Deficiencies (last 3 years)
Deficiencies (over 3 years)
21.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
170% worse than Idaho average
Idaho average: 7.9 deficiencies/year
Deficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of abuse and medication errors at the nursing home.
Complaint Details
The complaint investigation substantiated abuse of Resident #50 during transfers, resulting in injury and hospitalization. The facility also had multiple medication errors affecting 8 residents, confirmed by the Director of Nursing.
Findings
The facility failed to protect a resident from abuse resulting in actual harm when a resident was injured during a transfer against her will. Additionally, the facility failed to ensure residents were free from significant medication errors affecting multiple residents.
Deficiencies (2)
F 0600: The facility failed to protect Resident #50 from abuse during transfers, resulting in a fracture and seizure-like activity. Staff did not follow the care plan and transferred the resident against her will, causing actual harm.
F 0760: The facility failed to ensure residents were free from significant medication errors affecting 8 residents, including wrong medication administration, omitted doses, and incorrect dosages, resulting in harm or potential harm.
Report Facts
Residents affected by abuse: 1
Residents affected by medication errors: 8
Medication error incidents for Resident #6: 3
Pain level for Resident #5: 8
Pain level for Resident #5: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Provided statements regarding the abuse incident involving Resident #50 and reported concerns about the Director of Nursing's handling of statements. | |
| Director of Nursing | DON | Confirmed medication errors and involvement in the abuse incident investigation. |
| LPN #10 | Licensed Practical Nurse | Documented observations related to Resident #50 during the abuse incident. |
| CNA #14 | Certified Nurse Aide | Provided statements about Resident #50's behavior during the abuse incident. |
| CNA #3 | Certified Nurse Aide | Documented care provided to Resident #50 during the abuse incident. |
| LPN #20 | Licensed Practical Nurse | Instructed staff to leave Resident #50 in bed and confirmed medication errors. |
| RNA #1 | Restorative Nurse Aide | Involved in transferring Resident #50 during the abuse incident. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 3, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident rights, grievance policies, and safety measures in the nursing home.
Findings
The facility failed to investigate and take prompt corrective action regarding a resident's missing glass eye, potentially causing psychological harm. Additionally, the facility did not provide adequate supervision to prevent an accident involving a resident who suffered a burn from an unattended heating pad.
Deficiencies (2)
F 0585: The facility failed to ensure a resident's missing glass eye was investigated or corrective action taken, violating the grievance and complaint policy. This failure affected one resident and posed potential psychological harm.
F 0689: The facility failed to provide adequate supervision to prevent accidents, resulting in a resident suffering a burn from an unattended heating pad. Staff did not notify nursing or check the heating pad status, causing actual harm.
Report Facts
Residents affected: 1
Residents affected: 1
Inspection Report
Routine
Deficiencies: 11
Date: Apr 4, 2025
Visit Reason
The inspection was a routine regulatory survey of Karcher Post Acute nursing home to assess compliance with federal regulations regarding resident rights, abuse reporting, assessments, care planning, accident prevention, medication management, food service, and kitchen sanitation.
Findings
The facility was found deficient in multiple areas including failure to honor a resident's religious rights, delayed reporting and incomplete investigation of verbal abuse allegations, inaccurate resident assessments, incomplete care plans, inadequate care conference documentation, insufficient accident prevention interventions, unclear medication orders, medication errors, serving food at unsafe temperatures, and poor kitchen equipment sanitation.
Deficiencies (11)
F 0561: The facility failed to honor a resident's cultural/religious rights when a CNA cut Resident #28's hair without consent, causing psychosocial harm.
F 0609: The facility failed to timely report suspected verbal abuse of Resident #11 to the State Survey Agency within 5 days.
F 0610: The facility failed to thoroughly investigate allegations of verbal abuse for Resident #11, risking ongoing abuse without detection.
F 0641: The facility failed to ensure accurate MDS assessments by not marking PASARR level II status for Residents #16 and #30.
