Deficiencies (last 5 years)
Deficiencies (over 5 years)
13.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
72% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Dec 19, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey of the nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, protection from financial exploitation, use of restraints, care plan implementation, medication administration errors, food service and sanitation, infection control, and accurate resident assessments.
Deficiencies (13)
F 0550: The facility failed to ensure residents were treated with dignity during dining, including inappropriate labeling of residents as feeders and not serving meals simultaneously at the same table.
F 0602: The facility failed to protect residents from misappropriation of funds when a staff member used a resident's credit card for personal expenses.
F 0604: The facility failed to assess position change alarms as restraints and did not obtain required consents or physician orders for their use on residents.
F 0610: The facility failed to investigate a resident's missing personal item adequately, lacking documentation of the search and interviews.
F 0641: The facility failed to ensure resident MDS assessments accurately reflected resident status, including a mis-coded impairment assessment.
F 0656: The facility failed to follow residents' comprehensive care plans, including providing beverages not consistent with dietary orders.
F 0657: The facility failed to revise care plans as needed, including updating oxygen therapy orders and care plans for a resident.
F 0658: The facility failed to administer medications according to physician orders, including giving an incorrect dose of gabapentin.
F 0695: The facility failed to provide respiratory services as ordered, including not providing continuous oxygen therapy as prescribed.
F 0761: The facility failed to secure medications when unattended and failed to ensure pharmacy labels matched physician orders for controlled medications.
F 0802: The facility failed to provide timely meals to residents, with some residents waiting more than 45 minutes after posted meal times.
F 0812: The facility failed to ensure food safety practices including proper labeling, dating, covering of food, cleaning and sanitizing of cutting boards, dish racks, and refrigerator fans.
F 0880: The facility failed to provide adequate infection prevention and control, including sanitary laundry practices, hand hygiene by staff, and proper medication storage.
Report Facts
Unauthorized charges: 1900
Residents observed waiting for meals: 7
Residents affected by dignity issue: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Named in misappropriation of funds and dignity violation findings | |
| LPN #1 | Administered incorrect medication dose and left medications unattended | |
| LPN #2 | Left medication unattended and administered medication with mismatched pharmacy label | |
| RN #1 | Failed to perform hand hygiene before medication administration | |
| DON | Provided statements regarding meal timing, medication labeling, and investigations | |
| ED (Executive Director) | Involved in investigation of financial exploitation and facility responses | |
| Kitchen Manager | Provided statements on food safety and sanitation deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Dec 19, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and ensure resident safety and quality of care.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, protection from financial exploitation, use of restraints, care plan revisions, medication administration errors, respiratory care, medication security, food safety and sanitation, and infection prevention and control practices.
Deficiencies (11)
F 0550: The facility failed to ensure residents were treated with dignity during dining, including inappropriate labeling of residents as feeders and not serving meals simultaneously to residents at the same table.
F 0602: The facility failed to protect residents from misappropriation of funds when a staff member used a resident's credit card for personal expenses.
F 0604: The facility failed to assess position change alarms as restraints and did not obtain required consents or physician orders prior to their use on residents.
F 0610: The facility failed to investigate a resident's missing personal item adequately, lacking documentation of the search and interviews.
F 0641: The facility failed to ensure accurate MDS assessments, with one resident's impairment status incorrectly coded.
F 0657: The facility failed to revise care plans as needed, resulting in outdated oxygen therapy orders for a resident.
F 0658: The facility failed to administer medications according to physician orders, including a medication dosage error for a resident.
F 0695: The facility failed to provide respiratory services as ordered, with a resident not receiving prescribed oxygen therapy.
F 0761: The facility failed to secure medications properly and ensure pharmacy labels matched physician orders, risking medication errors and unauthorized access.
F 0812: The facility failed to ensure food safety by improper labeling, storage, and sanitation of food items and equipment, risking contamination and foodborne illness.
F 0880: The facility failed to implement effective infection prevention and control, including improper laundry handling, inadequate hand hygiene by staff, and unsafe medication storage practices.
Report Facts
Unauthorized charges: 1900
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Named in dignity deficiency and financial exploitation findings | |
| Executive Director (ED) | Involved in investigation and communication regarding financial exploitation and missing personal item | |
| Nursing Home Administrator (NHA) | Alerted to financial exploitation findings | |
| Registered Dietitian (RD) | Commented on meal serving practices | |
| Director of Nursing (DON) | Provided statements on restraint use and medication labeling | |
| Licensed Practical Nurse (LPN) #1 | Involved in medication administration errors and medication cart handling | |
| Licensed Practical Nurse (LPN) #2 | Observed leaving medications unattended and medication labeling issues | |
| Registered Nurse (RN) #1 | Observed not performing hand hygiene during medication pass | |
| Kitchen Manager | Provided statements on food safety and sanitation deficiencies | |
| Housekeeping Lead | Provided statements on laundry handling deficiencies |
Inspection Report
Life Safety
Deficiencies: 1
Date: 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)
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
Deficiencies: 3
Date: Dec 19, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety, waste disposal, and infection prevention standards at the facility.
Findings
The facility was found to have deficiencies in kitchen equipment cleanliness, food storage safety, garbage disposal practices, and infection prevention related to reusable medical equipment. These issues posed potential risks for food contamination, pest attraction, and cross-contamination among residents.
