Deficiencies (last 4 years)
Deficiencies (over 4 years)
19.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
147% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Deficiencies: 10
Date: Jan 23, 2026
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to assist residents in developing advance directives, inaccurate resident assessments, incomplete care plans, inadequate nail care, improper medication management, nutritional deficiencies, expired medications, unsanitary food preparation practices, infection control failures, and incomplete COVID-19 vaccination administration.
Deficiencies (10)
F 0578: The facility failed to help 1 of 7 residents develop an advance directive for health care decisions, risking non-compliance with residents' healthcare wishes.
F 0641: The facility failed to ensure accurate MDS assessments for 2 of 13 residents, leading to potential negative outcomes due to inaccurate monitoring.
F 0656: The facility failed to include toenail care in the comprehensive care plan for 1 of 13 residents, risking inadequate care.
F 0677: The facility failed to provide toenail care for 1 resident dependent on staff, risking social embarrassment due to toenail appearance.
F 0684: The facility failed to clarify the indication for psychotropic medication for 1 resident, risking adverse effects from improper medication use.
F 0692: The facility failed to adequately assess and provide nutritional needs for 1 resident with significant weight loss, including failure to provide non-dairy supplements.
F 0761: The facility failed to ensure medications were not expired and stored properly in temperature-controlled environments, risking decreased medication efficacy.
F 0812: The facility failed to maintain a clean and sanitary food preparation environment, including improper food handling, unclean equipment, and inadequate sanitation practices, risking foodborne illness.
F 0880: The facility failed to maintain infection prevention and control, including inadequate hand hygiene and failure to change and date medical equipment as ordered, increasing infection risk.
F 0887: The facility failed to ensure COVID-19 vaccinations were administered to eligible residents, placing residents at risk of severe illness and death.
Report Facts
Residents reviewed for advance directives: 7
Residents reviewed for MDS assessments: 13
Residents reviewed for care plans: 13
Residents reviewed for medication standards: 13
Residents reviewed for weight loss: 4
Medication carts inspected: 2
Residents affected by food safety deficiencies: 31
Residents reviewed for infection control: 1
Residents reviewed for COVID-19 vaccination: 5
Inspection Report
Routine
Deficiencies: 10
Date: Jan 23, 2026
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to assist residents in developing advance directives, inaccurate resident assessments, incomplete care plans, inadequate nail care, improper medication management, nutritional deficiencies, expired medications, unsanitary food preparation practices, infection control lapses, and failure to ensure COVID-19 vaccinations were administered.
Deficiencies (10)
F 0578: The facility failed to help 1 of 7 residents develop an advance directive for health care decisions, risking non-compliance with residents' healthcare wishes.
F 0641: The facility failed to ensure accurate MDS assessments for 2 of 13 residents, leading to potential negative outcomes due to inaccurate monitoring.
F 0656: The facility failed to include toenail care in the comprehensive care plan for 1 of 13 residents, risking inadequate care.
F 0677: The facility failed to provide toenail care to 1 resident dependent on staff, risking social embarrassment due to poor nail appearance.
F 0684: The facility failed to clarify the indication for psychotropic medication for 1 resident, risking adverse effects due to non-standard clinical practice.
F 0692: The facility failed to adequately assess and provide nutritional needs for 1 resident with significant weight loss, including failure to provide non-dairy supplements.
F 0761: The facility failed to ensure medications were not expired and stored properly in temperature-controlled environments, risking decreased medication efficacy.
F 0812: The facility failed to maintain a clean and sanitary food preparation environment, including improper food handling, unclean equipment, and unsanitary kitchen conditions, risking foodborne illness.
F 0880: The facility failed to maintain infection prevention practices, including lack of hand hygiene and improper glove use during medication administration, and failure to change Resident #49's graduated cylinder and syringe as ordered.
F 0887: The facility failed to ensure COVID-19 vaccinations were administered to eligible residents, including 1 of 5 residents reviewed, placing residents at risk of severe illness.
