Inspection Reports for
Family Life Memory Care
422 11th Ave S, Nampa, ID 83651, United States, ID, 83651
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1% better than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with medication management and labeling regulations at Wellspring Health & Rehabilitation of Cascadia.
Findings
The facility failed to ensure medications were properly labeled with open and discard dates, individual insulin syringes were labeled with the resident's name, expired medications were disposed of, and unknown pills were not properly identified on medication carts. These deficiencies posed potential risks for medication errors and adverse reactions.
Deficiencies (1)
F 0761: Medications were not labeled with open and discard dates, insulin pens lacked resident names, expired medications were not discarded, and unknown pills were found on medication carts. This posed risks for medication errors and suboptimal therapeutic outcomes.
Report Facts
Date of survey completion: Sep 18, 2025
Date of observations: Sep 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN19 | Licensed Practical Nurse | Observed and confirmed medication labeling issues on 200 hall medication cart |
| LPN20 | Licensed Practical Nurse | Observed and confirmed medication labeling issues on 300/500 hall medication cart |
| Director of Nursing | Director of Nursing | Provided policy and procedural expectations regarding insulin pen labeling and medication administration |
Inspection Report
Routine
Census: 84
Capacity: 120
Deficiencies: 11
Date: Jul 26, 2024
Visit Reason
Routine inspection of Wellspring Health & Rehabilitation of Cascadia to assess compliance with healthcare regulations, including resident care, infection control, and facility operations.
Findings
The facility had multiple deficiencies including failure to promptly resolve resident grievances, inadequate physician notification of significant weight loss, incomplete investigations of abuse allegations, incomplete care plans, inadequate incontinence care, improper feeding tube management, respiratory care deficiencies, unsanitary kitchen conditions, infection control failures including COVID-19 outbreak management, incomplete vaccination administration, and failure to calibrate glucometers properly.
Deficiencies (11)
F 0565: The facility failed to ensure grievances about call lights voiced by residents were documented, investigated, resolved, and followed up on, risking ongoing resident frustration and unmet care needs.
F 0580: The facility failed to notify the physician of a significant 9.2% weight loss in one resident, placing the resident at risk of complications.
F 0610: The facility failed to thoroughly investigate allegations of verbal abuse and medication errors for two residents, risking harm due to lack of investigation.
F 0656: The facility failed to develop and implement comprehensive resident-centered care plans for two residents, risking negative outcomes due to lack of information.
F 0690: The facility failed to provide timely incontinence care to a resident, resulting in a 25-minute delay and risk of embarrassment and skin impairment.
F 0693: The facility failed to prevent complications from a displaced nasogastric feeding tube, resulting in aspiration pneumonia and pneumothorax in one resident.
F 0695: The facility failed to follow physician orders for respiratory care and did not document treatment outcomes for two residents, risking respiratory infections.
F 0812: The facility failed to maintain kitchen equipment and environment in a sanitary manner, including dirt buildup on a refrigerator fan and residue on shelves, risking food contamination.
F 0880: The facility failed to implement an effective infection prevention and control program during a COVID-19 outbreak, including inadequate cohorting, improper PPE use, incomplete hand hygiene, and failure to vaccinate residents, placing many residents at immediate jeopardy.
F 0883: The facility failed to ensure residents who consented to pneumococcal and influenza vaccines received them, increasing risk of infection for three residents.
F 0908: The facility failed to ensure glucometers were calibrated as required, risking inaccurate blood glucose monitoring for residents on two halls.
Report Facts
Residents positive for COVID-19: 33
Staff positive for COVID-19: 16
Residents census: 84
Facility licensed capacity: 120
Weight loss percentage: 9.2
Residents with roommates positive for COVID-19: 11
Empty private rooms: 6
Empty double occupancy rooms: 4
Dates with missing respiratory treatment documentation: 15
Glucometer calibration missing months: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Noted displaced NG tube and contacted physician on 5/31/23 |
| CNO | Chief Nursing Officer | Interviewed regarding multiple deficiencies including grievance follow-up, weight loss notification, investigations, care plans, infection control, and vaccination documentation |
| CEO | Chief Executive Officer | Provided outbreak timeline and infection control responses during COVID-19 outbreak |
| RN #1 | Registered Nurse | Reported night shift nurses conduct glucometer calibration |
| LPN #3 | Licensed Practical Nurse | Provided care to Resident #81 and stated lack of knowledge on PPE donning/doffing |
| Clinical Resource Nurse #3 | Clinical Resource Nurse | Commented on NG tube incident and nursing practice |
| RT 2 | Respiratory Therapist | Verified missing respiratory treatment documentation |
| CNA #1 | Certified Nursing Assistant | Provided delayed incontinence care to Resident #4 |
| CNA #2 | Certified Nursing Assistant | Observed failing to perform hand hygiene after incontinence care |
| CNA #4 | Certified Nursing Assistant | Observed failing to perform hand hygiene after incontinence care |
| ACNO #1 | Assistant Chief Nursing Officer | Observed improper PPE use and hand hygiene |
Inspection Report
Annual Inspection
Census: 84
Capacity: 120
Deficiencies: 11
Date: Jul 26, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with healthcare regulations and standards at Wellspring Health & Rehabilitation of Cascadia.
