Inspection Report Summary
The most recent inspection on January 23, 2025, found deficiencies related to fire life safety code compliance, including missing documentation for smoke detector sensitivity testing, inadequate ventilation in oxygen transfilling rooms, and incomplete emergency fire drill procedures. Earlier inspections showed a pattern of multiple deficiencies involving medication management, staffing shortages, incomplete nursing assessments, and documentation issues. Complaint investigations noted concerns about cleanliness, infection control, and staffing sufficiency, though substantiation was not explicitly stated. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s inspection history indicates ongoing challenges with regulatory compliance, particularly in safety procedures and resident care documentation, with no clear trend of sustained improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Life Safety
Deficiencies: 3
Jan 23, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with life safety code standards and related regulations.
Findings
The facility failed to maintain Life Safety Code standards, including lack of documentation for smoke detector sensitivity testing within the last five years, inadequate ventilation in oxygen transfilling rooms, and failure to conduct emergency fire drills on a bi-monthly basis with required night drills. Additionally, the facility policy did not specify designated evacuation meeting locations as required.
Deficiencies (3)
| Description |
|---|
| Facility could not provide documentation of a smoke detector sensitivity test conducted within the last five years as required by NFPA 72. |
| Building 1 and Building 2 have exterior oxygen transfilling rooms without mechanical or natural ventilation as required by NFPA 99. |
| Facility failed to conduct emergency egress/fire drills on a bi-monthly basis with required night drills and did not specify designated evacuation meeting locations in policy. |
Report Facts
Fire drills conducted: 4
Fire drills dates: Specific drill dates include 1/21/25 night, 1/17/25 day, 11/14/24 night, 7/17/24 day, 3/25/24 night, 2/9/24 day, 11/10/23 day
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Mendoza | Administrator | Named as facility administrator in the report header |
| Jeremy Wilson | Survey Team Leader | Named as survey team leader conducting the inspection |
Inspection Report
Follow-Up
Deficiencies: 13
Mar 21, 2024
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with previous deficiencies and regulatory requirements at the facility.
Findings
The facility was found to have multiple deficiencies including failure to complete required Idaho State Police background checks for nurses, unsafe storage of toxic chemicals accessible to cognitively impaired residents, medication administration errors, lack of behavior plans for residents on psychotropic medications, incomplete six-month medication reviews, insufficient nursing assessments prior to admission, inadequate behavior evaluations, incomplete and unsigned Negotiated Service Agreements, inconsistent documentation of resident care and behaviors, and insufficient staffing on multiple occasions.
Deficiencies (13)
| Description |
|---|
| Two facility nurses did not have Idaho State Police background checks completed. |
| Disinfectant spray was stored in an unlocked laundry room accessible to cognitively impaired residents. |
| Residents did not receive medications as ordered, including missed doses and incorrect administration. |
| Residents did not have all as-needed (PRN) medications available. |
| Psychotropic medications were used as a first resort without behavior plans in place. |
| Six-month medication reviews for psychotropic medications were incomplete or missing behavioral updates. |
| Residents did not have comprehensive nursing assessments completed prior to admission. |
| The facility did not evaluate all residents' behaviors with all required components. |
| Residents' Negotiated Service Agreements did not clearly reflect needs or services, and were incomplete. |
| Negotiated Service Agreements were not signed by legal representatives or Power of Attorney. |
| Resident care records were inconsistently documented, including notifications of unusual events and PRN medication requests. |
| The facility did not track ongoing behaviors or effectiveness of interventions adequately. |
| Insufficient personnel were working at the facility on multiple occasions, with staff switching buildings leaving areas unattended. |
Report Facts
Missed medication doses: 30
Missed medication doses: 2
Missed medication doses: 52
Dates of disinfectant storage issue: Disinfectant spray was stored unlocked on 3/19/24, 3/20/24, and 3/21/24.
Date of resident pushing incident: Resident #7 pushed another resident on 3/4/24.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Mendoza | Administrator | Confirmed background checks were not completed; confirmed NSAs were not signed; stated no complaints about staffing; stated six-month medication reviews were incomplete. |
| Torrey Bollinger | Survey Team Leader | Led the health care licensure and follow-up survey. |
Inspection Report
Follow-Up
Deficiencies: 9
Sep 9, 2022
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
The facility was found to have multiple deficiencies including lack of a licensed administrator on several occasions, failure to implement corrective actions to prevent resident falls, medication administration errors, incomplete nursing assessments prior to admission, missing documentation of change of condition assessments, inadequate personnel records, and insufficient staffing during overnight shifts.