Report Facts
Residents reviewed for advance directives: 7
Residents reviewed for MDS assessments: 13
Residents reviewed for care plan: 13
Residents reviewed for nail care: 1
Residents reviewed for standards of practice: 13
Residents reviewed for weight loss: 4
Expired medication counts: 14
Residents affected by food safety issues: 31
Residents affected by infection control issues: 1
Residents reviewed for COVID-19 vaccination: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed no documentation of advance directive assistance for Resident #18. | |
| MDS Coordinator #2 | Acknowledged errors in MDS assessments for Residents #3 and #6. | |
| ADON | Assistant Director of Nursing | Acknowledged lack of toenail care and podiatrist referral for Resident #32. |
| DON | Director of Nursing | Reviewed medication and infection control issues, confirmed expired medications and infection control lapses. |
| RN #1 | Registered Nurse | Observed with expired medications and improper medication handling. |
| LPN #1 | Licensed Practical Nurse | Observed failing to perform hand hygiene and improper medication administration. |
| Dietary Manager (DM) | Acknowledged food safety and nutritional deficiencies. | |
| Dietary Aide #1 | Observed food safety violations including no hair net and improper glove use. | |
| Dietary Aide #2 | Observed improper sanitation bucket concentration. | |
| Regional Resource Nurse | Reviewed Resident #32's COVID-19 vaccination record. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 29, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to administer physician-ordered medications as prescribed to residents.
Complaint Details
The complaint investigation found substantiated failure to administer medications as prescribed to two residents, with missed doses due to medication unavailability.
Findings
The facility failed to ensure that physician-ordered medications were administered as prescribed for 2 of 3 residents reviewed, resulting in missed doses of essential medications and potential adverse outcomes.
Deficiencies (1)
F 0684: The facility failed to administer prescribed medications to Resident #1 and Resident #2 as ordered, resulting in missed doses documented as code 9 indicating medication was not available.
Report Facts
Missed medication administrations: 8
Missed medication administrations: 8
Missed medication administrations: 3
Missed medication administrations: 2
Missed medication administrations: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed medications were not administered due to unavailability |
Inspection Report
Routine
Deficiencies: 12
Date: Jan 10, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, staffing, infection control, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' dignity during dining, inadequate notification for resident transfers and bed holds, inaccurate resident assessments, medication administration errors, insufficient staffing, unsafe food storage and sanitation practices, and lapses in infection control procedures. Some deficiencies posed minimal harm while others involved actual harm to residents.
Deficiencies (12)
F 0550: The facility failed to maintain residents' dignity during dining by serving meals at different times to residents seated at the same table, delaying meal delivery up to 38 minutes.
F 0623: The facility failed to provide timely notification to the resident, representative, and ombudsman before transfer or discharge for 1 of 2 residents reviewed.
F 0625: The facility failed to notify residents or their representatives in writing about bed hold policies upon hospital transfer for 2 of 2 residents reviewed.
F 0641: The facility failed to ensure accurate Minimum Data Set assessments for 1 of 12 residents reviewed, resulting in inconsistent documentation of PASARR level II status.
F 0658: The facility failed to administer medications according to professional standards for 1 of 5 residents observed, including failure to prime an insulin pen before injection.
F 0689: The facility failed to provide adequate supervision and functioning devices to prevent falls, resulting in actual harm to 1 of 3 residents reviewed who sustained a head laceration from a wheelchair fall.
F 0725: The facility failed to provide sufficient nursing staff to meet residents' needs, causing delays in care and increased risk of harm for 3 of 41 residents reviewed.
F 0756: The facility failed to ensure pharmacist recommendations were followed for 1 of 5 residents reviewed, resulting in potential unnecessary medication use.
F 0760: The facility failed to ensure residents were free from significant medication errors, with documented errors for 3 residents including wrong dosing and missed medications.
F 0812: The facility failed to maintain kitchen equipment and environment in a clean, sanitary manner and failed to store food safely, including expired spices, undated opened food, and inadequate cleaning of refrigeration units.
F 0880: The facility failed to maintain infection control precautions by not wearing protective gowns when administering medications to a resident on enhanced barrier precautions.
F 0883: The facility failed to administer influenza vaccine to a resident who consented, creating potential risk for influenza transmission and complications.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Failed to prime insulin pen before administration to Resident #17 |
| CNA #1 | Certified Nursing Assistant | Unable to leave dining room to get meal tray for Resident #94 |
| CNA #2 | Certified Nursing Assistant | Explained meal tray delay for Resident #30 due to dining room change |
| Dietary Director | Responsible for food safety and kitchen sanitation; acknowledged food labeling and cleaning deficiencies | |
| DON | Director of Nursing | Provided statements on staffing, medication errors, infection control, and vaccination issues |
| Administrator | Provided statements on staffing, fall incident, and kitchen maintenance |
Inspection Report
Routine
Deficiencies: 13
Date: Jan 10, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, informed consent for medications, notification of transfers and bed hold notices, accuracy of resident assessments, medication administration errors, fall prevention, staffing adequacy, pharmacist recommendation follow-up, medication error prevention, food safety and sanitation, infection control, and immunization administration.
