Inspection Reports for Grace Assisted Living
1610 Sunnyridge Road, Nampa, ID, 83686
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 21, 2024, identified deficiencies related to fire safety documentation, use of prohibited multi-plug adapters, and maintenance of fuel-fired heating systems. Earlier inspections showed a pattern of fire safety and emergency preparedness issues, including incomplete testing documentation, improper use of electrical devices, and insufficient emergency drills. Prior reports also noted a core deficiency for operating without a licensed administrator for over six months and substantiated abuse allegations involving failure to report and investigate incidents properly. Complaint investigations were limited, with the most notable substantiated case involving abuse of two residents and inadequate administrative response. The facility’s inspection history indicates ongoing challenges with fire safety compliance and administrative oversight, with some issues persisting over multiple years.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Life Safety
Deficiencies: 4
Date: Nov 21, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Grace Assisted Living.
Findings
The facility failed to provide documentation of smoke detector sensitivity testing within the last five years, did not fully document fire suppression gauge inspections, used prohibited multi-plug adapters in resident room #126, and failed to maintain fuel-fired heating systems according to regulations.
Deficiencies (4)
Facility could not provide documentation of smoke detector sensitivity testing within the last five years.
Fire suppression gauges monitoring air or nitrogen pressure lacked documentation for system #1; water pressure gauges inspection documentation missing for two wet systems.
Use of prohibited multi-plug adapter in room #126 to power multiple devices including an oxygen concentrator.
Facility failed to maintain fuel-fired heating systems as required; last documented annual inspection was in April 2023.
Report Facts
Facility License Number: RC-812
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Berklee Hames | Administrator | Named as facility administrator |
| Jeremy Wilson | Survey Team Leader | Named as survey team leader for fire life safety and sanitation licensure |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 22, 2024
Visit Reason
The inspection was conducted as a health care licensure and follow-up survey to assess compliance with licensing requirements, specifically regarding the presence of a licensed administrator at the facility.
Findings
The facility operated without a licensed administrator from August 18, 2023, to February 22, 2024, totaling 188 days, which resulted in a core deficiency. The administrator was unaware that her license had expired on August 17, 2023.
Deficiencies (1)
Facility operated without a licensed administrator for 188 days, resulting in a core deficiency.
Report Facts
Days without licensed administrator: 188
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Anderson | Facility administrator whose license expired on 8/17/23 and was unaware of expiration | |
| Cody Bennett | Administrator | Named as facility administrator at time of survey |
| Megan Rideout | MHA Team Lead Health Facility Surveyor | Surveyor conducting the survey |
| Mina Ramirez | RN Health Facility Surveyor | Surveyor conducting the survey |
| Michael Oldfield | LMSW Health Facility Surveyor | Surveyor conducting the survey |
| Torrey Bollinger | QIDP Health Facility Surveyor | Surveyor conducting the survey |
Inspection Report
Life Safety
Deficiencies: 5
Date: Mar 30, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Grace Assisted Living.
Findings
The survey identified several non-core issues including unmarked smoking areas, incomplete fire alarm sensitivity testing documentation, prohibited use of extension cords and multiple plug adapters, improper oxygen use and storage, and insufficient emergency egress and relocation drills.
Deficiencies (5)
Smoking areas not clearly marked or identified; staff using unmarked area by dumpsters.
Fire alarm sensitivity testing documentation incomplete; did not provide range or tested sensitivity of smoke detectors.
Use of extension cords and multiple plug adapters prohibited; salon using a 6-2 MPA to supply power to hair dryers and curling irons (corrected on site).
Oxygen use and storage not properly signed; resident in room 154 is a smoker in possession of smoking materials despite policy.
Emergency egress and relocation drills conducted less than six times per year with no documented drills to the assembly point listed in the emergency plan.
Report Facts
Frequency of emergency drills: 6
Number of night drills: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Anderson | Administrator | Named as facility administrator in the report. |
| Sam Burbank | Survey Team Leader | Named as survey team leader conducting the inspection. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 7, 2022
Visit Reason
The inspection was conducted as a health care licensure and follow-up survey to assess compliance with medication storage requirements.
Findings
The facility failed to maintain appropriate refrigerator temperatures for storing residents' medications, including insulin, with temperatures below 38 degrees Fahrenheit recorded 90 times between September 1 and November 30, 2022.
Deficiencies (1)
The facility did not maintain appropriate temperatures for the refrigerator storing the residents' medications, including insulin.
Report Facts
Temperature deviations: 90
Lowest temperature recorded: 30
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation and licensure survey following allegations of abuse reported at Grace Assisted Living.
Complaint Details
The complaint investigation found substantiated abuse allegations involving two residents (#11 and #12) where caregivers were rough or forceful during care. The facility failed to report, investigate, and protect residents as required.
Findings
The facility failed to protect residents #11 and #12 from abuse by not reporting allegations to Adult Protective Services timely, not conducting thorough investigations, and not protecting residents during investigations. These failures resulted in abuse and had the potential to affect all residents at the facility.
Deficiencies (4)
The administrator failed to report all allegations of abuse to Adult Protection.
The administrator failed to investigate all allegations of abuse within thirty days.
The administrator failed to protect residents after being informed of allegations of abuse.
The facility did not protect residents #11 and #12 from abuse when policies regarding reporting, protecting, and investigating abuse were not followed.
Report Facts
Residents sampled: 12
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cody Bennett | Administrator | Named in findings related to failure to report and investigate abuse |
| Melvin Lu | Survey Team Leader | Conducted the complaint investigation and survey |
| Tom Moss | Health Facility Surveyor | Surveyor involved in complaint investigation |
| Teresa McClenathan | Health Facility Surveyor | Surveyor involved in complaint investigation |
Inspection Report
Life Safety
Deficiencies: 8
Date: Oct 27, 2021
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Grace Assisted Living.
Findings
Multiple deficiencies were identified related to fire and life safety standards, including lack of documented inspections and testing, unsealed penetrations reducing fire resistance, prohibited use of relocatable power taps, lack of staff training on disaster roles and oxygen risks, and inadequate emergency drills.
Deficiencies (8)
No documented monthly dry and wet system gauge and control valve inspections in accordance with NFPA 25.
Unsealed penetrations reducing existing 1-hour fire resistive features in multiple locations.
Room 218 using Relocatable Power Tap (RPT) to supply power to an oxygen concentrator.
Beauty Salon using RPT to supply power to all curling irons and hair dryer (corrected on site 10/27/21).
No documented 90 minute e-lite testing in accordance with NFPA 101.
No documented training for staff and residents on disaster plan roles and responsibilities.
No documented inservice for staff qualifications on risks associated with oxygen.
Emergency drills not conducted to a designated point of assembly and not all drills evaluated for improvement.
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