F 0656: The facility failed to include Resident #28's religious preferences regarding hair care in her care plan, risking violation of her rights.
F 0657: The facility failed to provide Resident #27 and her representative the opportunity to participate in care planning and attend care conferences.
F 0689: The facility failed to provide adequate supervision and interventions to prevent falls, resulting in Resident #20 falling due to unavailable soft touch call light.
F 0757: The facility failed to ensure Resident #9 was free from duplicate pain medication therapy without clear administration parameters.
F 0760: The facility failed to prevent significant medication errors for Residents #11 and #16, including incorrect dosing and wrong medication administration.
F 0804: The facility failed to serve food at appropriate temperatures, as observed with cold taco salad and other items served to Resident #40.
F 0812: The facility failed to maintain, clean, and sanitize kitchen equipment properly, including dusty pan drying racks, dirty freezer corners, and encrusted cooking skillets.
Report Facts
Residents reviewed for abuse: 6
Residents reviewed for medication errors: 2
Residents reviewed for unnecessary medications: 6
Residents reviewed for assessment accuracy: 14
Residents reviewed for care plans: 14
Residents reviewed for accidents: 4
Residents reviewed for dietary concerns: 4
Medication doses error: 10
Medication doses ordered: 5
Medication doses ordered: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Named in deficiency for cutting Resident #28's hair without consent. | |
| DON | Director of Nursing | Interviewed regarding abuse reporting, medication errors, and care conference documentation. |
| Administrator | Interviewed regarding Resident #28's hair care religious beliefs and kitchen cleaning responsibilities. | |
| MDS Coordinator | Interviewed regarding inaccurate MDS assessments for Residents #16 and #30. | |
| Dietitian | Registered Dietitian | Interviewed regarding verbal abuse grievance and food temperature issues. |
| Kitchen Manager | Interviewed regarding food temperature and kitchen sanitation deficiencies. |
Inspection Report
Routine
Deficiencies: 11
Date: Apr 4, 2025
Visit Reason
Routine inspection of Karcher Post Acute nursing home to assess compliance with regulatory requirements including resident rights, abuse reporting, assessments, care planning, accident prevention, medication management, food safety, and kitchen sanitation.
Findings
The facility was found deficient in multiple areas including failure to honor a resident's religious rights, delayed reporting and investigation of verbal abuse allegations, inaccurate resident assessments, incomplete care plans, inadequate care conference documentation, insufficient accident prevention interventions, unclear medication orders, medication errors, serving food at inappropriate temperatures, and poor kitchen equipment sanitation.
Deficiencies (11)
F 0561: The facility failed to honor a resident's cultural/religious rights when a CNA cut Resident #28's hair without consent, causing psychosocial harm.
F 0609: The facility failed to timely report suspected verbal abuse of Resident #11 to the State Survey Agency within 5 days.
F 0610: The facility failed to thoroughly investigate allegations of verbal abuse for Resident #11, resulting in potential ongoing abuse risk.
F 0641: The facility failed to ensure accurate MDS assessments for Residents #16 and #30 by not marking PASARR level II status correctly.
F 0656: The facility failed to include Resident #28's religious preferences regarding hair care in her care plan, risking violation of her rights.
F 0657: The facility failed to provide Resident #27 and representative opportunity to participate in care planning and attend care conferences.
F 0689: The facility failed to prevent accidents by not ensuring Resident #20's soft touch call light was available after room transfer, resulting in a fall.
F 0757: The facility failed to ensure Resident #9 was free from duplicate pain medication therapy without clear administration parameters.
F 0760: The facility failed to prevent significant medication errors for Residents #11 and #16, including incorrect dosing and wrong medication administration.
F 0804: The facility failed to serve food at appropriate temperatures, as observed with cold taco salad and other items served to Resident #40.