Deficiencies (13)
F 0550: The facility failed to maintain residents' dignity during dining when residents at the same table were served meals at different times, delaying meal service up to 38 minutes for some residents.
F 0552: The facility failed to obtain informed consent prior to initiating medications for 1 of 5 residents reviewed, placing residents at risk of receiving medications without knowledge of risks and benefits.
F 0623: The facility failed to provide timely notification to the resident representative and ombudsman before transfer or discharge for 1 of 2 residents reviewed, potentially affecting residents' rights.
F 0625: The facility failed to provide bed hold notices to residents or their representatives upon hospital transfer for 2 of 2 residents reviewed, risking residents' rights to return to their beds.
F 0641: The facility failed to ensure accurate Minimum Data Set assessments for 1 of 12 residents reviewed, resulting in inaccurate documentation of PASARR level II status.
F 0658: The facility failed to administer medications according to professional standards for 1 of 5 residents observed, including failure to prime an insulin pen before injection.
F 0689: The facility failed to provide adequate supervision and functioning devices to prevent a resident's fall, resulting in a head laceration requiring hospital treatment.
F 0725: The facility failed to provide sufficient nursing staff to meet residents' needs, resulting in delayed responses to call lights and increased risk of falls for multiple residents.
F 0756: The facility failed to ensure pharmacist recommendations were followed or addressed by the attending physician for 1 of 5 residents, risking unnecessary medication use.
F 0760: The facility failed to ensure residents were free from significant medication errors, with multiple incidents involving three residents and resulting in staff termination and corrective actions.
F 0812: The facility failed to maintain kitchen equipment and environment in a clean, sanitary manner and failed to store food safely, including expired spices, undated opened food, and inadequate cleaning of refrigeration units.
F 0880: The facility failed to maintain infection control precautions by not wearing protective gowns when administering medications to a resident with an enteral feeding tube requiring enhanced barrier precautions.
F 0883: The facility failed to administer influenza vaccine to a resident who consented to receive it, creating potential harm from influenza infection.
Report Facts
Residents reviewed for staffing concerns: 41
Residents reviewed for medication administration: 5
Residents reviewed for medication errors: 3
Residents affected by dignity deficiency: 3
Residents affected by informed consent deficiency: 1
Residents affected by transfer notification deficiency: 1
Residents affected by bed hold notice deficiency: 2
Residents affected by inaccurate assessment: 1
Residents affected by fall: 1
Residents affected by infection control deficiency: 1
Residents affected by immunization deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed medication administration without priming insulin pen |
| RN #1 | Registered Nurse | Observed administering medication without protective gown |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding delayed meal tray for Resident #94 |
| CNA #2 | Certified Nursing Assistant | Explained late meal tray for Resident #30 |
| Dietary Director | Interviewed regarding food storage and kitchen sanitation deficiencies | |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including staffing, medication errors, and immunizations |
| Administrator | Interviewed regarding transfer notifications, bed hold notices, and kitchen maintenance | |
| Clinical Resource Nurse | Interviewed regarding medication consent and staffing |
Inspection Report
Follow-Up
Deficiencies: 6
Date: 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)
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
Routine
Deficiencies: 10
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, nutrition, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to provide adequate transfer documentation, incomplete and non-person-centered care plans, inadequate supervision to prevent falls, insufficient pain management monitoring, medication errors, failure to honor resident food preferences, improper food handling and storage, inadequate waste containment, and lapses in infection control practices.
Deficiencies (10)
F 0622: The facility failed to provide all pertinent information to the receiving facility when a resident was transferred, risking adverse outcomes due to lack of information.
F 0656: The facility failed to develop and implement comprehensive, person-centered care plans for residents, lacking specific interventions and clear documentation.
F 0657: The facility failed to review and revise a resident's care plan after an unwitnessed fall, missing updated fall risk interventions.
F 0689: The facility failed to provide adequate supervision to prevent falls, resulting in harm when a resident was left unsupervised and fell in his room.
F 0697: The facility failed to monitor residents appropriately and offer non-pharmacological interventions while administering opioid pain medications to multiple residents.
F 0760: The facility failed to ensure a resident received ordered medication due to medication not being available despite being signed out.
