Inspection Reports for Quail Ridge
797 Hospital Way, Pocatello, ID 83201, United States, ID, 83201
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Unclassified
Inspection Report
Follow-Up
Deficiencies: 12
Aug 21, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
The facility was found to have multiple deficiencies including incomplete criminal background checks for employees, medication order discrepancies, failure to conduct change of condition assessments, improper medication refrigerator temperatures, medication distribution issues, incomplete medication destruction documentation, inadequate behavior documentation and plans, and lack of interventions to prevent resident falls.
Deficiencies (12)
| Description |
|---|
| One of eleven employees did not have a Department Criminal History and Background Check. |
| Two of five staff members lacked documentation of an Idaho State Police background check within 30 days of previous results. |
| Medication orders were inconsistent between medication bubble packs and medication administration records for two unsampled residents. |
| Facility nurse did not conduct change of condition assessments for residents after hospitalization or episodes of diarrhea. |
| Medication refrigerator temperatures were out of range (30-37°F) for 16 days in August 2025 with no corrective actions taken. |
| Medication technicians did not contact nurses prior to administering PRN medications to cognitively impaired residents. |
| Not all ordered PRN medications were available on the medication cart for residents. |
| Medication destruction log did not document all drug disposals consistently including resident names and methods of destruction. |
| Facility did not evaluate residents when they exhibited maladaptive behaviors; evaluations were incomplete and inaccurate. |
| Facility did not develop behavior plans with specific interventions for residents exhibiting maladaptive behaviors. |
| Facility did not document effectiveness of interventions after residents engaged in maladaptive behaviors. |
| Facility did not develop interventions to prevent recurrences after residents' falls; no new interventions found for multiple residents. |
Report Facts
Days medication refrigerator out of range: 16
Number of employees reviewed lacking background check: 1
Number of staff lacking Idaho State Police background check documentation: 2
Number of PRN medications missing: 3
Number of residents with unassessed condition changes: 3
Number of residents with falls lacking interventions: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ann Kolsen | Administrator | Interviewed regarding background checks and facility compliance |
| Bradley Perry | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Life Safety
Deficiencies: 5
Sep 25, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Quail Ridge Assisted Living.
Findings
The facility failed to maintain required fire suppression system inspections, had ventilation system deficiencies, prohibited use of relocatable power taps for medical devices and appliances, and improperly stored oxygen cylinders.
Deficiencies (5)
| Description |
|---|
| Facility failed to maintain fire suppression visual inspection of pressure gauges on wet system as required. |
| Facility failed to maintain UL 300 hood ventilation systems; kitchen hood ventilation system filters had gaps of 1 inch or greater. |
| Oxygen concentrators in Rooms #802 and #709 were powered using prohibited relocatable power taps (RPT). |
| A coffeemaker in Room #602 was powered using a prohibited relocatable power tap (RPT). |
| Four 'A' oxygen cylinders in Room #709 were not secured with chain, rack, or cart; one placed on floor and others within seat cushion. |
Report Facts
Oxygen cylinders: 4
Inspection date: Sep 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeremy Wilson | Survey Team Leader | Named as survey team leader for the inspection. |
| Ann Kolsen | Administrator | Named as facility administrator. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Feb 9, 2024
Visit Reason
The inspection was conducted as a health care complaint investigation to address multiple complaints regarding the facility's handling of resident behaviors and complaint responses.
Findings
The facility failed to provide written responses to complainants within 30 days, did not attempt non-drug interventions before prescribing psychotropic medications for Resident #6, and did not evaluate or develop behavior plans for residents exhibiting maladaptive behaviors, including Residents #5, #6, and #7.
Complaint Details
The investigation was triggered by complaints documented from May 2023 to December 2023, including six complaints made to the administrator with no written responses provided. The complaint involved concerns about the management of residents' maladaptive behaviors and medication use.
