Inspection Reports for The Cottages Assisted Living and Memory Care-Boise

The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire and life safety standards for existing buildings licensed for three through sixteen residents.

The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code, including two non-operational emergency lights and lack of documentation for periodic staff training on the emergency plan. Additionally, the facility did not conduct the required number of emergency egress and relocation drills, with missing drills for several months in two houses.

The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation to assess compliance with regulatory requirements and to verify correction of previous deficiencies.

The facility was found to have multiple deficiencies including lack of activities offered to residents, absence of a licensed administrator for 24 days, failure to conduct timely investigations of incidents, inadequate interim care plans, unsecured environment leading to resident elopements, incomplete nursing assessments, improper medication refrigerator temperature maintenance, lack of behavior management plans, incomplete psychotropic medication reviews, incomplete resident assessments and service agreements, unsigned NSAs, undocumented change of condition assessments, incomplete behavior evaluations and plans, and incomplete as-worked schedules.

The visit included a complaint investigation component as indicated by the survey type 'health care licensure and follow-up + complaint investigation'. Specific substantiation status was not stated.

The inspection was conducted as a fire life safety and sanitation licensure survey for The Cottages of Boise.

Multiple deficiencies were found related to fire and life safety standards, including lack of documented quarterly waterflow alarm testing since 2018, insufficient control valve documentation, a smoke detector failure with no documented replacement, overdue 5-year internal obstruction inspections, lack of emergency light testing since October 2021, overdue full flow trip testing last conducted in May 2018, and no documented fire drills since February 2021.

The inspection was conducted as a health care complaint investigation to assess compliance with facility administrator licensing and staffing requirements.

The facility lacked a licensed administrator for three separate periods over six months, resulting in unreported incidents and difficulties in reporting issues. Additionally, staffing was insufficient, especially during overnight shifts, leading to unmet resident care needs such as missed showers and caregivers leaving buildings unattended.

The visit was triggered by a health care complaint investigation. The report details substantiated issues with administrator licensing gaps and insufficient staffing impacting resident care.

The visit was a health care licensure and follow-up survey to assess compliance with prior deficiencies and regulatory requirements.

The facility failed to provide a secure environment as an unsampled resident knew and used door codes to exit and re-enter. The facility nurse did not timely assess residents after changes in condition, and a night shift caregiver worked alone without current CPR certification.