Inspection Report Summary
The most recent inspection on August 15, 2024, identified deficiencies related to medication administration and updating of a resident’s care plan. Earlier inspections showed a pattern of issues including incomplete background checks, lack of timely complaint responses, inadequate nursing assessments, and failures in abuse reporting and resident protection. Deficiencies mainly involved medication management, care planning, staff documentation, and abuse investigation and reporting procedures. Several complaint investigations substantiated allegations of abuse and failures to protect residents, but 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, with some recurring themes and no clear pattern of sustained improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 15, 2024
Visit Reason
The inspection was conducted as a health care complaint investigation regarding medication administration and care plan issues for Resident #4.
Findings
The facility failed to ensure Resident #4 received medications as ordered multiple times between March and April 2024, and the resident's Negotiated Service Agreement (NSA) was not updated to reflect current care needs, including wound care instructions and assistance levels.
Complaint Details
The investigation was triggered by a complaint related to medication administration and care planning for Resident #4. Substantiation status is not stated.
Deficiencies (2)
| Description |
|---|
| Resident #4 did not receive prescribed medications as ordered multiple times between March and April 2024. |
| Resident #4's Negotiated Service Agreement was not updated to reflect wound care instructions and actual assistance needs. |
Report Facts
Missed medication doses: 11
Missed medication doses: 2
Missed medication doses: 8
Missed medication doses: 7
Missed medication doses: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Gerlach | Administrator | Stated medications were not available as they had been sent out to be bubble packed. |
| Michael Oldfield | Survey Team Leader | Led the health care complaint investigation. |
Inspection Report
Follow-Up
Deficiencies: 5
Jan 5, 2024
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 survey identified multiple deficiencies including incomplete criminal background checks for staff, failure to provide written responses to complaints, inaccurate resident admission and discharge registers, incomplete personnel records, and lack of delegation of nursing tasks by the new facility nurse.
Complaint Details
The visit included investigation of complaints from Resident #7's family alleging sexual abuse and Resident #6 regarding missing leftovers; both complaints lacked timely written responses from the administrator.
Deficiencies (5)
| Description |
|---|
| Facility had not obtained completed criminal history background checks for three of ten staff members, and these staff worked alone without line-of-sight supervision by cleared employees. |
| Administrator did not provide written responses to complaints regarding sexual abuse allegation and missing resident property within required 30 days. |
| Facility did not maintain an up-to-date admission and discharge register accurately documenting current residents. |
| Personnel records for all ten staff reviewed lacked required documentation including orientation, training, certification, continuing education, and CPR/first aid certifications. |
| New facility nurse had not delegated medication administration and nursing tasks to staff members, leaving staff uncertain about care procedures. |
Report Facts
Staff members without completed background checks: 3
Staff records reviewed: 10
Staff members not delegated by nurse: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Gerlach | Administrator | Named in findings related to lack of written complaint responses and awareness of staff background check issues. |
| Teresa McClenathan | Survey Team Leader | Led the health care licensure and follow-up survey. |
Inspection Report
Complaint Investigation
Deficiencies: 10
Aug 18, 2023
Visit Reason
The inspection was conducted as a health care complaint investigation to assess allegations of abuse and the facility's compliance with policies and procedures related to resident protection and incident reporting.
Findings
The facility failed to protect residents from abuse, did not immediately notify Adult Protective Services, did not conduct thorough investigations, and failed to implement adequate corrective actions and protective measures. Multiple allegations of physical and sexual abuse were substantiated involving several residents, with failures in reporting, investigation, and resident protection.
Complaint Details
The complaint investigation focused on multiple allegations of abuse involving Residents #1, #2, #4, and #7. The allegations included physical abuse by staff members and sexual abuse by Resident #7. The investigation found failures in reporting, investigating, protecting residents, and implementing corrective actions. The administrator failed to notify Adult Protective Services promptly and did not conduct thorough investigations. Protective measures such as immediate suspension of alleged abusers and 1:1 supervision were not implemented. The facility's behavior plans were inadequate and not updated to address aggressive sexual behaviors. These failures had the potential to affect 100% of residents.
Deficiencies (10)
| Description |
|---|
| The facility did not ensure policies and procedures were implemented to fulfill abuse reporting and protection requirements. |
| Failure to immediately notify Adult Protective Services of abuse allegations. |
| Failure to immediately notify the administrator of abuse allegations. |
| Failure to conduct thorough investigations into abuse allegations within thirty days. |
| Failure to protect residents during investigations, including failure to suspend alleged abusers immediately. |
| Failure to implement corrective actions to prevent recurrence of abuse and injuries. |
| Failure to notify licensing agency within one business day of incidents. |
| Failure to conduct nursing assessments after changes in residents' health status. |
| Failure to consistently document unusual incidents or accidents in residents' records. |
| Failure to develop or implement behavior plans with specific interventions for residents exhibiting maladaptive behaviors. |
Report Facts
Number of residents sampled: 7
Number of residents affected by abuse: 3
Dates of key incidents: Multiple dates including 5/23/22, 12/27/22, 1/25/23, 4/9/23, and others
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joe Rudd | Administrator | Failed to ensure abuse policies were followed, did not notify Adult Protective Services, and did not conduct thorough investigations |
| Caregiver Z | Alleged perpetrator of physical abuse to Resident #4, was placed on leave and criminally prosecuted | |
| Staff member Y | Involved in alleged abuse of Resident #2, was not suspended during investigation | |
| Staff member L | Reported sexual abuse incident involving Resident #7 and Resident #1 | |
| Staff member V | Witnessed sexual abuse incident involving Resident #7 and Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 4
Mar 10, 2023
Visit Reason
The inspection was conducted as a health care complaint investigation to evaluate the facility's response to complaints and resident health care practices.