Findings
The facility was found deficient in multiple areas including grievance resolution, physician notification of significant changes, investigation of abuse allegations, comprehensive care planning, incontinence care, feeding tube management, respiratory care, kitchen sanitation, infection control including COVID-19 outbreak management, vaccination administration, and equipment calibration.
Deficiencies (11)
F 0565: Facility failed to ensure grievances about call lights voiced by residents were documented, investigated, resolved, and followed up on, risking resident frustration and unmet care needs.
F 0580: Facility failed to notify the physician of a significant weight loss (9.2%) for Resident #50, risking complications related to unexpected weight changes.
F 0610: Facility failed to thoroughly investigate allegations of verbal abuse and medication errors for Residents #44 and #81, risking harm due to lack of investigation.
F 0656: Facility failed to develop and implement comprehensive resident-centered care plans for Residents #26 and #74, risking negative outcomes due to lack of care plan information.
F 0690: Facility failed to provide timely incontinence care to Resident #4, resulting in a 25-minute delay and risk of embarrassment, skin impairment, and psychosocial harm.
F 0693: Facility failed to ensure proper care and verification of nasogastric tube placement for Resident #85, resulting in aspiration pneumonia and pneumothorax.
F 0695: Facility failed to follow physician orders and document respiratory care and equipment maintenance for Residents #48 and #231, risking respiratory infections.
F 0812: Facility failed to maintain kitchen equipment and environment in a sanitary manner, including dirt buildup on refrigerator fan and residue on steam table shelf, risking food contamination.
F 0880: Facility failed to implement infection prevention and control measures during a COVID-19 outbreak, including cohorting, hand hygiene, PPE use, and vaccination administration, placing 84 residents at immediate jeopardy.
F 0883: Facility failed to ensure residents #52, #64, and #73 received pneumococcal and influenza vaccinations as offered and consented, increasing risk of respiratory infections.
F 0908: Facility failed to ensure glucometers on 100 and 200 Halls were calibrated consistently, risking inaccurate blood glucose monitoring.
Report Facts
Residents positive for COVID-19: 33
Staff positive for COVID-19: 16
Residents census: 84
Facility licensed capacity: 120
Weight loss percentage: 9.2
Number of residents with roommates positive for COVID-19: 11
Number of residents positive for COVID-19 in single rooms: 5
Dates with missing respiratory treatment documentation: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Nurse providing care to Resident #81 on 1/7/23 and discussed fentanyl patch incident | |
| CNO | Chief Nursing Officer | Interviewed multiple times regarding grievances, investigations, care plans, infection control, and vaccination documentation |
| CEO | Chief Executive Officer | Provided information on COVID-19 outbreak and infection control measures |
| Clinical Resource Nurse #3 | Commented on NG tube incident with Resident #85 | |
| RT 2 | Respiratory Therapist | Verified missing respiratory treatment documentation |
| CDM | Certified Dietary Manager | Confirmed kitchen cleaning issues |
| RD | Registered Dietitian | Commented on kitchen cleaning and audits |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 3, 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 facility was found to have deficiencies including failure to monitor and document medication refrigerator temperatures containing insulin, lack of six-month psychotropic medication reviews for residents on such medications, and staff not having specialized training for traumatic brain injury despite admitting a resident with that diagnosis.
Deficiencies (3)
Medication refrigerator temperatures were not monitored and documented daily for several months despite containing insulin.
Four residents on psychotropic medications for at least six months did not have required six-month medication reviews completed.
Five staff members lacked specialized training for traumatic brain injury, although the facility had a resident diagnosed with this condition.
Report Facts
Residents on psychotropic medications without six-month reviews: 4
Staff without traumatic brain injury training: 5
Survey date: Apr 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carry Avalos | Administrator | Stated facility had not been documenting medication refrigerator temperatures and confirmed admission of resident with traumatic brain injury |
| Bradley Perry | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Life Safety
Capacity: 16
Deficiencies: 7
Date: Dec 12, 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 three through sixteen residents.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code and related standards, including lack of documentation for emergency plan training, oxygen safety training, policies on flammable substances, monthly inspections of suppression systems, a resident room door that would not latch, unsecured exterior gates, and hot water temperature exceeding the allowed maximum.
Deficiencies (7)
Lack of documentation for periodic emergency plan training and bi-monthly in-service training for staff.
No documentation showing staff are trained periodically on safety guidelines and oxygen use.
