Inspection Reports for Grace Assisted Living – Grace Boise Englefield
ID, 83709
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Inspection Report
Complaint Investigation
Deficiencies: 9
Oct 17, 2025
Visit Reason
The inspection was conducted as a health care licensure and follow-up visit combined with a complaint investigation at Grace Assisted Living at Englefield Green.
Findings
Multiple deficiencies were identified including lack of clearly marked designated smoking areas, medication refrigerator temperature violations, incomplete and inaccurate residents' Negotiated Service Agreements, failure to follow medication and treatment orders, incomplete personnel records and training documentation, lack of delegation for medication administration, failure of the administrator to complete timely investigations of incidents, and failure to review and implement new medical orders.
Complaint Details
The visit included a complaint investigation as indicated by the survey type and the findings related to medication errors, inadequate documentation, and failure to follow orders.
Deficiencies (9)
| Description |
|---|
| The facility did not have a designated smoking area that was clearly marked. |
| The facility did not maintain medication refrigerator temperatures between 38 and 45 degrees F and failed to document temperatures daily. |
| Residents' Negotiated Service Agreements did not clearly reflect residents' needs or describe services provided. |
| The facility failed to follow medication and treatment orders for residents, including incorrect medication administration and diet orders. |
| Nine of fifteen staff files lacked documentation of 16 hours orientation training; seven lacked mental illness and traumatic brain injury training documentation. |
| One medication technician did not have an Idaho Board of Nursing approved medication assistance course. |
| One staff member assisting with medications was not delegated by the current facility nurse. |
| The administrator did not complete investigations and written reports within 30 days of accidents and incidents. |
| The facility nurse did not review and implement new orders for residents' medications and treatments. |
Report Facts
Days medication refrigerator temperature was below 38 degrees: 17
Staff files lacking 16 hours orientation training: 9
Staff files lacking mental illness and traumatic brain injury training: 7
Medication technicians without approved medication assistance course: 1
Staff not delegated by current facility nurse: 1
Falls of Resident #9 not investigated: 5
Incorrect administration of cataract combo drops to Resident #4: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 13, 2022
Visit Reason
The inspection was conducted as a health care licensure and follow-up visit combined with a complaint investigation.
Findings
A Licensed Practical Nurse (LPN) conducted multiple quarterly assessments for several residents, which should have been conducted by a Licensed Registered Nurse (RN). The facility RN was unaware of this requirement.
Complaint Details
The visit included a complaint investigation component as indicated by the survey type.
Deficiencies (1)
| Description |
|---|
| A facility Licensed Practical Nurse (LPN) conducted multiple quarterly assessments for Resident #4, #5, and #6, which were required to be conducted by an RN. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allan Perren | Administrator | Named as the facility administrator. |
| Melvin Lu | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey. |
Inspection Report
Life Safety
Deficiencies: 4
Jan 10, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey of Grace Assisted Living at Englefield Green.
Findings
The facility did not maintain compliance with the 2018 edition of NFPA 101 Life Safety Code, with deficiencies including non-operational emergency lights, lack of a recent 90-minute emergency lighting test, an unsealed hole in the laundry room wall, improperly sealed conduit allowing potential smoke and fire hazards, inadequate safety screens on gas fireplaces, and use of a prohibited extension cord in the activity room.
Deficiencies (4)
| Description |
|---|
| Two non-operational emergency lights and failure to produce a 90-minute annual test of emergency lighting. |
| Approximately 24" x 42" hole in the laundry room wall and improperly sealed conduit in electrical and riser rooms. |
| Gas fireplace screens do not provide an adequate safety barrier to prevent injury from hot surfaces. |
| Use of an extension cord in the activity room, which is prohibited. |
Report Facts
Non-operational emergency lights: 2
Hole size: 24
Hole size: 42
Gas fireplaces: 2
Screen distance: 0.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Chaney | Survey Team Leader | Named as survey team leader conducting the fire life safety and sanitation licensure survey. |
| Allan Perren | Administrator | Facility administrator named in the report header. |
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