Deficiencies per Year
12
9
6
3
0
Unclassified
Inspection Report
Follow-Up
Deficiencies: 9
May 9, 2025
Visit Reason
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.
Findings
Multiple deficiencies were identified including failure to complete required Idaho State Police background checks for employees, failure to notify Licensing and Certification of resident falls within one business day, incomplete nursing assessments, lack of self-administration medication assessments, failure to review negotiated service agreements annually, missing psychotropic medication reviews, incomplete comprehensive assessments prior to admission, missing as-worked schedules for previous administrators, and insufficient personnel with current first aid and CPR certifications.
Complaint Details
The visit included a complaint investigation component as indicated by the survey type, but no specific substantiation status was provided in the report.
Deficiencies (9)
| Description |
|---|
| Three of seven employees did not have Idaho State Police background checks completed prior to working alone with residents. |
| Facility did not notify Licensing and Certification within one business day of resident falls requiring hospital or emergency room assessment. |
| Registered nurse did not conduct ninety-day nursing assessments or complete initial nursing assessments for multiple residents. |
| Resident did not have a self-administration of medication assessment completed by the registered nurse. |
| Negotiated Service Agreements for residents were not reviewed every 12 months. |
| Residents taking psychotropic medications for longer than six months did not have six month medication reviews completed. |
| Comprehensive assessments were not completed by the registered nurse prior to residents being admitted to the facility. |
| Facility did not maintain as-worked schedules for three previous administrators dating back to 2/15/24 through 1/10/25. |
| Eight of nine sampled direct care staff did not have current first aid and/or CPR certifications. |
Report Facts
Employees without background checks: 3
Resident falls not reported within one business day: 3
Residents without timely nursing assessments: 5
Residents without psychotropic medication reviews: 3
Administrators' schedules missing: 3
Direct care staff without current first aid/CPR certifications: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ciera Walton | Administrator | Confirmed background checks were not completed and acknowledged failure to report incidents. |
| Torrey Bollinger | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Aug 11, 2023
Visit Reason
The inspection was conducted as a health care complaint investigation to assess the facility's response to incidents, resident care, and compliance with regulations.
Findings
The investigation found multiple deficiencies including inadequate staff training on emergency response for hospice residents, failure to conduct timely investigations, failure to notify licensing within required timeframes, inconsistent functioning of the call light system, medication administration errors, incomplete nursing assessments, failure to follow negotiated service agreements, outdated care plans, and insufficient staffing leading to unmet resident needs and safety risks.
Complaint Details
The visit was complaint-related, focusing on allegations of inadequate emergency response, failure to investigate incidents, notification failures, medication errors, insufficient nursing assessments, unmet care needs, and staffing shortages. The report documents multiple substantiated issues.
Deficiencies (9)
| Description |
|---|
| Facility staff were not adequately trained on the process for responding to emergencies for residents on hospice services and to report residents' incidents. |
| Administrator did not conduct investigations within 30 days for injuries and incidents involving residents. |
| Facility did not notify Licensing and Certification within one business day of certain resident injuries and incidents. |
| Call light system was not consistently functioning; staff did not always receive pages when residents pushed call pendants. |
| Residents did not consistently receive medications and treatments as ordered, including incorrect Fentanyl dosing and missed oxygen saturation checks. |
| Facility nurse did not consistently conduct nursing assessments when residents experienced changes in physical or mental health status. |
| Residents did not consistently receive cares as outlined in their Negotiated Service Agreements (NSA), including repositioning and assistance with transfers. |
| NSAs were not updated to reflect significant changes in care needs or health status. |
| Facility did not schedule sufficient personnel to provide care during all hours, resulting in unattended units and unmet resident needs. |
Report Facts
Shifts with only two staff members overnight: 11
Oxygen saturation checks missed: 41
Fentanyl dosage: 50
Duration resident #1 went unassisted: 3.25
Alarm duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara McLean | Administrator | Named in relation to training staff on emergency response and investigations. |
| Stacey Brown | Survey Team Leader | Led the health care complaint investigation survey. |
Inspection Report
Life Safety
Deficiencies: 10
Nov 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 and sanitation regulations.
Findings
The facility did not maintain compliance with the 2018 edition of NFPA 101 Life Safety Code and other related standards, including issues with emergency lighting, fire/smoke barriers, door self-closing devices, kitchen hood suppression inspections, fire extinguisher inspections, waterflow alarm testing, relocation agreements, hot water temperature, and presence of portable space heaters in restricted areas.
