Inspection Reports for Rosetta Assisted Living – Pocatello
1590 Delphic Way, Pocatello, ID 83201, United States, ID, 83201
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 27, 2025, identified deficiencies related to medication reviews for residents on long-term psychotropic medications and violations of Idaho Food Code standards involving a facility dog in food areas and unrestrained hair during meal service. Earlier inspections showed a pattern of medication management issues, fire and life safety code violations, and sanitation concerns, including improper use of relocatable power taps, oxygen cylinder storage, and fire alarm testing. Complaint investigations substantiated medication errors, improper disposal, and controlled substance management problems, while other inspections noted deficiencies in fire safety equipment maintenance and facility conditions such as water damage and lighting. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history reflects ongoing challenges primarily with medication oversight and fire safety compliance, with no clear trend of improvement or worsening over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% better than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 27, 2025
Visit Reason
The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation.
Complaint Details
The visit included a complaint investigation component as indicated by the survey type.
Findings
Two residents on long-term psychotropic medications lacked required six-month medication reviews, and the facility failed to meet Idaho Food Code standards, including the presence of a facility dog in food preparation and dining areas and staff not restraining hair during food service.
Deficiencies (2)
Two residents on psychotropic medications for longer than six months did not have six-month medication reviews completed, and one resident lacked a behavioral update in the review.
Facility did not meet Idaho Food Code standards; a facility dog was observed in the kitchen and dining areas during food preparation and service, and staff did not have hair restrained during meal preparation and service.
Report Facts
Dates of food code violations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Douponce | Administrator | Facility administrator acknowledged awareness of psychotropic medication review issues. |
| Torrey Bollinger | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 9, 2024
Visit Reason
The inspection was conducted as a health care complaint investigation to assess medication administration, disposal, and controlled substance management at the facility.
Complaint Details
The investigation was triggered by complaints regarding medication errors, improper disposal of medications, and failure to maintain controlled substance counts. The findings substantiate these issues.
Findings
The facility failed to properly review and implement medication orders, leading to incorrect dosages and missed medications. There was an accumulation of unused, discontinued, or expired medications without proper documentation of disposal, and controlled substances were not counted daily as required, with medications stored improperly and not accounted for.
Deficiencies (3)
The facility nurse did not review and implement all orders for Residents #1, #2, and #3, resulting in incorrect transcription and misadministration of medications.
The facility had an accumulation of unused, discontinued, or expired medications for more than 30 days without proper documentation of disposal.
The facility did not maintain a daily count of controlled substances for Residents #1, #2, #3, and others, and medications were stored improperly without accountability.
Report Facts
Medication destruction log pages: 3.5
Medication destruction log pages: 8
Missed daily controlled substance counts: 6
Missed daily controlled substance counts: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Ness | Administrator | Named as responsible for implementing medication orders and involved in medication disposal and narcotic storage |
| Jenny Walker | Survey Team Leader | Led the health care complaint investigation |
Inspection Report
Life Safety
Deficiencies: 4
Date: Sep 24, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at the facility.
Findings
The facility was found to have multiple fire and life safety deficiencies including prohibited use of relocatable power tabs to supply power to medical devices and appliances, improper storage of oxygen cylinders directly on the floor, and failure to maintain required monthly visual inspections of fire suppression system pressure gauges.
Deficiencies (4)
Use of a relocatable power tab (RPT) to supply power to an oxygen concentrator is prohibited.
Use of a relocatable power tab (RPT) to supply power to a miniature refrigerator is prohibited.
Three 'E'-size oxygen cylinders were placed directly on the floor instead of being stored in appropriate racks, carts, or stands.
Facility failed to provide documentation of monthly visual inspection of fire suppression system wet gauge pressure.
Report Facts
Oxygen cylinders: 3
Inspection Report
Life Safety
Deficiencies: 3
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at the Rosetta of Pocatello facility.
Findings
The inspection identified deficiencies related to fire alarm system testing and improper use of relocatable power taps, including daisy-chaining and powering appliances with RPTs in multiple rooms.
Deficiencies (3)
Fire alarm report does not provide all testing information for all devices (did not demonstrate testing of door releases). Did not document according to the reporting per Section 7.8.2.
Relocatable power taps (RPTs) shall not be used connected in series (daisy-chained). Room 9 is using a RPT to supply power to another RPT (daisy-chained) to supply power to personal devices.
Relocatable power taps (RPTs) shall not be used to provide power to appliances: Room 5 is using a RPT to supply power to a microwave, toaster and refrigerator. Room 10 using a RPT to supply power to a refrigerator.
Inspection Report
Life Safety
Deficiencies: 1
Date: Jun 9, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for the facility.
Findings
The facility was found to have a non-core issue where the laundry room door does not self-close as designed and sticks on the flooring when opened, which is a violation of fire and life safety standards.
Deficiencies (1)
Facility laundry room door does not self-close as designed, sticks on the flooring when opened.
Inspection Report
Life Safety
Deficiencies: 6
Date: Feb 3, 2021
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with applicable life safety codes and sanitation standards.
Findings
The facility was found to have multiple deficiencies including only one relocation agreement instead of the required two, lack of annual review of the relocation agreement, failure to maintain compliance with NFPA 101 Life Safety Code standards including issues with smoke detector sensitivity testing and staff training on oxygen use, water damage and mold in the mechanical room floor, hot water temperature at 128 degrees, a resident room door that would not latch, and inadequate lighting in the laundry room.
Deficiencies (6)
Facility had only one relocation agreement instead of the required two, and the agreement had not been updated annually since 1/12/2017.
Facility smoke detectors failed sensitivity testing and lacked documentation of required follow-up testing; staff training on oxygen use and handling was not documented.
Floor in mechanical/electrical room was badly damaged by water with warped subfloor and apparent mold growth.
Hot water temperature in the facility was 128 degrees.
Door to resident room #2 would not latch.
Laundry room was not well lit; one light fixture was not working.
Report Facts
Hot water temperature: 128
Number of relocation agreements: 1
Date of last relocation agreement update: Jan 12, 2017
Date of smoke detector sensitivity test: Jul 29, 2019
Date of smoke detector replacement: Aug 23, 2019
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