13 Reports
Inspection Report — Aug 27, 2026
Routine
Date: Aug 27, 2026
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state regulations.
Findings
Six deficiencies were identified related to medication availability, background checks, staff training, medication refrigerator temperatures, and staff certifications.
Deficiencies (6)
.310.01.f. Medication Distribution: the facility did not ensure all residents' as-needed (PRN) medications were available in the facility, including dulcolax suppository, Milk of Magnesia, Mylanta, azelastine nasal spray, emema, refresh tears, Senna, and tums.
.009.01. Criminal History and Background Check: two employees did not have a Department Criminal History and Background Check, and six employees did not have the required Idaho State Police Background Check completed.
.625.01. Number of Hours of Training: eleven staff did not contain documentation of 16 hours of orientation nor completed orientation within 30 days of hire.
.625.02.d. Content for Training: eleven staff did not document mental illness training despite the facility providing services to residents with mental illness diagnoses.
.310.01.c. Medication Distribution: the facility did not maintain medication refrigerator temperatures per manufacturer's guidelines of 36 to 46 degrees F, with documented temperatures below 36 degrees on multiple occasions and no corrective action taken.
.600.03. Cardio-Pulmonary Resuscitation (CPR) and First Aid Certification: all staff lacked documentation of first aid certification, and ten staff lacked documentation of CPR certification.
Report Facts
temperature: 28.6
temperature: 31.5
count: 2
count: 6
count: 11
count: 11
count: 15
count: 10
Inspection Report — Jan 7, 2025
Life Safety
Date: Jan 7, 2025
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable safety standards.
Findings
One non-core deficiency was identified related to improper storage of oxygen cylinders in the facility.
Deficiencies (1)
.405.03 Medical Gases: facility failed to maintain proper storage of oxygen cylinders in accordance with NFPA 99, Chapter 11, Section 11.6.2.3 (11); approximately six A-sized oxygen cylinders were sitting directly on the carpeted floor instead of being stored in a rack or cart.
Inspection Report — Jan 18, 2024
Life Safety
Date: Jan 18, 2024
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with emergency preparedness and fire safety standards.
Findings
The facility failed to perform required bimonthly emergency drills and did not update relocation agreements annually. Documentation for monthly emergency generator testing was missing, and staff training on the emergency plan was not conducted bimonthly. Additionally, fire/smoke barrier doors did not close completely, leaving a gap.
Deficiencies (4)
.410. Requirements for emergency actions and fire drills: the facility failed to perform bimonthly emergency egress and relocation drills, with drills only performed in March, June, and December of 2023.
.155.01. Relocation agreements: the two relocation agreements had not been updated annually; the last reviews were in 2020 and 2021.
.155.03. Emergency generators: the facility could not produce documentation for a monthly load test and conductivity testing of the battery for February 2023 as required by NFPA Standard 110.
.404. Fire and life safety standards for existing buildings: staff training on the emergency plan was not conducted bimonthly, and fire/smoke barrier doors outside resident rooms 123 and 124 did not close completely, leaving an approximately 2 inch gap.
Report Facts
: 3
: 2
: 2020
: 2021
Inspection Report — Aug 3, 2023
Routine
Date: Aug 3, 2023
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with regulatory requirements.
Findings
Ten residents' records lacked updated Negotiated Service Agreements reflecting their current needs, including medication management and wound care.
Deficiencies (1)
.320. Negotiated service agreement requirements: ten residents' NSAs were not updated to accurately reflect current needs such as medication administration, home health services, wound care, and other pertinent information.
Inspection Report — Jan 19, 2023
Life Safety
Date: Jan 19, 2023
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with applicable fire and life safety standards.
Findings
Six deficiencies were identified related to emergency generator maintenance, fire and life safety standards including compartmentation and fire suppression system maintenance, electrical installations, and medical gas safety.
Deficiencies (4)
.155.03 Emergency Generators: EPSS generator monthly logs did not document battery conductivity testing for the months of February through April and June through October of 2022.
.404 Fire and life safety standards for existing buildings: fire suppression system pendants had non-factory applied paint requiring replacement; compartmentation was not maintained with missing ceiling tiles and smoke barrier sections exposing the roof deck and interstitial spaces; and door releases and magnetic locking arrangements lacked annual testing documentation (previously cited 12/17/2021).