Deficiencies (4)
| Description |
|---|
| The facility did not provide a written response to complainants within 30 days. |
| The facility did not attempt non-drug interventions prior to requesting medications for Resident #6's behaviors. |
| The facility did not evaluate residents when they exhibited maladaptive behaviors, including Resident #5 calling for assistance excessively and Residents #6 and #7 exhibiting aggressive and disruptive behaviors. |
| The facility did not develop a behavior plan that included specific interventions for Residents #5, #6, and #7's behaviors. |
Report Facts
Complaints documented: 6
Resident #5 call for assistance: 1594
Resident #5 calls in one day: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ann Kolsen | Administrator | Named in relation to failure to provide written complaint responses and documentation regarding resident behaviors. |
| Bradley Perry | Survey Team Leader | Led the health care complaint investigation. |
Inspection Report
Follow-Up
Deficiencies: 9
Nov 30, 2022
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 deficient in multiple areas including incomplete abuse/neglect/exploitation policies, failure to conduct timely investigations and develop corrective actions for incidents, inadequate resident health assessments, lack of self-administration medication assessments, failure to evaluate and document maladaptive behaviors, incomplete negotiated service agreements, absence of behavior plans, and missing as-worked staff schedules.
Deficiencies (9)
| Description |
|---|
| The facility's abuse/neglect/exploitation policy did not include all required elements such as adult protection phone number and steps to protect residents. |
| Administrator did not conduct investigations within 30 days for incidents involving Resident #3 and Resident #10. |
| Administrator did not develop interventions to prevent recurrence of incidents for Resident #3 and Resident #10. |
| Facility RN did not conduct physical assessments when residents experienced changes in condition, including Resident #1, #7, and #8. |
| Facility nurse did not assess Resident #8's ability to self-administer medications every 90 days. |
| Facility did not evaluate maladaptive behaviors for Resident #3 and Resident #6. |
| Negotiated Service Agreements for Residents #1, #3, #6, #7, and #9 did not clearly reflect specific needs or services. |
| Facility did not develop behavior plans with interventions for Residents #3 and #6. |
| Facility's as-worked schedules did not document exact times staff were at the facility; administrator, LPN, and RN lacked documented schedules. |
Report Facts
Falls: 4
Dates of incidents: Resident #3 attempted to remove Resident #1's shirt on 10/31/22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ann Kolsen | Administrator | Named in relation to failure to conduct investigations and develop corrective actions |
| Veronica LeMaster | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Life Safety
Deficiencies: 5
Jul 25, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for Quail Ridge Assisted Living.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code, including missing documentation for quarterly waterflow alarm testing, monthly visual inspections of wet suppression system gauges, weekly emergency generator inspections, and inspections of fire and smoke dampers and fuel-fired heating systems.
Deficiencies (5)
| Description |
|---|
| Facility could not produce documentation for quarterly waterflow alarm testing for fourth quarter 2021. |
| Facility could not produce documentation to show monthly visual inspections of wet suppression system gauges and secured control valves were completed. |
| Facility could not produce documentation for weekly emergency generator inspections for all of 2021 and the 2nd & 3rd week of July 2022. |
| Facility was not able to produce documentation to show fire and smoke dampers had been inspected in the past four years. |
| Fuel-fired heating devices and systems were not inspected, serviced, and cleaned at least annually; last known inspection was 5/28/21. |
Report Facts
Facility License Number: RC-502
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ann Kolsen | Administrator | Named as facility administrator |
| Linda Chaney | Survey Team Leader | Named as survey team leader |
Inspection Report
Life Safety
Deficiencies: 8
May 12, 2021
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with life safety codes and related regulations.
Findings
The facility was found non-compliant with several fire and life safety standards including outdated relocation agreements, physical deficiencies such as holes in walls, non-factory painted sprinkler heads, lack of documentation for testing alcohol-based hand rub dispensers, missing staff training records on oxygen use, absence of recent inspections for gas fireplaces and furnaces, prohibited electrical installations, and missing documentation for emergency generator battery testing.
Deficiencies (8)
| Description |
|---|
| Relocation agreements were not updated annually as required. |
| Facility did not maintain compliance with NFPA 101 Life Safety Code including physical damages and non-compliant sprinkler heads. |
| No documentation for testing/inspection of Alcohol Based Hand Rub dispensers upon refill. |
| No documentation showing staff training on oxygen use and handling at hire and annually. |
| No documentation of inspection for gas fireplaces and gas-powered furnaces within the past 12 months; last known inspection was in 2018. |
| Use of prohibited extension cords and multi-plug adapters in various facility locations. |
| Prohibited use of Relocatable Power Taps including daisy chaining and multiple appliances plugged into one RPT. |
| No documentation for monthly conductivity test of emergency generator batteries as required by NFPA Standard 110. |
Report Facts
Number of relocation agreements: 2
Number of gas fireplaces and furnaces: 2
Number of non-factory painted sprinkler heads: 2
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