F 0812: The facility failed to maintain, clean, and sanitize kitchen equipment properly, including dusty pan drying racks, dirty freezer corners, and encrusted skillets.
Report Facts
Residents reviewed for abuse: 6
Residents reviewed for medication errors: 2
Residents reviewed for unnecessary medications: 6
Residents reviewed for dietary concerns: 4
Residents reviewed for accidents: 4
Residents reviewed for assessment accuracy: 14
Residents reviewed for care planning: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Named in finding for cutting Resident #28's hair without consent. | |
| Administrator | Interviewed regarding Resident #28's hair cutting incident and kitchen cleaning responsibilities. | |
| DON | Director of Nursing | Interviewed regarding abuse reporting, medication errors, accident prevention, and care conference documentation. |
| MDS Coordinator | Interviewed regarding inaccurate MDS assessments for Residents #16 and #30. | |
| Dietitian | Registered Dietitian | Interviewed and participated in meal test tray evaluation for Resident #40. |
| Kitchen Manager | Interviewed regarding food temperature and kitchen sanitation issues. |
Inspection Report
Original Licensing
Deficiencies: 4
Date: Jan 15, 2025
Visit Reason
The inspection was conducted as an initial licensure survey for Karcher Senior Living facility.
Findings
The inspection identified multiple deficiencies including incomplete criminal history checks for employees, unsigned resident admission agreements, improper medication refrigerator temperature monitoring, and lack of First Aid certification for staff working alone.
Deficiencies (4)
Four of seven employees did not have a Department Criminal History and Background Check completed.
Residents #1, #2, #4, #5, #6, and #7 did not sign their admission agreements prior to or on the day of admission or after change of ownership.
Medication refrigerator temperatures were not maintained between 38 and 45 degrees F, with out-of-range temperatures documented 31 times in October 2024, 28 times in November 2024, and 31 times in December 2024 without corrective action.
Six of six staff members who worked alone did not have evidence of First Aid certification.
Report Facts
Out-of-range medication refrigerator temperature occurrences: 31
Out-of-range medication refrigerator temperature occurrences: 28
Out-of-range medication refrigerator temperature occurrences: 31
Employees without criminal history check: 4
Residents without signed admission agreements: 6
Staff without First Aid certification: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gena Haling | Administrator | Confirmed lack of criminal history checks, unsigned admission agreements, and staff First Aid certification |
| Torrey Bollinger | Survey Team Leader | Led the initial licensure survey |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 2, 2024
Visit Reason
The inspection was conducted following a complaint and incident report involving Resident #1 being discharged from the facility after an altercation with another resident and concerns about the adequacy of the discharge process and resident rights.
Complaint Details
The complaint investigation was triggered by an incident where Resident #1 sprayed another resident with a garden hose. The facility discharged Resident #1 citing behavior issues. The investigation found the discharge was not properly documented or communicated, and Resident #1 was not informed of his right to appeal. The discharge caused psychosocial harm and inadequate medical support.
Findings
The facility failed to ensure Resident #1's right to remain in the facility and to appeal the facility-initiated discharge. Resident #1 was discharged to a motel without adequate support for his medical needs, including insulin administration and blood sugar monitoring, causing psychosocial harm.
Deficiencies (1)
F 0622: The facility did not transfer or discharge Resident #1 with an adequate reason and failed to provide proper documentation and information regarding the discharge and appeal rights. Resident #1 was discharged to a motel without the ability to safely manage his insulin and blood sugar monitoring.
