Inspection Reports for Sage Grove Assisted Living
290 North 4064 East, Rigby, ID, 83442
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 26, 2024, identified multiple deficiencies related to staff training, medication management, resident safety, and documentation practices. Earlier inspections from July 20, 2022, also noted deficiencies primarily involving fire safety system maintenance, documentation, and emergency preparedness. The main issues across reports included inadequate staff training and supervision, unsecured hazardous materials accessible to residents, incomplete medication administration and reviews, and lapses in fire safety compliance. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports, and no complaint investigations were noted. The pattern of findings suggests ongoing challenges in maintaining regulatory standards, with no clear indication of improvement over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Follow-Up
Deficiencies: 16
Date: Jul 26, 2024
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to assess compliance with facility policies, staff training, medication management, resident safety, and documentation practices.
Findings
The facility failed to ensure adequate staff training, secure environment for residents with cognitive impairments, proper medication availability and administration, consistent resident health assessments, and accurate documentation. Multiple deficiencies were noted including unsecured toxic chemicals, missing psychotropic medication reviews, incomplete behavior evaluations, and lack of delegation for medication passing staff.
Deficiencies (16)
Staff were insufficiently trained on facility policies, documentation, responding to resident behaviors, and use of medical equipment.
Administrator failed to ensure facility policies included proper reporting of abuse, neglect, and exploitation.
Facility did not provide a secure environment for residents at risk of elopement in both buildings.
Facility was not maintained in a clean, safe, and orderly manner with broken gates, chipped concrete, missing furnace cover, and soiled areas.
Toxic chemicals were stored unsecured and accessible to cognitively impaired residents on multiple occasions.
Ordered medications were not consistently available for residents, including multiple missed doses and unavailable medicated shampoo.
Facility nurse did not consistently assess residents for changes in physical or psychological conditions.
Medication refrigerator temperatures were not monitored or maintained within required ranges.
Residents did not have all ordered as-needed (PRN) medications available.
Six-month psychotropic medication reviews were not performed for residents requiring them.
Physical assessments were not performed by the facility nurse prior to admission for several residents.
Text messages and communications between staff and nurse were not consistently documented in resident records.
Facility did not evaluate Resident #1's behavior when physically aggressive and Resident #2's behaviors including outbursts and elopement attempts.
Behavior plans with interventions were not developed for Residents #1 and #2 for new maladaptive behaviors.
As-worked schedules did not document dates and times facility administrator and nurses were present, nor positions of all staff.
Staff member passing medications was not delegated by the facility nurse and worked alone on night shifts.
Report Facts
Missed vitamin B12 doses: 28
Missed antipsychotic doses: 5
Missed medication doses: 21
Medication refrigerator out-of-range occurrences: 15
Medication refrigerator out-of-range occurrences: 17
Medication refrigerator out-of-range occurrences: 12
Medication refrigerator out-of-range occurrences: 5
Medication refrigerator out-of-range occurrences: 14
Medication refrigerator out-of-range occurrences: 16
Medication refrigerator unmonitored days: 2
Medication refrigerator unmonitored days: 7
Night shifts worked alone: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rackham | Administrator | Named as facility administrator acknowledging training and security deficiencies |
| Teresa McClenathan | Survey Team Leader | Named as survey team leader for the inspection |
Inspection Report
Life Safety
Deficiencies: 5
Date: Jul 20, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey of Sage Grove Assisted Living facility.
Findings
The inspection identified multiple deficiencies including outdated relocation agreements, lack of documented five-year calibration and piping inspection of the fire suppression system, missing testing documentation for alcohol-based hand rub dispensers, absence of sensitivity testing for fire alarm systems, and no documented fire drills since 2020.
Deficiencies (5)
Documented relocation agreement is dated 2018; facility must have at least two relocation agreements with separate locations reviewed annually.
Old building fire suppression system gauges dated 2017 and 2018 with no documented five-year calibration or piping inspection per NFPA 25.
No documented testing for automatic alcohol-based hand rub dispensers each time a refill is replaced per NFPA 101.
No documented sensitivity testing for new and old building fire alarm systems within five years as required by NFPA 72.
No documented fire drills since 2020; facility must conduct at least six drills per year including two on night shift per NFPA 101.
Report Facts
Response Due Date: Aug 19, 2022
Survey Date: Jul 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rackham | Administrator | Named as facility administrator |
| Sam Burbank | Survey Team Leader | Named as survey team leader for the inspection |
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