.405.01 Electrical Installations and Equipment: serving carts were parked in front of electrical disconnect panels on the third and second floor dietary serve-out kitchens, obstructing access.
.405.03 Medical Gases: unsecured oxygen cylinders were found lying on their side and standing unsecured in resident rooms; no documented policy or procedure existed for eliminating ignition sources and misuse of flammable substances.
Report Facts
months_missing_battery_testing: 7
unsecured_oxygen_cylinders: 6
missing_ceiling_tiles: 4
Inspection Report — Feb 16, 2022
Life Safety
Date: Feb 16, 2022
Visit Reason
A fire life safety and sanitation licensure survey was conducted to assess compliance with safety standards and emergency preparedness.
Findings
Two non-core deficiencies were identified related to emergency generator testing and fire drill documentation.
Deficiencies (2)
.155.03 Emergency Generators: no documented conductivity testing for starter battery.
.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: documented fire drills did not document evacuation to the designated point of assembly as outlined in the emergency plan; all drills shall perform evacuation as outlined in the disaster plan in accordance with NFPA 101, Chapter 33, Section 33.7.3.3.
Inspection Report — Mar 18, 2021
Routine
Date: Mar 18, 2021
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state regulations.
Findings
Three deficiencies were found related to the absence of a licensed administrator, incomplete resident care records, and lack of specialized mental illness training documentation for staff.
Deficiencies (3)
.215.02 Availability of Administrator: the facility had no licensed administrator to oversee daily operations on two separate occasions from 10/25/19 to 11/13/19 and 12/15/19 to 12/17/19.
.330.04 Resident Care Records: individual care record documentation was not maintained for each resident with all entries kept current and completed by the person providing the care; caregivers' notes were all on one form and not recorded into each resident's chart.
.630.02 Mental Illness: seven of seven staff records did not contain documentation of specialized training for mental illness.
Inspection Report — Jan 13, 2021
Life Safety
Date: Jan 13, 2021
Visit Reason
A Fire Life Safety Survey was conducted to evaluate the facility's compliance with fire safety and sanitation licensure requirements.
Findings
Six deficiencies were identified related to relocation agreements, emergency plan training, electrical panel obstructions, sealing of penetrations, fire alarm inspection documentation, and fire suppression system inspections and testing.
Deficiencies (6)
.155.01 Relocation agreements: the facility relocation agreement is for one separate facility; two relocation agreements must be provided and reviewed annually.
.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: no documented review by staff of emergency plan training every two months and no documented training of residents on their emergency response roles.
.405.01 Electrical installations and equipment: electrical panels shall be maintained free of obstructions; the electrical panel shut-off at 2nd floor mechanical space was blocked by Christmas decorations.
.415.01 Maintenance of equipment and systems: penetrations between floors and into interstitial spaces were not sealed to resist flame spread; three conduits entering the attic in the third floor mechanical room were unsealed.
.415.04 Fire alarm smoke detection system service and testing: documentation for fire alarm inspection did not indicate the actual date of inspection and showed a date when no vendors or facility personnel were present.
.415.05 Automatic fire extinguishing system service and testing: only one of two required UL 300 hood suppression system inspections was completed; multiple missing quarterly waterflow alarm inspections and conflicting inspection dates were documented, with no annual inspection verified.
Report Facts
: 2
: 2
: 17
: 3
: 2
: 2
Inspection Report — Oct 17, 2019
Life Safety
Date: Oct 17, 2019
Visit Reason
A Fire Life Safety Survey was conducted at The Terraces of Boise to assess compliance with fire safety and sanitation licensure requirements.
Findings
Non-core issue deficiencies were identified related to the maintenance and testing of the automatic fire extinguishing system, including missing records for quarterly sprinkler waterflow alarm testing and inspections of dry system gauges and control valves.
Deficiencies (1)
.415.05 Automatic Fire Extinguishing System Service and Testing: no record of a quarterly sprinkler waterflow alarm testing conducted during the second quarter of 2019, and no records for dry system gauge weekly inspection or secured control valve monthly inspections.