Report Facts
Residents Affected: 3
Discharge notice period: 30
Insulin dose: 25
Insulin pen setting: 24
Hotel reservation nights: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Stated she had not witnessed any incidents involving Resident #1 and Resident #2 |
| CNA #1 | Certified Nursing Assistant | Provided care to Resident #1 and stated he never yelled or became aggressive |
| CNA #2 | Certified Nursing Assistant | Stated she never saw Resident #1 yelling or acting out |
| LPN #1 | Licensed Practical Nurse | Provided care to Resident #1 and stated he could be hard to redirect but had not witnessed physical aggression |
| Social Services Director | Social Services Director | Instructed to find placement for Resident #1 and discussed discharge options |
| Administrator | Facility Administrator | Stated the discharge was appropriate due to Resident #1's behavior and statements |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jan 26, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide adequate documentation and communication during resident transfers to hospitals, failure to provide bed hold notices, incomplete care plans, unsafe smoking assessments, improper monitoring of psychoactive medications, and unsanitary food storage and handling practices.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure in transfer documentation, bed hold notices, care planning, smoking safety assessments, psychoactive medication monitoring, and food safety.
Findings
The facility failed to ensure pertinent health information was provided to receiving hospitals for transferred residents, failed to provide bed hold notices to residents or their representatives upon transfer, did not develop comprehensive care plans for some residents, failed to assess a resident's safety for smoking quarterly, did not monitor psychoactive medication target behaviors properly, and failed to maintain sanitary food storage and serving practices.
Deficiencies (6)
F 0622: The facility failed to provide pertinent medical information to the receiving hospital for 3 of 3 residents transferred, risking adverse outcomes due to lack of timely treatment information.
F 0625: The facility failed to provide bed hold notices to residents or their representatives upon transfer to the hospital for 3 of 3 residents, risking residents not being informed of their right to return to their bed.
F 0656: The facility failed to develop and implement comprehensive resident-centered care plans for 2 of 13 residents, risking negative outcomes due to lack of documented needs and treatments.
F 0689: The facility failed to assess a resident quarterly for safe smoking, risking negative outcomes due to lack of proper supervision and assessment.
F 0758: The facility failed to ensure residents receiving psychoactive medications had resident-specific target behaviors identified and monitored, risking harm from inappropriate medication use.
F 0812: The facility failed to ensure food was stored, labeled, and served in a sanitary manner, risking contamination and food-borne illnesses for all 53 residents.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 53
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jan 26, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide adequate transfer documentation, bed hold notices, comprehensive care plans, safe smoking assessments, psychoactive medication monitoring, and food safety practices.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to provide transfer documentation, bed hold notices, comprehensive care plans, safe smoking assessments, psychoactive medication monitoring, and food safety.
Findings
The facility failed to provide pertinent medical information during resident transfers to hospitals for 3 residents, did not provide bed hold notices upon transfer for 3 residents, failed to develop comprehensive care plans for 2 residents, did not assess a resident quarterly for safe smoking, failed to monitor psychoactive medication target behaviors for 1 resident, and did not ensure food was stored, labeled, and served in a sanitary manner.
Deficiencies (6)
F 0622: The facility failed to provide pertinent health information to the receiving hospital for 3 of 3 residents transferred, risking adverse outcomes due to lack of timely treatment information.
F 0625: The facility failed to provide bed hold notices in writing to residents or their representatives upon transfer to the hospital for 3 of 3 residents, risking residents not being informed of their right to return to their bed.
F 0656: The facility failed to develop and implement comprehensive resident-centered care plans for 2 of 13 residents, risking negative outcomes if services were not provided or provided incorrectly.
F 0689: The facility failed to assess a resident quarterly to determine if they were safe to smoke cigarettes, risking potential negative outcomes.
F 0758: The facility failed to ensure residents receiving psychoactive medication had resident-specific target behaviors identified and monitored for 1 of 5 residents, risking harm from inappropriate medication use.
F 0812: The facility failed to ensure food was stored, labeled, and served in a sanitary manner, risking contamination and adverse health outcomes for all 53 residents.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 53
Inspection Report
Annual Inspection
Deficiencies: 21
Date: Jan 13, 2023
Visit Reason
Annual state survey inspection of Karcher Post Acute nursing home to assess compliance with regulatory requirements including resident care, safety, medication management, abuse prevention, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of condition changes, failure to prevent resident abuse, medication misappropriation and diversion, failure to provide timely reporting and investigation of abuse, inadequate care planning, insufficient activity programming, medication administration errors, inadequate respiratory care, lack of behavioral health services, improper disposal of garbage, improper execution of arbitration agreements, infection control lapses, and inadequate dining room lighting.
