Inspection Reports for Swan Falls Assisted Living
194 W White Way, Kuna, ID 83634, United States, ID, 83634
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 19, 2024, found multiple deficiencies, including continued issues from prior surveys and a failed kitchen inspection requiring a mandatory re-inspection. Earlier inspections also identified numerous deficiencies related to nursing assessments, medication management, documentation, staff training, and service agreements. Inspectors noted problems with provider responsibilities, facility maintenance, resident care planning, and staff certification, and the facility lacked a Certified Food Protection Manager at the time of the latest survey. Complaint investigations were part of the inspections, but no specific substantiation status was provided in the most recent report, and enforcement actions such as fines or license suspensions were not listed in the available reports. The pattern of deficiencies suggests ongoing challenges without clear improvement over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
16.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
109% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Follow-Up
Deficiencies: 17
Jul 19, 2024
Visit Reason
The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation to assess compliance with state regulations and to verify correction of previous deficiencies.
Findings
The facility remained out of compliance on multiple non-core deficiencies from a previous survey, including issues with provider responsibilities, admission agreements, housekeeping, nursing assessments, medication orders, resident health status assessments, service agreements, behavior documentation, food and nutritional care services, and staff training. The kitchen inspection failed and requires a mandatory re-inspection within 10 days.
Complaint Details
The visit included a complaint investigation component as indicated by the survey type, but no specific substantiation status was provided.
Deficiencies (17)
| Description |
|---|
| Licensee did not provide necessary resources to ensure compliance with rules and statutes, leading to repeated deficiencies and failed kitchen inspection. |
| Admission agreements for memory care residents lacked complete breakdown of charges and charged full amount when residents were out of the facility. |
| Facility was not maintained in a clean, safe, and orderly manner with issues in courtyards, lighting, furniture, siding, plaster, and fencing. |
| Facility nurse did not complete initial nursing assessments for all residents after admission. |
| Residents' current diet orders were not followed as ordered; staff unaware of diet orders. |
| Residents were not assessed by the nurse after changes in physical, mental, or psychological condition. |
| Resident assessments for demographics, personal assistance, and outside services were incomplete prior to admission. |
| Five of eleven residents did not have completed interim care plans upon admission. |
| Negotiated Service Agreements (NSAs) were not implemented, including failure to assist Resident #7 with eating. |
| NSAs were not signed and dated by residents or legal representatives within 14 days of completion. |
| NSAs were not updated to reflect significant changes in residents' care needs or health status. |
| Five of eleven residents' records lacked documentation of assessments after changes in condition. |
| Facility did not evaluate residents' history of aggressiveness and refusing care. |
| Facility did not develop interventions for residents after maladaptive behaviors. |
| Facility's as-worked schedule did not include last names and positions of care staff. |
| Facility failed kitchen inspection and did not have a Certified Food Protection Manager at time of survey. |
| Two medication technicians lacked approved medication assistance course certification. |
Report Facts
Non-core deficiencies from previous survey: 6
Residents without admission agreements: 4
Residents with diet order issues: 2
Resident falls: 4
Residents without completed interim care plans: 5
Residents with unsigned NSAs: 4
Medication technicians without approved training: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Paris | Administrator | Named in relation to lack of knowledge and awareness of deficiencies and resident care issues. |
| Torrey Bollinger | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey. |
Inspection Report
Original Licensing
Census: 44
Deficiencies: 16
Apr 7, 2023
Visit Reason
The inspection was conducted as an initial licensure survey combined with a complaint investigation for Swan Falls Assisted Living.
Findings
Multiple deficiencies were identified including incomplete criminal background checks for employees, unsigned admission agreements after ownership change, medication administration errors, missing current medication orders, unavailable PRN medications, unsigned and outdated negotiated service agreements, lack of documentation of nurse notifications and nursing assessments, inaccurate admission and discharge register, incomplete staff schedules, inadequate food portion sizes, insufficient personnel certifications and training, and lack of delegation for medication administration.
Complaint Details
The visit included a complaint investigation component as indicated by the survey type 'health care initial licensure + complaint investigation'.
Deficiencies (16)
| Description |
|---|
| Two of ten employees did not have Department Criminal History and Background Checks completed. |
| Four of nine residents' admission agreements were not signed after the change of ownership. |
| Facility nurse did not ensure residents received medications and treatments as ordered, including missed injections and incorrect doses. |
| Actual written, signed, and dated medication orders were missing in residents' care records. |
| Not all residents' as-needed (PRN) medications were available at the facility. |
| Negotiated Service Agreements (NSAs) were not signed and dated by residents or their representatives. |
| NSAs were not updated to reflect significant changes in residents' care needs or health status. |
| Facility lacked system for staff to document nurse notifications; no documentation of nurse notifications in resident records. |
| Facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status. |
| Admission and discharge register was not up-to-date; discrepancy between register and resident roster. |
| As-worked staff schedules did not document last names, positions, or exact times staff were at the facility. |
| Facility served inadequate portion sizes of meals, not following dietitian approved menu. |
| Five of seven sampled direct care staff lacked current first aid and/or CPR certification. |
| Two of ten employees did not receive required sixteen hours of job-related orientation training including infection control. |
| Ten of twelve staff did not receive specialized training for residents with dementia, mental illness, developmental disability, or traumatic brain injury. |
| Two staff members had not received gait belt training; medication delegation was incomplete for overnight staff. |
Report Facts
Residents documented in admission and discharge register: 11
Residents documented in resident roster: 44
Employees without criminal background checks: 2
Residents with unsigned admission agreements: 4
Direct care staff without current first aid/CPR certification: 5
Employees without required orientation training: 2
Staff without specialized training for dementia/mental illness: 6
Staff interviewed without specialized training: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Paris | Administrator | Confirmed admission agreements and NSAs were not signed or dated after ownership change. |
| Torrey Bollinger | Survey Team Leader | Led the health care initial licensure and complaint investigation survey. |
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