Inspection Report Summary
The most recent inspection on July 3, 2024, found multiple deficiencies related to employee background checks, abuse and neglect policies, water temperature, housekeeping, and resident assessments. Earlier inspections from 2022 also cited deficiencies, primarily involving fire life safety documentation, emergency lighting, oxygen signage, heating system inspections, chemical storage, and dietary compliance. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. There were no complaint investigations noted in any of the reports. The pattern of deficiencies suggests ongoing challenges in compliance with both safety and administrative requirements over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% better than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Follow-Up
Deficiencies: 6
Jul 3, 2024
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to verify compliance with regulatory requirements and to address previously identified issues.
Findings
The facility was found to have multiple deficiencies including incomplete criminal background checks for employees, inadequate abuse/neglect/exploitation policies, inconsistent water temperature maintenance, poor housekeeping and maintenance conditions, and failure to complete a comprehensive assessment for a resident prior to admission.
Deficiencies (6)
| Description |
|---|
| One of four employees did not have a Department Criminal History and Background Check completed. |
| One employee did not have an Idaho State Police background check completed prior to working alone with residents. |
| The facility's abuse/neglect/exploitation policy lacked required definitions, reporting procedures, education protocols, investigation steps, and documentation processes. |
| Water temperatures in several resident rooms were observed to be between 131 and 137 degrees Fahrenheit, exceeding the required range of 105 to 120 degrees Fahrenheit. |
| The facility was not maintained in a clean, safe, and orderly manner, including cracked tile, chipped countertops, separating baseboards, strong urine odor, and damaged exit doors. |
| Resident #2 did not have a comprehensive assessment, including a nursing assessment, completed prior to admission on 3/2/23. |
Report Facts
Facility License Number: RC-1260
Water temperature range: 131
Water temperature range: 137
Resident admission date: Resident #2 admitted on 3/2/23 without comprehensive assessment
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Ellis | Administrator | Confirmed missing background checks and incomplete assessments |
| Teresa McClenathan | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Life Safety
Deficiencies: 4
Nov 8, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for the facility Sunny Ridge.
Findings
The inspection identified deficiencies including lack of documented weekly or monthly inspections for dry and wet system gauges and control valves, absence of documented emergency light testing, missing oxygen use signage in rooms 101 and 110, and no documented annual inspection for fuel-fired heating.
Deficiencies (4)
| Description |
|---|
| No documented weekly or monthly inspections for dry system and wet system gauges and control valves in accordance with NFPA 25. |
| No documented emergency light testing for 30 seconds monthly and 90 minutes annually in accordance with NFPA 101, Chapter 7, Section 7.9. |
| Signs for oxygen use shall be in accordance with NFPA 99, Chapter 11, Section 11.5.2.3: Rooms 101 and 110 are using oxygen and no signs are placed at rooms or entrances. |
| No documented annual for fuel-fired heating inspection. |
Inspection Report
Original Licensing
Deficiencies: 2
Oct 7, 2022
Visit Reason
The inspection was conducted as an initial licensure survey for the healthcare facility Sunny Ridge.
Findings
The inspection identified non-core issues including unsafe storage of toxic chemicals accessible to cognitively impaired residents and failure to provide residents with physician-ordered diets during lunch observations.
Deficiencies (2)
| Description |
|---|
| Toxic chemicals were stored in an unlocked area accessible to cognitively impaired residents on multiple occasions. |
| Residents were not provided their physician ordered diets during lunch observations on specified dates. |
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