No policy for elimination of ignition sources and misuse of flammable substances.
No documentation of monthly visual inspections of wet suppression system gauges and secured control valves.
Resident room #2 door would not latch when fully closed.
Exterior yard gates are not secured by locks, only latching mechanisms.
Hot water temperature at plumbing fixtures was 125°F, exceeding the allowed maximum of 120°F.
Report Facts
Total licensed capacity: 16
Hot water temperature: 125
Fence height: 6
Number of gates: 2
Inspection Report
Life Safety
Deficiencies: 4
Date: Jun 4, 2021
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with applicable fire and life safety standards.
Findings
The facility had several non-core issues including an outdated relocation agreement, an emergency plan lacking a designated point of assembly, and improper use of relocatable power taps which were corrected on site during the inspection.
Deficiencies (4)
Facility has one relocation agreement dated 2017; facility shall have two relocation agreements with two separate locations, reviewed not less than annually.
Facility emergency plan does not show point of assembly; drills shall be conducted at designated point of assembly per NFPA 101.
Relocatable power taps (RPTs) shall not be daisy-chained; RPTs were daisy-chained in main living room (corrected on site).
RPTs shall not be used for appliances; RPT used to supply power to an air purifier in main living room (corrected on site).
Report Facts
Facility relocation agreements required: 2
Relocation agreements present: 1
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 10, 2020
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with nursing assessments, staff scheduling documentation, and food protection manager certification requirements.
Findings
The facility failed to consistently conduct nursing assessments for residents with changes in health status, did not maintain accurate as-worked staff schedules, and lacked an employee certified as a food protection manager at the time of the survey.
Deficiencies (3)
Facility nurse did not consistently conduct nursing assessments when residents experienced changes in physical or mental health status.
Facility did not maintain as-worked schedules documenting personnel on duty at any given time.
Facility did not have an employee with certified food protection manager certification at the time of survey.
Report Facts
Facility License Number: RC-1059
Survey Date: Dec 10, 2020
Response Due Date: Jan 9, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carry Avalos | Administrator | Named as facility administrator |
| Stacey Brown | Survey Team Leader | Named as survey team leader |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Nov 15, 2019
Visit Reason
The inspection was conducted as a comprehensive annual survey of Wellspring Health & Rehabilitation of Cascadia to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to respect residents' dignity by not dressing them in personal clothing, failure to revise and update care plans, inadequate provision of activities meeting residents' needs, insufficient pressure ulcer prevention care, ineffective pain management, inaccurate nurse staffing postings, and failure to perform proper infection control hand hygiene.
Deficiencies (7)
F 0550: The facility failed to respect a resident's dignity by not dressing Resident #39 in her personal clothing, instead using hospital-type gowns.
F 0657: The facility failed to revise and update care plans for Residents #18 and #44, risking inappropriate care due to inaccurate information.
F 0679: The facility failed to provide activities meeting Resident #39's individual needs, resulting in potential boredom and lack of stimulation.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevention for Residents #10 and #39, including failure to apply prescribed boots and pillows.
F 0697: The facility failed to ensure effective pain management for Resident #44, including failure to notify the physician of ineffective pain medication.
F 0732: The facility failed to post daily nurse staffing information per shift accurately and failed to maintain records for a minimum of 18 months.
F 0880: The facility failed to ensure appropriate hand hygiene was performed by staff, risking cross contamination and infection.
Report Facts
Residents reviewed for dignity: 15
Residents reviewed for care plans: 15
Residents reviewed for activities: 3
Residents reviewed for skin breakdown: 4
Residents reviewed for pain management: 4
Residents reviewed for infection control: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in pain management deficiency related to use of warm towel and failure to revise care plan. |
| LPN #1 | Licensed Practical Nurse | Named in pain management deficiency for failing to notify physician effectively. |
| CNA #9 | Certified Nursing Assistant | Named in dignity and pressure ulcer prevention deficiencies regarding Resident #39's clothing and boot application. |
| CNA #10 | Certified Nursing Assistant | Named in dignity and pressure ulcer prevention deficiencies regarding Resident #39's clothing and boot application. |
| DON | Director of Nursing | Named in pain management and infection control deficiencies. |
| RT #1 | Respiratory Therapist | Named in infection control deficiency for failure to perform hand hygiene. |
| CNA #2 | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene after pericare. |
| Scheduler | Named in nurse staffing deficiency regarding posting and record keeping. | |
| Activities Director | Activities Director | Named in activities deficiency regarding Resident #39. |
| UM #1 | Utilization Manager | Named in care plan deficiency regarding Resident #18. |
| UM #2 | Utilization Manager | Named in dignity, pressure ulcer, activities, pain management, and infection control deficiencies. |
| Wound Nurse | Wound Nurse | Named in pressure ulcer prevention deficiency. |
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