Deficiencies (9)
| Description |
|---|
| The facility had no licensed administrator to oversee daily operations on four separate occasions. |
| The facility did not ensure corrective actions were put in place to prevent recurrence of residents' falls. |
| Residents did not receive medications and diets as ordered, including missed doses and unavailable medications. |
| Not all residents' records contained current, signed orders for all medications and treatments. |
| Medication refrigerator was not monitored for appropriate temperatures and documentation was lacking. |
| Seven sampled residents did not have comprehensive nursing assessments completed prior to admission. |
| The facility did not maintain documentation of all change of condition assessments; documentation was lost. |
| Five of seven direct caregiving staff did not have documentation of delegation from the facility nurse. |
| The administrator did not schedule sufficient personnel during all hours; medication technician was not staffed during overnight shifts on multiple dates. |
Report Facts
Days without licensed administrator: 65
Missed medication doses for Resident #1: 5
Missed medication doses for Resident #3: 15
Missed medication doses for Resident #5: 20
Missed medication doses for Resident #6: 30
Overnight shifts without medication technician staffing: 4
Sampled residents without nursing assessment prior to admission: 7
Direct caregiving staff without delegation documentation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Mendoza | Administrator | Named as administrator responsible for facility operations and staffing |
| Stacey Brown | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 3
Apr 6, 2022
Visit Reason
The inspection was conducted as a health care complaint investigation regarding facility maintenance, infection control, and staffing sufficiency.
Findings
The facility was found to have cleanliness issues including stained carpets and soiled linens, inadequate infection control practices with staff not properly wearing masks, and insufficient staffing to meet residents' needs including assistance with ADLs and housekeeping.
Complaint Details
The visit was triggered by a health care complaint. The report documents multiple deficiencies related to housekeeping, infection control, and staffing shortages. Substantiation status is not explicitly stated.
Deficiencies (3)
| Description |
|---|
| Facility was not maintained in a clean, safe and orderly manner with stained carpets and soiled linens. |
| Staff and outside agency nursing staff were observed not wearing masks properly. |
| Insufficient staff scheduled to provide necessary care and assistance to residents. |
Report Facts
Resident census: 29
Staff interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timmothy Pape | Administrator | Named as the facility administrator responsible for staffing and maintenance. |
| Jenny Walker | Survey Team Leader | Led the health care complaint investigation survey. |
Inspection Report
Life Safety
Deficiencies: 8
Dec 29, 2021
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire and life safety standards for existing residential board and care occupancies.
Findings
The facility failed to maintain compliance with multiple fire and life safety requirements including lack of documentation for annual smoke alarm inspection, inconsistent monthly inspections of wet suppression system gauges, missing emergency lighting tests, absence of periodic staff training on oxygen safety and emergency action plans, missing documentation for fuel-fired heating system inspection, incomplete emergency egress and relocation drill records, and lack of available report for the annual sprinkler system inspection.
Deficiencies (8)
| Description |
|---|
| No documentation for annual inspection of the smoke alarm system; last known inspection was 6/3/2020. |
| Monthly visual inspections of wet suppression system gauges and secured control valves were not documented consistently; last known inspection was 6/7/21. |
| No documentation for 30 second monthly and 90 minute annual testing of emergency lighting. |
| No documentation to show staff are trained periodically on safety guidelines, usage requirements, and risks associated with handling and use of oxygen. |
| No documentation for periodic staff training on the facility emergency action plan. |
| No documentation showing fuel-fired heating devices and systems had been inspected in the past 12 months; last known inspection was 4/27/20. |
| No emergency egress and relocation drill documentation for the past 12 months; staff reported some drills done but no records located. |
| No report available for review of the annual sprinkler system inspection completed in March 2021 despite sprinkler riser tag. |
Report Facts
Last known smoke alarm inspection date: Jun 3, 2020
Last known wet suppression system inspection date: Jun 7, 2021
Last known fuel-fired heating system inspection date: Apr 27, 2020
Annual sprinkler system inspection date: 202103
Inspection Report
Follow-Up
Deficiencies: 1
Jul 6, 2021
Visit Reason
The visit was a follow-up inspection to verify correction of previously identified health care core deficiencies.
Findings
The inspection found that 3 of 3 sampled residents requiring 90-day assessments did not have their current assessments completed.
Deficiencies (1)
| Description |
|---|
| 3 of 3 sampled residents that required 90-day assessments did not have their current assessment completed. |
Report Facts
Residents sampled: 3
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