Deficiencies (3)
F 0812: The facility failed to ensure kitchen equipment was clean and food was stored safely, with dust on refrigerator air conditioner fan covers and pink slime mold inside the ice machine. This posed a risk of food contamination and adverse health outcomes for 36 residents.
F 0814: The facility failed to properly dispose of garbage to minimize insect and rodent attraction, with edible and non-edible refuse observed around the garbage compactor area. This posed a risk to all residents, staff, and visitors.
F 0880: The facility failed to ensure reusable medical equipment was disinfected between residents, as observed with a mobile vital signs machine used on multiple residents without cleaning. This increased risk of cross contamination and infection for residents.
Report Facts
Residents affected: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietitian | Confirmed presence of pink slime mold in ice machine and uncertainty about last cleaning | |
| Maintenance Technician | Confirmed quarterly cleaning schedule for ice machine and walk-in refrigerator air conditioning covers | |
| Administrator | Confirmed garbage compactor cleaning schedule and nursing staff responsibility for cleaning vital signs machines | |
| LPN #1 | Observed not disinfecting mobile vital signs machine between residents | |
| CNA #1 | Reported mobile vital signs machines cleaned once daily by night shift |
Inspection Report
Life Safety
Deficiencies: 5
Date: 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)
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
Annual Inspection
Deficiencies: 12
Date: Dec 15, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with federal regulations for nursing homes, including resident rights, abuse prevention, medication management, and food safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, inadequate investigation of suspected abuse, failure to provide bed hold notifications, unsafe environment leading to resident falls, improper medication management and labeling, failure to monitor residents for side effects of opioid medications, and deficiencies in food storage and safety practices.
Deficiencies (12)
F 0550: The facility failed to ensure residents were treated with dignity and respect, resulting in residents being served last and left with food uneaten, placing them at risk of embarrassment and diminished self-worth.
F 0609: The facility failed to timely report suspected abuse and thoroughly investigate an incident involving a resident with a hematoma, risking ongoing abuse without detection.
F 0610: The facility failed to ensure potential abuse, neglect, and mistreatment were thoroughly investigated according to policy, risking ongoing harm to residents.
F 0625: The facility failed to notify a resident or representative in writing about bed hold rights during hospitalization or therapeutic leave, risking psychosocial distress.
F 0689: The facility failed to ensure call lights were within reach, resulting in a resident falling and sustaining fractures to the hip and wrist.
F 0755: The facility failed to ensure controlled substances were tracked and disposed of timely, including repackaging medications improperly, risking misuse or diversion.
F 0757: The facility failed to monitor residents for side effects and offer non-pharmacological interventions prior to administering opioid medications, risking adverse reactions.
F 0759: The facility failed to prevent a medication error involving incorrect documentation and administration of a laxative, risking resident harm.
F 0761: The facility failed to ensure medications were properly labeled and dated, including expired vaccines and unlabeled blister packs, risking cross-contamination and ineffective treatment.
F 0812: The facility failed to ensure food items were dated, labeled, covered, and temperatures documented, risking foodborne illness for all residents.
F 0847: The facility failed to explain the binding arbitration agreement and the 30-day rescission right to residents and representatives, risking uninformed consent.
F 0848: The facility failed to provide a neutral arbitrator and convenient venue in the binding arbitration agreement, risking an unfair arbitration process.
Report Facts
Residents signed Arbitration Agreement: 39
Residents in facility: 43
Medication administrations without documented non-pharmacological interventions: 20
Medication carts observed: 3
Opened seasoning containers without use by date: 7
Opened food items with past use by dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Named in medication error finding for incorrect administration and documentation of Bisacodyl | |
| LPN #3 | Named in controlled substance repackaging and labeling deficiency | |
| RN #2 | Named in fall incident involving Resident #49 and call light placement | |
| CNA #2 | Named in fall incident involving Resident #49 and call light placement | |
| Administrator | Provided statements regarding arbitration agreement and abuse investigation | |
| DON | Director of Nursing | Provided statements regarding abuse investigation, medication administration, and fall risk |
| Dietician | Commented on serving order of Resident #35 | |
| CNA #1 | Commented on Resident #5 eating last | |
| Executive Chef | Commented on food temperature monitoring and food safety practices | |
| Admission Counselor | Discussed arbitration agreement explanation process |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 21, 2023
Visit Reason
The inspection was conducted following a complaint alleging that a resident (Resident #1) was subjected to abuse by withholding pain medication.
Complaint Details
The complaint investigation substantiated that RN #1 withheld pain medication from Resident #1, constituting abuse. RN #1 was terminated on 5/19/23. The facility found no other incidents of medication withholding or abuse after this event.
Findings
The facility failed to ensure Resident #1 was free from abuse when RN #1 withheld her prescribed pain medication multiple times without notifying the physician. The facility terminated RN #1's employment and took corrective actions including reviewing other residents' records and providing staff training.
Deficiencies (1)
F 0600: The facility failed to protect Resident #1 from abuse by withholding prescribed pain medication without proper physician notification or documentation. RN #1 held multiple doses of oxycodone despite the resident's scheduled pain regimen.
Report Facts
Dates medication withheld: 9
Date of termination: May 19, 2023
Date of complaint report submission: May 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication withholding abuse finding and terminated for this reason. |
| Administrator | Interviewed and confirmed investigation findings. | |
| Director of Nursing (DON) | Interviewed and confirmed investigation findings. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: 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)
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
Date: 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)
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
Date: 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)
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
Date: 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)
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
Date: 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)
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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