Inspection Reports for
The Terraces of Boise

.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.

.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.

.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.

.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.

.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.

.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.

.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.

.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.

.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.

.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.

.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.

.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.

.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.

.F 0550 Honor the resident's right to a dignified existence: residents were referred to as feeders needing assistance 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 funds, causing emotional and financial harm.

.F 0604 Ensure residents are free from physical restraints unless medically needed: position change alarms were used without proper assessment or consent for Residents #14 and #22, risking physical deterioration.

.F 0610 Respond appropriately to alleged violations: the facility failed to investigate the missing ring of Resident #34 adequately, lacking documentation and proper follow-up.

.F 0641 Ensure accurate resident assessments: Resident #6's MDS assessment was inaccurately coded as impaired when no impairment existed.

.F 0657 Develop and revise care plans timely: Resident #8's care plan was not updated to reflect discontinuation of oxygen therapy, risking inadequate treatment.

.F 0658 Provide nursing services meeting professional standards: Resident #42 received incorrect gabapentin dosage, risking adverse effects.

.F 0695 Provide safe respiratory care: Resident #8 was not provided oxygen as ordered, risking shortness of breath.

.F 0761 Ensure drugs and biologicals are properly labeled and secured: medications were left unattended; Resident #30's oxycodone label did not match physician's order, risking medication errors.

.F 0812 Procure and handle food safely: food items were uncovered, unlabeled, and stored improperly; cutting boards were pitted and stained; dish racks and refrigerator fans were dusty; cross-contamination risks observed during food preparation.

.F 0880 Provide and implement infection prevention and control: wet laundry was left unattended; clean and dirty laundry were mixed; staff failed to perform hand hygiene consistently; medications were stored improperly, risking resident harm.

F 0550 Honor the resident's right to a dignified existence: residents were referred to as feeders needing assistance 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 a resident's credit card during a short-stay rehabilitation stay; facility delayed internal investigation until police involvement.

F 0604 Ensure residents are free from physical restraints unless medically necessary: position change alarms were used without proper assessment or consent for two residents, risking physical deterioration.

F 0610 Respond appropriately to all alleged violations: the facility failed to properly investigate a resident's missing personal ring, lacking documentation of search efforts.

F 0641 Ensure each resident receives an accurate assessment: a resident's MDS assessment was inaccurately coded as having impairments when none existed.

F 0656 Develop and implement a complete care plan: a resident received sweetened beverages despite a no-sweetened-beverage diet order.

F 0657 Develop the complete care plan within 7 days and revise as needed: a resident's care plan and physician's order were not updated after oxygen therapy was discontinued.

F 0658 Ensure services meet professional standards: a resident was given the wrong dose of gabapentin due to medication administration error.

F 0695 Provide safe and appropriate respiratory care: a resident was not provided oxygen as ordered, risking shortness of breath.

F 0761 Ensure drugs and biologicals are labeled and stored properly: medications were left unattended; a resident's oxycodone pharmacy label did not match physician's order.

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 food from approved sources and store, prepare, distribute, and serve food per standards: food items were uncovered, unlabeled, and stored improperly; cutting boards were pitted and discolored; dish racks and refrigerator fans were dusty; cross-contamination risks observed during food preparation.

F 0880 Provide and implement an infection prevention and control program: wet laundry was left in washers too long; clean and dirty laundry were mixed; staff failed to perform hand hygiene consistently; medications were stored improperly on medication carts.

.0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: kitchen equipment was dusty and the ice machine had pink slime mold, indicating inadequate cleaning and maintenance (previously cited 11/26/2024).

.0814 Dispose of garbage and refuse properly: garbage compactor area had edible and non-edible refuse spread around, risking insect and rodent attraction.

.0880 Provide and implement an infection prevention and control program: reusable medical equipment was not disinfected between residents, risking cross contamination and infection.

F 0550 Honor the resident's right to a dignified existence: residents #5 and #35 were served last at meals without adequate consideration of their needs, causing risk of embarrassment and diminished dignity.

F 0609 Timely report suspected abuse: the facility failed to thoroughly investigate suspected abuse for Resident #39, missing potential ongoing abuse without protective measures.

F 0610 Respond appropriately to all alleged violations: the facility did not follow its Elder Abuse Prevention policy, failing to promptly investigate allegations of abuse for Resident #39.

F 0625 Notify the resident or representative in writing about bed hold duration: Resident #49 was not offered a bed hold at hospital transfer, risking psychosocial distress.

F 0689 Ensure nursing home area is free from accident hazards: Resident #49's call light was inaccessible, contributing to a fall causing fractures to her left hip and wrist.

F 0755 Provide pharmaceutical services: controlled substance Lyrica was repackaged by staff without original bottle or timely disposal, risking misuse or diversion.

F 0757 Ensure drug regimens are free from unnecessary drugs: Residents #34, #49, and #102 received opioid medications without documented non-pharmacological interventions or monitoring for side effects.

F 0759 Ensure medication error rates are below 5 percent: Resident #102 received a Bisacodyl suppository instead of the ordered oral tablet, with failure to document or notify physician properly.

F 0761 Ensure drugs and biologicals are properly labeled and stored: medications including Lyrica and vaccines were unlabeled, undated, or expired in medication storage areas.

F 0812 Procure and store food properly: multiple food items were undated, uncovered, or past use-by dates, and food temperatures were not documented during serving, risking foodborne illness.

F 0847 Inform residents of arbitration agreement rights: 39 residents signed arbitration agreements without clear explanation or notification of 30-day rescission rights.

F 0848 Provide a neutral and fair arbitration process: the arbitration agreement lacked provisions for a neutral arbitrator and convenient venue, risking unfair arbitration for residents.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to ensure Resident #1 was free from abuse when RN #1 withheld her prescribed oxycodone pain medication on multiple dates without physician notification, resulting in termination of RN #1's employment (previously cited 5/19/2023).