Inspection Reports for North Star Assisted & Senior Living
2340 W Seltice Way, Coeur d'Alene, ID 83814, ID, 83814
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 8, 2024, found deficiencies related to missing documentation for multiple fire and life safety inspections and repeated issues from a prior survey. Earlier inspections showed a pattern of deficiencies involving fire safety documentation, staff background checks, infection control practices, and administrative procedures such as complaint responses and fee notifications. The main themes across reports included incomplete fire and life safety records, staff compliance with background checks and certifications, and infection control measures. Complaint investigations were conducted but did not result in substantiated findings, and no enforcement actions or fines were listed in the available reports. The facility’s inspection history indicates ongoing challenges with documentation and procedural compliance, with some repeated deficiencies suggesting limited improvement in certain areas over time.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% better than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Life Safety
Deficiencies: 7
Date: Feb 8, 2024
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 the facility.
Findings
The facility failed to provide required documentation for multiple fire and life safety inspections and tests, including fire damper inspections, smoke detector sensitivity testing, emergency light testing, and annual fuel-fired heating system inspections. Several deficiencies were repeated from a prior survey dated 9/25/2020, indicating unresolved issues.
Deficiencies (7)
Facility could not provide documentation for inspection/testing of Fire Dampers within the last 4 years.
Facility could not provide documentation for the 5-year smoke detector sensitivity testing.
Facility could not provide documentation for Emergency Light testing 30 seconds monthly and 90 minutes annually.
Multi plug adapters prohibited. Room 144 and Room 149 using multi plug adapters.
Facility could not provide documentation for Annual Fuel-Fired heating systems inspection and service.
Facility failed to ensure Fire and Life Safety Records were maintained, missing 5-year smoke detector sensitivity testing results leading to a repeated deficiency.
Facility failed to resolve previously cited deficiencies since last survey date of 9/25/2020, leading to 3 repeat deficiencies.
Report Facts
Repeat deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeremy Wilson | Survey Team Leader | Named as survey team leader for fire life safety and sanitation licensure survey |
| Rachel Jensen | Administrator | Facility administrator named in report header |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jan 25, 2023
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to verify compliance with previous deficiencies and regulatory requirements.
Findings
Two deficiencies were identified: two of seven employees lacked required state police background checks, and the facility did not have any staff with Certified Food Protection Manager certification at the time of the survey.
Deficiencies (2)
Two of seven employees, who required a state police background check and whose records were reviewed, did not have one completed.
The facility did not have any staff with Certified Food Protection Manager certification at the time of survey.
Report Facts
Employees lacking background check: 2
Employees reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Jensen | Administrator | Interviewed regarding incomplete ISP background checks. |
| Melvin Lu | Survey Team Leader | Led the health care licensure and follow-up survey. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 19, 2022
Visit Reason
The inspection was conducted as a health care complaint investigation regarding the facility's adherence to infection control practices.
Complaint Details
The visit was triggered by a complaint related to infection control practices; no substantiation status is stated.
Findings
The facility failed to follow public health district and CDC recommendations for preventing infectious disease transmission, with staff, management, and visitors observed not wearing masks properly between 5/18/22 and 5/19/22.
Deficiencies (1)
The facility did not follow the public health district or CDC recommendations when caring for residents to prevent transmission of infectious disease; masks were worn improperly or not at all by staff, management, and visitors.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Jensen | Administrator | Named as facility administrator during the complaint investigation. |
| Gloria Keathley | Survey Team Leader | Led the health care complaint investigation survey. |
Inspection Report
Life Safety
Deficiencies: 6
Date: Sep 25, 2020
Visit Reason
A Fire Life Safety Survey was conducted at North Star Retirement Community to assess compliance with fire and life safety regulations.
Findings
Multiple deficient practices were found including missing relocation agreements, incomplete fire drill documentation, improper electrical installations, lack of documentation for required inspections and tests, non-operational self-closing doors, missing fire sprinklers in certain areas, and safety hazards related to the gas fireplace and kitchen hood.
Deficiencies (6)
Facility had only one relocation agreement instead of two as required.
Missing fire drills for first shift on first and second quarter 2020; incomplete fire drill documentation for second shift, fourth quarter 2019.
Use of extension cords and multi-plug adapters in kitchen for appliances.
No documentation for annual inspection of gas fireplace in living area.
Non-compliance with NFPA 101 Chapter 33 including missing sensitivity test for smoke detectors, missing emergency lighting documentation and installations, missing sprinkler inspections and tests, multiple penetrations in mechanical room, non-operational self-closing doors, missing fire sprinklers in kitchen cooler/freezer, painted sprinkler heads, and gaps in kitchen hood filters.
Gas fireplace in common living area did not have a safety barrier.
Report Facts
Relocation agreements required: 2
Relocation agreements present: 1
Fire drills missing: 2
Sprinkler heads with non-factory paint: 9
Sprinkler inspection intervals: 5
Sprinkler system trip test interval: 3
Survey date: Sep 25, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Chaney | Health Facility Surveyor | Named as survey team leader and contact for the Fire Life Safety Survey. |
| Tambra Maple | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 9, 2019
Visit Reason
The inspection was conducted as a health care complaint investigation to address concerns related to service charges, complaint responses, and fee change notifications at the facility.
Complaint Details
The visit was complaint-related, investigating issues with service charges, complaint response procedures, and fee change notifications. No substantiation status was provided.
Findings
The facility failed to adjust service package points when outside services were paid, potentially causing residents to be overcharged. The administrator did not provide written responses to all complainants, responding verbally instead. Additionally, the facility did not provide written notice five days prior to fee changes related to level of care increases.
Deficiencies (3)
Facility used a point system to determine service package charges but failed to adjust points down when outside services were paid, potentially causing overcharges.
Administrator did not provide written responses to all complainants, responding verbally instead.
Facility did not provide written notice five days prior to fee changes when residents had level of care increases.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Veronica LeMaster | Survey Team Leader | Named as survey team leader for the health care complaint investigation. |
| Tambra Maple | Administrator | Named as administrator responsible for complaint response and fee change issues. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Sep 14, 2016
Visit Reason
A healthcare licensure and follow-up survey was conducted at North Star Retirement Community to assess correction of previously cited deficiencies.
Findings
Deficient practices were found including lack of evidence for state-only background checks for employees, no documented delegation by the facility nurse to medication technicians, and failure of the facility RN to assess residents with changes in condition.
Deficiencies (3)
Two of 7 employees did not have evidence a state only background check was completed.
There was no documented evidence the facility nurse had delegated to 4 of 4 medication technicians.
The facility RN did not document she had assessed residents when they had changes of condition, including wounds, weight loss, post-op wound, edema, swollen knee, and urinary tract infection.
Report Facts
Employees without state only background check: 2
Medication technicians without documented delegation: 4
Residents not assessed by RN: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Henscheid | Health Facility Surveyor, Team Leader | Named as survey team leader and contact for questions |
| Tambra Maple | Administrator | Facility administrator named in report |
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