Report Facts
date: Oct 17, 2019
date: Nov 17, 2019
quarter: Q2 2019
Inspection Report — Oct 11, 2018
Follow-Up
Date: Oct 11, 2018
Visit Reason
A health care core deficiency follow-up survey was conducted to evaluate compliance with previously cited deficiencies and to ensure corrective actions were implemented.
Findings
The facility failed to implement required policies and procedures for incident investigations and behavior management evaluations. Several resident service agreements were outdated, corrective actions for abuse allegations were not implemented, and resident care records lacked documentation of behaviors and intervention effectiveness.
Deficiencies (5)
.215.01 Administrator responsibility: the administrator did not implement required policies and procedures when incidents were not investigated and interventions were not put into place to prevent recurrence (previously cited 6/15/18).
.225.01 Evaluation for behavior management: the facility did not evaluate behaviors for multiple residents, including incidents of physical and verbal intimidation and unclear behavior descriptions (previously cited 1/4/17 and 6/15/18).
.320.01 Use of negotiated service agreement: NSAs were not updated to reflect residents' specific needs, including seating arrangements, supervision requirements, and safety measures (previously cited 1/4/17 and 6/15/18).
.350.06 Corrective action for known allegations: the facility failed to implement a plan to protect a resident from abuse after incidents of verbal and physical abuse were documented.
.711.01 Ongoing resident care records: the facility did not document times and dates of behaviors, interventions used, or effectiveness for several residents.
Inspection Report — Sep 14, 2018
Life Safety
Date: Sep 14, 2018
Visit Reason
A Fire Life Safety Survey was conducted to assess the facility's compliance with fire safety and sanitation licensure requirements.
Findings
Two non-core deficiencies were found related to emergency lighting testing and fire drill documentation. The facility lacked documentation for the annual 90-minute emergency lighting test and was missing fire drill records for multiple shifts and quarters.
Deficiencies (2)
.405.05 Structure, Maintenance, Equipment to Assure Safety: no documentation for a 90 minute annual test of the emergency lighting.
.410.02 Fire Drills: missing fire drill documentation for first shift, first quarter 2018; third shift, second quarter 2018; second shift, third quarter 2017/2018; and first shift, fourth quarter 2017.
Inspection Report — Jun 15, 2018
Routine
Date: Jun 15, 2018
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state regulations and facility policies.
Findings
The facility was found deficient in multiple areas including failure to conduct required background checks, inadequate administrator oversight of abuse prevention and reporting, lack of behavior management evaluations, incomplete psychotropic medication reviews, insufficient documentation of negotiated service agreements, failure to notify and investigate incidents and complaints, and failure to protect residents from abuse. Core issues involved failure to protect residents from abuse and failure to implement abuse policies and procedures.
Deficiencies (14)
.009.06.c Use of Previous Criminal History and Background Check: three of six current employees required to have Idaho State Police background checks did not have documentation of those checks in their records.
.215.01 Administrator Responsibility: the facility administrator did not implement the facility's policies and procedures related to abuse prevention, reporting, and investigation when Resident #2 abused Resident #1, failed to report allegations immediately to APS, did not investigate the allegation, and did not protect Resident #4 who stated she was manhandled and choked by a caregiver.
.216.08 Dually Licensed Administrator: the facility administrator did not have documentation of an approved plan of operation to be the administrator over a 48 bed skilled nursing facility and a 64 bed assisted living facility and memory care unit.
.225.01 Evaluation for Behavior Management: the facility did not evaluate Resident #2's behaviors or develop a behavior management plan when Resident #2 continued to be physically and verbally abusive to Resident #1 (previously cited 1/4/17).
.310.04.e Psychotropic or Behavior Modifying Medication: the facility did not ensure six month psychotropic medication reviews were conducted by the physician or provide behavioral updates to the physician for Residents #3 and #4.
.320.01 Use of Negotiated Service Agreement: NSAs did not clearly reflect residents' care needs and services; for example, Residents #1 through #7's NSAs did not document emergency response, supervision, night needs, bathing, housekeeping, transferring assistance, frequency of services, eating assistance, toileting, medication assistance, and skin issues (previously cited 1/4/17).
