, lack of documented medical gas policies, unsecured oxygen cylinders, and missing fire suppression system inspection documentation.
Deficiencies (11)
Mechanical room in the East hall had an approximately 24 inch by 24 inch unsealed hole in the one-hour separation to the attic.
Smoke detector in the Housekeeping storage of the C hall was removed and left with exposed wiring.
Two inspection reports from 2022 indicated a failure of 28 smoke detectors with no documentation showing replacement.
Duration of monthly emergency lighting testing was not documented from March to May 2022 and no documented 90 minute testing since March 2021.
No documentation for last full trip of the dry system as required every 3 years.
Maintenance office had an approximately 10 inch by 10 inch electrical panel open exposing wiring (corrected on site). Boiler panel cover off exposing wiring.
Relocatable power taps used to supply power to a mini-fridge in Room 28 of the A hall (corrected on site).
No documented policy for medical gas elimination of ignition sources and misuse of flammable substances; one resident with respiratory therapy possessed smoking materials.
Facility use, handling, and storage of oxygen not in accordance with NFPA 99; volumes exceeded 300 cubic feet without adequate storage and ventilation.
Room 70 had four unsecured oxygen cylinders.
Missing documentation for first and second quarter fire suppression system inspections.
Report Facts
Number of failed smoke detectors: 28
Size of unsealed hole: 24
Size of open electrical panel: 10
Volume of stored medical gases: 484
Volume of stored medical gases: 316
Number of unsecured oxygen cylinders: 4
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 19, 2022
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, investigating allegations including missing money from Resident #4's room and failure to report abuse to Adult Protection.
Findings
The facility was found to have multiple deficiencies including incomplete background checks for employees, failure to report allegations of abuse to Adult Protection, inadequate heating and air conditioning in residents' rooms, improper medication refrigerator temperature maintenance, lack of psychotropic medication reviews, and failure to delegate medication administration properly.
Deficiencies (6)
Three of six employees did not have required state police background checks completed.
Administrator failed to report allegations of abuse and missing money to Adult Protection.
Facility did not have working heating and air conditioning in all residents' rooms, with temperatures ranging from 66.9 to 83.3 degrees F.
Medication refrigerator containing insulin was not maintained between 38 and 45 degrees F; temperatures were under 38 degrees F nine times with no corrective action.
Residents on psychotropic medications did not have required six-month medication reviews.
Five staff who passed medications were not delegated by the current facility nurse.
Report Facts
Employees missing background checks: 3
Rooms with temperature issues: 4
Medication refrigerator temperature violations: 9
Staff not delegated to pass medications: 5
Inspection Report
Life Safety
Deficiencies: 7
Date: Jul 26, 2021
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for the facility Brookdale Pocatello.
Findings
The report identified multiple deficiencies related to fire and life safety standards, including lack of documented testing for alcohol-based hand rub dispensers, obstructions on fire suppression system pendants, missing documentation for dry system full flow trip testing, improper oxygen storage, prohibited appliance use on power strips, lack of fuel-fired heating inspection since 2019, and incomplete hood cleaning/inspection documentation.
Deficiencies (7)
No documented testing for installed manually activated Alcohol-Based Hand Rub dispensers each time a refill is replaced.
Fire suppression system pendants obstructed by hard water deposits above kitchen grill.
No documentation for dry system full flow trip since May 2017.
Oxygen storage in room 51 and breakroom not in accordance with NFPA 99 ventilation requirements.
Microwave plugged into power strip in Room 43, which is prohibited.
No documented fuel-fired heating inspection for gas fireplace since 2019.
No documentation for 1 of 2 hood cleaning/inspections in the past twelve months.
Report Facts
Oxygen storage volume: 1575
Survey date: Jul 26, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amber Moore | Administrator | Named as facility administrator. |
| Sam Burbank | Survey Team Leader | Named as survey team leader conducting fire life safety and sanitation licensure survey. |
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