Deficiencies (10)
| Description |
|---|
| Main entrance doors equipped with magnetic locking arrangement and keypad override not located in memory care portion and should have unobstructed egress. |
| Installed approximately 18” X 18” transfer grille in fire/smoke barrier wall between kitchen and dining room allowing communication between compartments. |
| Two non-operational emergency lights and inability to produce 90-minute annual emergency lighting test documentation. |
| Self-closing device on laundry room door not operating correctly; magnetic hold open device broken and door held open by door chock and rock. |
| Missing one of two semi-annual kitchen hood suppression system inspections and hood cleaning/inspection documentation. |
| Fire extinguishers had not undergone annual inspection since September 2020. |
| Facility could not produce documentation for quarterly waterflow alarm testing for third quarter 2021 or fourth quarter 2020/2021. |
| Relocation agreements not updated annually; last known update was in 2019. |
| Hot water temperature at plumbing fixtures was 126°F, exceeding the required maximum of 120°F. |
| Portable space heaters observed in sprinkler riser room and Assistant Executive Director's office. |
Report Facts
Emergency lights non-operational: 2
Kitchen hood suppression inspections missing: 1
Fire extinguisher annual inspection overdue: 1
Water temperature: 126
Relocation agreements: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara McLean | Administrator | Named as facility administrator in the report header. |
| Linda Chaney | Survey Team Leader | Named as survey team leader conducting the fire life safety and sanitation licensure survey. |
Inspection Report
Follow-Up
Deficiencies: 2
Nov 17, 2021
Visit Reason
The visit was a follow-up survey to assess correction of previously cited non-core deficiencies related to medication administration and staffing.
Findings
The facility was found to have ongoing issues with residents not receiving medications as ordered and insufficient staffing to meet residents' needs, including delayed call light responses and inadequate supervision leading to multiple falls.
Deficiencies (2)
| Description |
|---|
| Residents were not provided with their medications as ordered, including missed doses of antibiotics, nerve pain medication, antifungal medication, and others in October 2021. |
| Insufficient staffing to meet residents' needs, resulting in dirty clothes, cluttered rooms, unanswered call lights, and inadequate supervision to prevent falls. |
Report Facts
Missed medication doses: 30
Missed medication doses: 7
Missed medication doses: 4
Missed medication doses: 13
Missed medication doses: 9
Call light wait time (minutes): 10
Resident falls: 7
Inspection Report
Follow-Up
Deficiencies: 12
Aug 27, 2021
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with state regulations and verify correction of previously cited deficiencies.
Findings
Multiple deficiencies were found including incomplete background checks for employees, lack of activities in the memory care unit, inadequate abuse and neglect policies, failure to investigate resident incidents, insufficient resident protection, inadequate corrective actions for frequent falls, maintenance and housekeeping issues, medication administration errors, unsecured medication storage, incomplete staff scheduling records, undocumented menu substitutions, and insufficient staffing to meet residents' needs.
Deficiencies (12)
| Description |
|---|
| Two of two employees who required a state police background check did not have one completed. |
| No activities were offered to residents in the memory care unit except one resident escorted to church. |
| Abuse, neglect, and exploitation policy lacked necessary components including steps for alleged perpetrators who are visitors or residents. |
| Falls sustained by residents were not investigated by the administrator; an unaccounted morphine dose was investigated. |
| Facility did not protect a resident from alleged physical and verbal abuse by a staff member who continued to work. |
| Inadequate corrective action taken for a resident who fell 20 times in six months. |
| Memory care secured yard fence had missing slat and loose posts; multiple maintenance and housekeeping issues noted including torn furniture, debris, and strong urine odor. |
| Residents did not receive medications as ordered, including missed doses for multiple residents. |
| Medication room and memory care medication cart were observed unlocked on multiple occasions. |
| As-worked schedules did not document exact times staff were at the facility and lacked full names and positions. |
| Menu substitutions were not documented for several months. |
| Facility did not schedule sufficient staff to meet residents' needs, evidenced by long call light response times and delayed pain medication administration. |
Report Facts
Falls: 20
Missed medication doses: 7
Missed medication doses: 4
Missed medication doses: 13
Missed medication doses: 15
Observation days: 4
Staff and resident statements: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara McLean | Administrator | Confirmed background checks had not been completed and provided schedules |
| Michael Oldfield | Survey Team Leader | Led the health care licensure and follow-up survey |
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