.350.01 Notification of Accidents, Incidents, and Complaints: the administrator was not notified of all incidents or complaints by the assisted living manager, including missing antiques, trinkets, and a TV reported by memory care residents; staff handled complaints themselves and only escalated if unresolved.
.350.02 Administrator or Designee Investigation Within Thirty Days: the facility did not complete or document investigations when Resident #1 was physically and verbally abused repeatedly by Resident #2, when Resident #4 stated she was choked and manhandled by a caregiver, and for incidents including bruising of unknown origin, multiple falls, and missing items.
.350.03 Resident Protection: the facility did not put preventative measures in place to protect residents after resident-to-resident abuse; Resident #2 was physically and verbally abusive to Resident #1, and Resident #4 was not protected from abuse when a caregiver was allowed to work after allegations were made known.
.350.04 Written Response to Complaint Within Thirty Days: the facility management did not provide written responses to all complainants; assisted living and memory care residents reported missing TV, money, trinkets, hearing aids, and dentures, but management had no complaint documentation or written responses.
.350.05 Facility Notification to Appropriate Agencies: the facility did not notify Adult Protection Services when Resident #2 physically and verbally abused Resident #1 or when Resident #4 stated a caregiver choked and manhandled her.
.350.07 Notification of Licensing and Survey Agency Within Twenty-Four Hours: the facility did not notify Licensing and Certification when a resident eloped on 4/11/18, when a resident fell on 5/30/18 requiring treatment, or when Resident #1 had significant bruising on her face after rolling out of bed.
.730.01.e Personnel: four of seven employees did not have documented evidence of specialized training for mental illness in their employee records.
.510 Requirements To Protect Residents From Abuse: the administrator failed to protect Residents #1 and #4 from abuse, did not implement abuse prevention policies, failed to report allegations to APS, did not investigate or protect residents from further abuse, and allowed an alleged perpetrator to continue working without administrative leave. Resident #2 was verbally and physically abusive to Resident #1 on multiple occasions, causing injuries and fear, and the facility failed to report these incidents to APS or protect residents from abuse.
Report Facts
: 3
: 4
: 6
: 7
: 48
: 64
: 19
Inspection Report — Jan 4, 2017
Original Licensing
Date: Jan 4, 2017
Visit Reason
Health care initial licensure survey conducted to evaluate compliance with licensing requirements.
Findings
Seven deficiencies were found related to behavior management, secure environment, negotiated service agreements, behavior management records, and contract records for outside service providers.
Deficiencies (7)
.225.01 Evaluation for Behavior Management: the facility did not evaluate Resident #2's behaviors and develop a behavior management plan when residents complained that Resident #2 had been wandering into their rooms.
.225.02 Intervention: the facility did not develop interventions for each behavior Resident #2 exhibited, such as wandering into other residents' rooms and wandering the hallways without being fully clothed.
.250.14 Secure Environment: the facility did not provide a secure interior and exterior environment for Resident #2 who had impaired cognition and had repeated episodes of being lost and wandering in the assisted living section of the facility.
.320.01 Use of Negotiated Service Agreement: NSAs did not clearly reflect the resident's care needs and services, including Resident #2's assistance with toileting, eating, transportation, money management, shopping, night needs and emergency response/self-evacuation needs, and Resident #3's assistance with peri-care and night needs.
.711.01.b Behavior Management Records: the facility did not document the interventions that were used when Resident #2 exhibited wandering behavior.
.711.01.c Behavior Management Records: the facility did not document the specific outcome of each intervention implemented for Resident #2's behaviors.
.730.03 Contract Records: the facility did not develop, implement or maintain a copy of the contract for an outside service provider regarding coordination of care for Resident #4 and a private duty caregiver/companion.
5 CMS Surveys
Inspection Report — Dec 19, 2025
Routine
Date: Dec 19, 2025
Visit Reason
A routine health care licensure and follow-up survey was conducted to assess compliance with state and federal regulations.
Findings
The facility was found deficient in multiple areas including resident dignity, protection from misappropriation, use of restraints, care planning, medication administration, respiratory care, food safety, and infection control. Deficiencies ranged from failure to update care plans and assessments, improper medication handling, to inadequate sanitation and hand hygiene practices.