F 0806: The facility failed to ensure residents' food preferences were honored, resulting in residents receiving unwanted foods and lack of documentation of preferences.
F 0812: The facility failed to ensure food items were dated and labeled properly and failed to follow hygiene practices, risking foodborne illness.
F 0814: The facility failed to ensure waste was properly contained with lids on dumpsters, risking pest infestation.
F 0880: The facility failed to maintain infection control practices by not performing hand hygiene and changing gloves during wound care, risking cross-contamination.
Report Facts
Medication administrations without non-pharmacological interventions: 51
Medication administrations without non-pharmacological interventions: 2
Medication administrations without non-pharmacological interventions: 5
Pain monitoring opportunities: 60
Skin tear size: 1
Skin tear size: 5
Skin tear size: 2
Skin tear size: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed failing to change gloves during wound care for Resident #14 |
| LPN #2 | Licensed Practical Nurse | Observed failing to change gloves during wound care for Resident #10 |
| LPN #3 | Licensed Practical Nurse | Could not recall medication administration issue with ABHR cream for Resident #32 |
| DON | Director of Nursing | Provided statements regarding transfer documentation, fall supervision, pain management, and medication errors |
| Social Services Director | Provided statements regarding deficiencies in care plans for Residents #23 and #33 | |
| Registered Dietician | RD | Provided statements regarding food preferences and tray card documentation |
| Chef | Confirmed food items were not dated and dumpster lid was open | |
| Dietary Aide #1 | Observed not wearing beard restraint and unsure of policy | |
| Dietary Aide #2 | Observed handling bread with bare hands without hand hygiene | |
| Regional Nurse | Confirmed lack of non-pharmacological pain interventions |
Inspection Report
Routine
Deficiencies: 10
Date: Feb 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements for nursing home care, including resident transfer procedures, care planning, fall prevention, pain management, medication administration, dietary services, food safety, waste disposal, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide adequate transfer documentation, incomplete and non-person-centered care plans, inadequate fall supervision, insufficient pain management monitoring, medication errors, failure to honor resident food preferences, improper food handling and storage, uncovered waste dumpsters, and lapses in infection control practices.
Deficiencies (10)
F 0622: The facility failed to ensure all pertinent information was provided to the receiving facility when a resident was transferred, risking adverse outcomes due to lack of information.
F 0656: The facility failed to develop and implement comprehensive, person-centered care plans for residents, lacking specific interventions and clear documentation.
F 0657: The facility failed to review and revise a resident's care plan after an unwitnessed fall, missing updated fall risk interventions.
F 0689: The facility failed to provide adequate supervision to prevent falls, resulting in harm when a resident was left unsupervised and fell in his room.
F 0697: The facility failed to ensure residents receiving opioid pain medications were appropriately monitored and offered non-pharmacological interventions, risking adverse reactions and unmanaged pain.
F 0760: The facility failed to ensure a resident received ordered medication due to medication not being available despite being signed out.
F 0806: The facility failed to honor food preferences for two residents, risking hunger or weight loss due to meals not provided according to needs or preferences.
F 0812: The facility failed to ensure food items were dated and labeled properly and failed to follow hygiene practices, risking foodborne illness for all residents.
F 0814: The facility failed to ensure waste was properly contained with lids on dumpsters, risking insect and pest infestation.
F 0880: The facility failed to maintain infection control practices when staff did not change gloves between wound care tasks, risking cross-contamination and infection.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 32
Food items not dated: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed not changing gloves between wound care tasks for Resident #14 |
| LPN #2 | Licensed Practical Nurse | Observed not changing gloves between wound care tasks for Resident #10 |
| LPN #3 | Licensed Practical Nurse | Could not recall medication administration issue for Resident #32 |
| DON | Director of Nursing | Provided statements regarding multiple deficiencies including transfer documentation, fall supervision, pain management, and medication errors |
| Social Services Director | Interviewed regarding care plan deficiencies for Residents #23 and #33 | |
| Registered Dietician | RD | Interviewed regarding food preference documentation and tray card updates |
| Chef | Interviewed regarding food labeling and dumpster lid issues | |
| Dietary Aide #1 | Observed not wearing beard restraint and uncertain about policy | |
| Dietary Aide #2 | Observed handling bread with bare hands without hand hygiene | |
| Regional Nurse | Confirmed lack of non-pharmacological pain interventions |
Inspection Report
Life Safety
Deficiencies: 4
Date: 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)
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
Date: 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)
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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