Findings
The facility failed to provide written responses to complaints, did not conduct nursing assessments for residents with changes in health status, inconsistently made recommendations for follow-up care, and lacked interventions to prevent recurrence of incidents such as falls.
Complaint Details
The investigation was complaint-related, focusing on the facility's failure to respond to complaints and deficiencies in resident health assessments and care interventions.
Deficiencies (4)
| Description |
|---|
| The administrator was unable to provide a complaint log with written responses to complaints within thirty days. |
| The facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including multiple falls and infections. |
| The facility nurse did not consistently make recommendations to medical providers, outside agency staff, or families regarding residents' health needs requiring follow-up care. |
| The facility did not have interventions for incidents and accidents to prevent recurrences, despite multiple falls experienced by residents. |
Report Facts
Falls experienced by Resident #3: 14
Falls experienced by Resident #2: Multiple falls between October 2022 and November 2022
Antibiotic treatment duration: 5
Inspection Report
Life Safety
Deficiencies: 8
Sep 15, 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 buildings licensed for seventeen or more residents and multi-story buildings.
Findings
The survey identified multiple deficiencies including lack of documentation for testing of Alcohol-Based Hand Rub dispensers, staff and resident training on Emergency Action Plan roles, prohibited use of relocatable power taps with medical equipment and appliances, absence of policy for elimination of ignition sources related to medical gases, and incomplete documentation of emergency evacuation drills.
Deficiencies (8)
| Description |
|---|
| No documentation for testing of installed Alcohol-Based Hand Rub dispensers each time a refill is replaced. |
| No documentation for staff training being reviewed bi-monthly on roles and responsibilities in the Emergency Action Plan. |
| No documentation for residents' training on roles and responsibilities of the Emergency Action Plan. |
| Use of relocatable power taps (RPTs) prohibited with medical equipment: RPTs used to supply power to oxygen concentrators in rooms 209A and B. |
| RPTs prohibited to be daisy-chained: IT closet had two RPTs daisy-chained together. |
| RPTs prohibited with appliances: Room 209A used RPT to power mini-fridge; Beauty salon used RPT to power curling irons and hair dryers. |
| No policy and procedure for elimination of sources of ignition or misuse of flammable substances related to medical gases. |
| Emergency egress and relocation drills did not document evacuation to any of the three listed points of assembly in the Emergency Action Plan. |
Inspection Report
Follow-Up
Deficiencies: 4
May 12, 2022
Visit Reason
The inspection was a health care licensure and follow-up survey to verify compliance with regulatory requirements.
Findings
The facility was found to have multiple deficiencies including incomplete criminal history and background checks for employees, medication refrigerator temperatures out of range, lack of behavior plans for residents exhibiting certain behaviors, and missing documentation of current CPR and first aid certifications for employees.
Deficiencies (4)
| Description |
|---|
| Two of seven employees did not have a Department criminal history and background check completed. |
| Medication refrigerator temperatures were not consistently maintained within the correct range, with multiple instances of out-of-range temperatures and missing temperature recordings. |
| The facility did not develop behavior plans and interventions for residents exhibiting behaviors such as physical aggression and lack of personal hygiene. |
| Two of seven employees did not have evidence of current CPR or first aid certification documented. |
Report Facts
Employees without criminal history check: 2
Employees without CPR/first aid certification documentation: 2
Medication refrigerator temperature out-of-range occurrences: 26
Medication refrigerator temperature out-of-range occurrences: 47
Medication refrigerator temperature not recorded occurrences: 8
Medication refrigerator temperature not recorded occurrences: 4
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 31, 2022
Visit Reason
The inspection was conducted as a health care complaint investigation to evaluate medication administration, resident health assessments, and staff delegation practices.
Findings
The facility failed to ensure residents received medications as ordered, did not conduct nursing assessments for residents with changes in health status, and had staff passing medications without proper delegation by the facility nurse.
Complaint Details
The visit was complaint-related as indicated by the survey type 'health care complaint investigation'.
Deficiencies (3)
| Description |
|---|
| Facility nurse did not ensure residents received medications as ordered, including missed doses of Lantus and hydrocodone-acetaminophen due to miscommunication and medication shortages. |
| Facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, such as swollen lip, fall, and bruising without assessment. |
| Four of fifteen staff who passed medications were not delegated by the facility nurse. |
Report Facts
Staff passing medications without delegation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Storm | Administrator | Confirmed medication shortages and delegation issues. |
| Bradley Perry | Survey Team Leader | Led the health care complaint investigation survey. |
Inspection Report
Life Safety
Deficiencies: 3
Jul 12, 2021
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for the facility Edgewood Spring Creek Eagle Island, LLC.
Findings
The inspection identified non-core issues including lack of documentation for testing Alcohol Based Hand Rub dispensers upon refill, missing sensitivity testing for the addressable fire alarm system since 2015, and one unsecured oxygen cylinder in the memory care medication room which was corrected on site.
Deficiencies (3)
| Description |
|---|
| No documentation for testing of Alcohol Based Hand Rub (ABHR) dispensers each time a refill is replaced in accordance with NFPA 101. |
| No documented sensitivity testing completed for addressable fire alarm system since new construction in 2015 (repeat). |
| One unsecured oxygen cylinder in med room of memory care; corrected on site 7/12/2021. |
Report Facts
Facility licensed for residents: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Storm | Administrator | Named as facility administrator. |
| Sam Burbank | Survey Team Leader | Named as survey team leader for fire life safety and sanitation licensure. |
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