Deficiencies (11)
.0550 Honor the resident's right to a dignified existence: residents were referred to as feeders and meals were not served simultaneously at the same table, causing potential psychosocial harm.
.0602 Protect each resident from wrongful use of belongings or money: a staff member misappropriated $1900 from a resident's funds, causing emotional and financial harm.
.0604 Ensure residents are free from physical restraints unless medically needed: position change alarms were used without proper assessment or consent, potentially causing physical deterioration.
.0610 Respond appropriately to all alleged violations: the facility failed to properly investigate a resident's missing personal ring, lacking documentation and thorough follow-up.
.0641 Ensure each resident receives an accurate assessment: a resident's MDS assessment was inaccurately coded as impaired when no impairment existed.
.0657 Develop complete care plans within 7 days and revise as needed: a resident's care plan was not updated to reflect removal of oxygen treatment, risking inadequate care.
.0658 Ensure nursing facility services meet professional standards: a resident was given the wrong dosage of gabapentin medication.
.0695 Provide safe and appropriate respiratory care: a resident was not provided oxygen as ordered, risking shortness of breath.
.0761 Ensure drugs and biologicals are labeled and stored properly: medications were left unattended, and pharmacy labels did not match physician orders, risking medication errors.
.0812 Procure and handle food according to professional standards: food was improperly stored uncovered and unlabeled, cutting boards were pitted and discolored, equipment was dusty, and cross-contamination occurred during food preparation.
.0880 Provide and implement an infection prevention and control program: wet laundry was left unattended, clean and dirty laundry were mixed, hand hygiene was not consistently performed by staff, and medications were improperly handled, risking resident exposure to infection.
Report Facts
: misappropriated funds from Resident #39
: oxygen ordered for Resident #8
: Oxycodone dose ordered for Resident #30
: maximum time for cleaning food-contact surfaces
: maximum time wet laundry should wait before moving to dryer
Inspection Report — Dec 19, 2025
Routine
Date: Dec 19, 2025
Visit Reason
A routine health care licensure and follow-up survey was conducted to evaluate compliance with state and federal regulations.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, protection from misappropriation of funds and property, use of restraints, care plan accuracy and implementation, medication administration errors, food service deficiencies, and infection control practices. These deficiencies had the potential to cause emotional, physical, and psychosocial harm to residents.
Deficiencies (13)
F 0550 Honor the resident's right to a dignified existence: residents were referred to as feeders and meals were not served simultaneously at the same table, causing potential psychosocial harm (previously cited 12/17/2021).
F 0602 Protect each resident from wrongful use of belongings or money: a staff member misappropriated $1900 from Resident #39's credit card during a short-stay rehabilitation stay, causing emotional and financial harm.
F 0604 Ensure residents are free from physical restraints unless medically necessary: position change alarms were used without proper assessment or consent for Residents #14 and #22, potentially causing physical harm.
F 0610 Respond appropriately to all alleged violations: the facility failed to investigate the missing personal ring of Resident #34 adequately, creating potential emotional distress.
F 0641 Ensure each resident receives an accurate assessment: Resident #6's Quarterly MDS assessment was inaccurately coded with impairments that did not exist.
F 0656 Develop and implement a complete care plan: Resident #22 received sweetened beverages contrary to her no sweetened beverage diet order.
F 0657 Develop the complete care plan within 7 days and revise as needed: Resident #8's care plan was not updated to reflect discontinuation of oxygen therapy, risking inadequate respiratory care.
F 0658 Ensure nursing facility services meet professional standards: Resident #42 was administered the wrong dose of gabapentin, risking adverse effects.
F 0695 Provide safe and appropriate respiratory care: Resident #8 was not provided oxygen as ordered, risking respiratory distress.
F 0761 Ensure drugs and biologicals are labeled and stored properly: medications were left unattended; Resident #30's oxycodone pharmacy label did not match physician's order, risking medication errors.
F 0802 Provide sufficient support personnel for food and nutrition service: residents experienced delayed meal service beyond 45 minutes of posted time, risking nutritional and psychosocial harm.
F 0812 Procure and handle food according to professional standards: food items were uncovered, unlabeled, and stored improperly; cutting boards and equipment were unclean and unsanitized, risking food contamination and illness.
