Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Life Safety
Deficiencies: 1
Jan 7, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey of the facility.
Findings
The facility failed to maintain proper storage of oxygen cylinders in accordance with NFPA 99 standards, specifically with approximately six A-sized oxygen cylinders found sitting directly on the carpeted floor in room 308 instead of being stored in a rack or cart.
Deficiencies (1)
| Description |
|---|
| Facility failed to maintain proper storage of oxygen cylinders in accordance with NFPA 99, Chapter 11, Section 11.6.2.3 (11). Approximately 6 A-sized oxygen cylinders were found sitting directly on the carpeted floor in room 308 instead of being properly stored in a rack or cart. |
Report Facts
Oxygen cylinders improperly stored: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bobbi Moore | Administrator | Named as facility administrator in the report header |
| Jeremy Wilson | Survey Team Leader | Named as survey team leader conducting the fire life safety and sanitation licensure survey |
Inspection Report
Life Safety
Deficiencies: 5
Jan 18, 2024
Visit Reason
The inspection was conducted to assess fire life safety and sanitation licensure compliance at the facility.
Findings
The facility failed to perform required bimonthly emergency drills, did not update relocation agreements annually, lacked documentation for monthly emergency generator testing, and did not maintain compliance with NFPA 101 Life Safety Code including staff training and fire/smoke barrier door functionality.
Deficiencies (5)
| Description |
|---|
| Failed to perform emergency egress and relocation drills bimonthly; drills only performed in March, June, and December 2023. |
| Relocation agreements with two separate locations were not updated annually; last updates were in 2020 and 2021. |
| No documentation for monthly load test/conductivity testing of emergency generator battery for February 2023. |
| No documented bimonthly in-service staff training on the emergency plan as required by NFPA 101. |
| Fire/smoke barrier doors outside resident rooms 123 & 124 did not close completely, leaving approximately a 2-inch gap. |
Report Facts
Number of emergency drills performed: 3
Years since last relocation agreement update: 3
Gap size in fire/smoke barrier doors: 2
Inspection Report
Follow-Up
Deficiencies: 1
Aug 3, 2023
Visit Reason
The inspection visit was a health care licensure and follow-up survey to assess compliance with regulatory requirements.
Findings
The facility failed to update Negotiated Service Agreements (NSAs) for ten residents reviewed, resulting in inaccurate reflection of residents' current needs including medication administration, home health services, and wound care.
Deficiencies (1)
| Description |
|---|
| Ten of ten residents' NSAs were not updated to accurately reflect current needs such as medication independence, home health services, wound care, and other pertinent information. |
Report Facts
Residents with deficient NSAs: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bobbi Moore | Administrator | Named as facility administrator during the inspection |
| Melvin Lu | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Life Safety
Deficiencies: 8
Jan 19, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with applicable fire safety codes and regulations.
Findings
The facility was found to have multiple fire and life safety deficiencies including lack of documented battery conductivity testing for emergency generators, non-factory applied paint on fire suppression system pendants, missing ceiling tiles compromising compartmentation, unsecured oxygen cylinders, and serving carts blocking electrical disconnect panels.
Deficiencies (8)
| Description |
|---|
| Emergency Power Supply System (EPSS) generator monthly logs did not document battery conductivity testing for the months of Feb-April and June-Oct of 2022. |
| Non-factory applied paint on fire suppression system pendants inside mechanical rooms requiring replacement. |
| Compartmentation was not maintained on the third floor of the assisted living occupancy with missing ceiling tiles and smoke barrier exposing the roof deck. |
| Drain valve access cover of janitor's closet by kitchen serve-out was open exposing interstitial space. |
| No documentation that door releases and door hold open magnetic locking arrangements were tested during the 2022 inspection cycle. |
| Serving carts parked in front of electrical disconnect panels in both third and second floor dietary serve-out kitchens. |
| Unsecured oxygen cylinders found in Room 310 and Room 208. |
| No documented policy or procedure for elimination of sources of ignition and misuse of flammable substances. |
Report Facts
Unsecured oxygen cylinders: 6
Missing ceiling tiles: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bobbi Moore | Administrator | Named as facility administrator. |
| Sam Burbank | Survey Team Leader | Conducted fire life safety and sanitation licensure survey. |
Inspection Report
Life Safety
Deficiencies: 2
Feb 16, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at The Terraces of Boise facility.
Findings
The inspection identified non-core issues including lack of documented conductivity testing for the emergency generator starter battery and incomplete documentation of fire drills, specifically failure to document evacuation to the designated assembly point as required by the emergency plan and NFPA 101 standards.
Deficiencies (2)
| Description |
|---|
| No documented conductivity testing for starter battery |
| Documented fire drills did not document evacuation to the designated point of assembly as outlined in the emergency plan |
Inspection Report
Follow-Up
Deficiencies: 3
Mar 18, 2021
Visit Reason
The inspection was conducted as a health care licensure and follow-up survey to assess compliance with licensing requirements and verify correction of previous deficiencies.
Findings
The facility was found to have no licensed administrator overseeing daily operations on two separate occasions, incomplete individual resident care record documentation, and lack of specialized mental illness training documentation for seven staff members.
Deficiencies (3)
| Description |
|---|
| The facility had no licensed administrator to oversee the daily operations on two separate occasions from 10/25/19 to 11/13/19 and 12/15/19 to 12/17/19. |
| Individual care record documentation was not maintained for each resident with all entries kept current and completed by the person providing care; caregivers' notes were all on one form and not recorded into each resident's chart. |
| Seven of seven staff records did not contain documentation of specialized training for mental illness. |
Inspection Report
Life Safety
Deficiencies: 8
Jan 13, 2021
Visit Reason
A Fire Life Safety Survey was conducted at The Terraces of Boise to assess compliance with fire and life safety standards.
Findings
The facility was found to be providing a safe environment for its residents; however, several deficiencies were noted including lack of documented emergency plan training, blocked electrical panels, unsealed penetrations, incomplete fire alarm inspection documentation, and missing fire suppression system inspections.
Deficiencies (8)
| Description |
|---|
| Facility relocation agreement is for one (1) separate facility; two (2) relocation agreements are required and must be reviewed annually. |
| No documented review by staff of emergency plan training conducted every two months as required by NFPA 101. |
| No documented training of residents on their roles and responsibilities for emergency response as required by NFPA 101. |
| Electrical panel shut-off panel at 2nd floor Mechanical space blocked by Christmas decorations, violating NFPA 70. |
| Penetrations between floors and into interstitial spaces not sealed to resist flame spread in third floor mechanical room. |
| Fire alarm inspection documentation did not indicate actual date of inspection and included a holiday date when no personnel were present. |
| Only 1 of 2 required fire suppression system inspections for UL 300 hood system completed; inspections required at least every six months. |
| Two missing quarterly waterflow alarm inspections for second and third quarter of 2020; documentation for main fire suppression system inspections was conflicting and unsubstantiated. |
Report Facts
Deficiencies cited: 8
Survey date: Jan 13, 2021
Response due date: Feb 12, 2021
Facility license number: RC-1115 (alphanumeric, not numeric only)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nate Elkins | Supervisor, Facility Fire Safety & Construction Program | Signed the report and is the contact for questions about the visit. |
| Carolyn Smith | Administrator | Administrator of The Terraces of Boise at time of survey. |
| Sam Burbank | Survey Team Leader | Led the fire life safety and sanitation licensure survey. |
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