Inspection Report Summary
The most recent inspection on September 12, 2025, found multiple deficiencies related to employee background checks, medication administration, nursing assessments, staffing levels, privacy violations, and incident investigations. Earlier inspections showed a pattern of issues including administration availability, emergency preparedness, fire safety, and staffing concerns. Deficiencies mainly involved medication management, staffing adequacy, resident safety, and documentation practices. Complaint investigations did not clearly state substantiation but noted multiple regulatory violations without enforcement actions or fines listed in the available reports. The facility’s deficiencies appear consistent over time with no clear trend of improvement or worsening.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Follow-Up
Deficiencies: 21
Sep 12, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to verify correction of previously cited deficiencies and assess compliance with regulatory requirements.
Findings
The facility was found to have multiple deficiencies including incomplete background checks for employees, failure to provide a secure environment for residents with cognitive impairments, medication administration errors, incomplete nursing assessments, missing psychotropic medication reviews, incomplete comprehensive assessments, insufficient staffing, privacy violations due to cameras in resident rooms, and failure to investigate and intervene after resident incidents.
Deficiencies (21)
| Description |
|---|
| Three of four employees did not have Idaho State Police background checks completed. |
| Facility did not provide a secure environment for residents at risk of elopement; Resident #5 was observed exiting the facility and entering other residents' rooms. |
| Residents' medications were not given as ordered, including multiple missed doses for Residents #1 through #9. |
| Nursing assessments were not conducted when residents experienced changes in health status. |
| Psychotropic medication reviews were not completed for six residents requiring them. |
| Pre-admission comprehensive and nursing assessments were not completed for Residents #3, #4, and #7. |
| Negotiated Service Agreement was not completed within 14 days of admission for Resident #10. |
| NSAs were not updated to reflect significant changes for Residents #2 and #9. |
| Facility staff documentation was not completed by the staff making observations; medication technicians charted for care staff. |
| Medication technicians did not document insulin amounts for Resident #6 for the entire month of August 2025. |
| Facility nurse did not document changes of condition for multiple residents after falls and hospital visits. |
| Facility did not evaluate or develop interventions for ongoing behaviors of Resident #10 and Resident #5. |
| Staff records lacked required documentation such as orientation and infection control training. |
| Facility failed to meet Idaho Food Code standards; kitchen inspection failed requiring mandatory re-inspection within 10 days. |
| Buildings were left unattended for short periods due to insufficient staffing on night shifts. |
| Facility did not schedule sufficient personnel to meet residents' needs, including memory care unit with only one staff for several hours. |
| Medication delegations were not done individually and lacked skill demonstration. |
| Facility nurse did not implement all residents' orders; some orders were only reviewed by RCC prior to medication administration. |
| Residents' rights to privacy were violated by presence of cameras in Resident #8's room and bathroom without proper notification or consent. |
| Administrator did not ensure facility incidents were investigated for multiple residents' falls and injuries. |
| Facility did not develop interventions to prevent recurrences after residents' incidents and falls. |
Report Facts
Residents in memory care unit: 13
Missed medication doses: 44
Falls: 12
Staff records missing documentation: 3
Medication delegations reviewed: 5
Inspection Report
Complaint Investigation
Deficiencies: 5
Jun 26, 2025
Visit Reason
The inspection was conducted as a health care complaint investigation to assess compliance with regulatory requirements and address concerns related to facility administration, medication management, emergency preparedness, and supply availability.
Findings
The facility was found to have multiple deficiencies including lack of a licensed administrator for 28 days, no authorized designee during administrator absences, accumulation of discontinued and expired medications without proper destruction documentation, failure to conduct bimonthly fire drills, and inadequate basic and medical supplies for residents.
Complaint Details
The investigation was triggered by a health care complaint. The report documents multiple regulatory violations related to administration availability, medication management, emergency preparedness, and supply shortages. Substantiation status is not explicitly stated.
Deficiencies (5)
| Description |
|---|
| Facility did not have a licensed administrator from 12/31/24 to 1/29/25 for 28 days. |
| Former administrator did not authorize in writing a designee to act in their absence during multiple periods. |
| Accumulation of unused, discontinued, or expired medications for more than 30 days with incomplete medication destruction logs. |
| Facility did not conduct fire drills on a bimonthly basis as required. |
| Facility did not provide basic necessary supplies and medical supplies for residents' basic services. |
Report Facts
Days without licensed administrator: 28
Fire drills documented: 2
Medication destruction log pages: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kari Hakala | Administrator | Named as former administrator who was not available and did not authorize designee |
| Jenny Walker | Survey Team Leader | Led the health care complaint investigation |
Inspection Report
Life Safety
Deficiencies: 4
Mar 17, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with emergency actions, fire drills, electrical installations, and fire and life safety standards for the facility buildings.
Findings
The facility failed to conduct required emergency fire drills, maintain proper electrical safety practices, and uphold fire and life safety standards including self-closing doors, operable emergency lighting, smoke detector sensitivity testing, fire suppression alarm testing, and employee emergency procedure training.
Deficiencies (4)
| Description |
|---|
| Facility failed to conduct emergency egress/fire drills as required, including bi-monthly drills with at least two during sleeping hours and evacuation to designated areas. |
| Use of prohibited multi-plug adapters and extension cords identified in multiple buildings and rooms. |
| Oxygen concentrators were improperly powered using relocatable power taps, which is prohibited. |
| Facility failed to maintain fire and life safety standards including lack of self-closing laundry room doors, inoperable emergency lights, lack of monthly emergency light testing, missing smoke detector sensitivity testing, inadequate fire suppression waterflow alarm testing, and lack of employee instruction documentation. |
Report Facts
Buildings inspected: 4
Last documented fire drill: 2024
Fire drill frequency: 1
Emergency light testing frequency: 30
Smoke detector sensitivity testing timeframe: 5
Inspection Report
Original Licensing
Deficiencies: 4
Jul 25, 2023
Visit Reason
The inspection was conducted as an initial licensure survey for the healthcare facility.
Findings
The inspection identified multiple deficiencies including incomplete State Police Background Checks for employees, inconsistent documentation of resident assessments after changes in condition, insufficient certified staff to pass medications during night shifts, and lack of delegation for staff passing medications.
Deficiencies (4)
| Description |
|---|
| Two of three employees did not have required State Police Background Checks completed. |
| Facility nurse assessed residents after changes of condition but did not consistently document these assessments. |
| Insufficient staff certified or delegated to pass medications on night shift, resulting in staff working alone and leaving buildings unsupervised. |
| Five of five staff who passed medications were not delegated by the current facility nurse. |
Report Facts
Employees missing background checks: 2
Residents with undocumented assessments: 3
Staff not delegated to pass medications: 5
Buildings with single uncertified night staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bobbi Swan | Administrator | Confirmed missing background checks and lack of delegation. |
| Melvin Lu | Survey Team Leader | Led the initial licensure inspection. |
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