F 0880 Provide and implement an infection prevention and control program: laundry was left wet and mixed between clean and dirty sides; staff failed to perform hand hygiene consistently; medications were left exposed on medication carts, risking infection and contamination.
Report Facts
: misappropriated funds from Resident #39
: oxygen ordered for Resident #8
: dose of oxycodone ordered for Resident #30
: maximum acceptable delay for meal service
Inspection Report — Dec 19, 2024
Date: Dec 19, 2024
Visit Reason
A survey was conducted to assess compliance with food safety, waste disposal, and infection prevention standards.
Findings
The facility was found deficient in food safety due to unclean kitchen equipment and improper food storage, garbage disposal practices that could attract pests, and failure to disinfect reusable medical equipment between residents, risking cross contamination.
Deficiencies (3)
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the kitchen equipment was not clean, including dust on air conditioner fan covers and pink slime mold inside the ice machine, which had not been serviced as frequently as required (previously cited 11/26/24).
F 0814 Dispose of garbage and refuse properly: garbage was improperly disposed of around the compactor area, with edible and non-edible refuse spread on the ground, increasing risk of insect and rodent attraction.
F 0880 Provide and implement an infection prevention and control program: reusable medical equipment, specifically the mobile vital signs machine, was not disinfected between resident uses, risking cross contamination and infection.
Report Facts
: 36
: 11/26/2024
: 12/19/2024
Inspection Report — Dec 15, 2023
Routine
Date: Dec 15, 2023
Visit Reason
A routine health care licensure and follow-up survey was conducted to assess compliance with state and federal regulations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, abuse investigation, bed hold notification, accident hazard prevention, medication management, food safety, and arbitration agreement processes. These deficiencies posed risks ranging from minimal to actual harm to residents.
Deficiencies (12)
.0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: residents requiring assistance with eating were served last without clear communication or consent, placing them at risk of embarrassment and diminished dignity.
.0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report and investigate a hematoma injury on a resident's perineal area as potential abuse, missing required reporting to the State Agency's Long Term Care Reporting Portal.
.0610 Respond appropriately to all alleged violations: the facility did not follow its abuse prevention policy by failing to promptly investigate and report a suspected injury, lacking assessment of the environment, evidence collection, and interviews.
.0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave: the facility failed to document offering a bed hold to a resident upon hospital transfer.
.0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to ensure call lights were within reach, resulting in a resident falling and sustaining fractures.
.0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: controlled substances were repackaged by staff without pharmacy involvement and not disposed of timely, risking misuse or diversion.
.0757 Ensure each resident’s drug regimen must be free from unnecessary drugs: residents receiving opioid medications were not monitored for side effects nor offered non-pharmacological pain interventions prior to administration.
.0759 Ensure medication error rates are not 5 percent or greater: a nurse administered a rectal suppository instead of an oral laxative and failed to document or report the error properly.
.0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: medications and vaccines were found unlabeled, undated, or expired in medication storage areas.
.0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: food items were found uncovered, undated, or past use-by dates, and food temperature monitoring was not documented during serving.
.0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse: the facility failed to explain the arbitration agreement and did not inform residents of their 30-day rescind rights.
.0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue: the arbitration agreement did not include provisions for a neutral arbitrator or a convenient venue for both parties.
Report Facts
dates:
counts:
Inspection Report — Aug 21, 2023
Complaint Investigation
Date: Aug 21, 2023
Visit Reason
A complaint investigation was conducted regarding allegations of abuse involving withholding pain medication from a resident.
Complaint Details
The complaint was about abuse involving withholding pain medication from Resident #1. The allegation was substantiated by the facility's investigation.
Findings
The facility failed to ensure a resident was free from abuse when RN #1 withheld pain medication from Resident #1. The investigation confirmed the withholding and resulted in termination of RN #1's employment.
Deficiencies (1)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: RN #1 withheld oxycodone pain medication from Resident #1 on multiple dates without notifying the physician, resulting in minimal harm (previously cited 5/19/23).
Report Facts
date: May 19, 2023
date: May 12, 2023
date: Apr 5, 2023
date: Apr 30, 2023
date: Aug 21, 2023
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