Deficiencies (21)
F580: Facility failed to notify resident's representative immediately of changes in condition for Resident #30, risking lack of advocacy and support.
F600: Facility failed to protect Resident #7 from sexual abuse by another resident, resulting in potential ongoing harm.
F602: Facility failed to prevent misappropriation of controlled pain medication for Resident #101, risking uncontrolled pain and medication diversion.
F609: Facility failed to timely report suspected narcotic diversion to law enforcement, State Agency, and Ombudsman for Resident #101.
F610: Facility failed to ensure thorough investigation and timely reporting of narcotic diversion to State Survey Agency within 5 working days for Resident #101.
F623: Facility failed to provide written notification of hospital transfer to Resident #41, her representative, and State Ombudsman.
F625: Facility failed to notify Resident #41 and her representative in writing of bed hold policy upon hospital transfer.
F656: Facility failed to develop and implement comprehensive care plans for multiple residents including pressure sore and pain treatment for Resident #101 and catheter care for Resident #41.
F679: Facility failed to provide an ongoing activity program meeting the interests and needs of Resident #8, resulting in potential boredom and lack of meaningful engagement.
F684: Facility failed to administer medication as ordered for Resident #64, missing doses of Budesonide-Formoterol inhaler without documentation.
F688: Facility failed to provide restorative nursing program and range of motion services for Resident #19, risking further decline in mobility.
F689: Facility failed to ensure safe resident transfer and provide a safe, supervised smoking area with appropriate safety equipment for Residents #55 and #17, resulting in injury and safety risks.
F695: Facility failed to provide respiratory care per physician orders for Resident #32, including improper use and cleaning of BiPap machine and incorrect oxygen flow rate.
F740: Facility failed to provide behavioral health services and monitor specific target behaviors for Resident #32, resulting in unmet psychological needs and distress.
F758: Facility failed to monitor specific target behaviors and nonpharmacological interventions for residents receiving psychotropic medications, including Residents #7, #16, #32, and #45.
F760: Facility failed to ensure residents were free from significant medication errors; Resident #101 received incorrect dose of Enoxaparin Sodium multiple times.
F791: Facility failed to provide routine and emergency dental services for Resident #31, resulting in untreated dental issues and discomfort.
F814: Facility failed to properly dispose of garbage and refuse around dumpsters, creating potential for pest infestation.
F847: Facility failed to properly execute arbitration agreements for residents #42 and #301, limiting residents' rights to rescind agreements within required timeframe.
F880: Facility failed to consistently implement infection prevention and control practices including mask use, hand hygiene, and clean wound care procedures.
F920: Facility failed to provide sufficient lighting in Dining Hall D, impairing residents' ability to see food and maintain independent functioning.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Lights not functioning: 6
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Administered incorrect dose of Enoxaparin Sodium to Resident #101 | |
| LPN #4 | Failed to follow wound care infection control procedures for Residents #16 and #19 | |
| Housekeeper #1 | Failed to perform hand hygiene when entering/exiting resident rooms | |
| Administrator | Acknowledged smoking safety issues and lack of dental services | |
| DNS | Acknowledged infection control lapses and medication errors | |
| RCM #1 | Responsible for care planning and medication oversight | |
| RCM #2 | Responsible for medication oversight and behavioral health coordination | |
| SSD | Social Services Director involved in behavioral health and dental care coordination | |
| Admission Director | Responsible for arbitration agreement process | |
| LPN #3 | Signature forged in narcotic log | |
| RN #2 | Tested positive for narcotics, terminated for alleged diversion |
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