Inspection Reports for Truewood by Merrill, Boise
2600 N Milwaukee St, Boise, ID 83704, ID, 83704
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16
12
8
4
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Inspection Report
Complaint Investigation
Deficiencies: 5
May 31, 2024
Visit Reason
The inspection was conducted as a health care licensure survey combined with a follow-up and complaint investigation to assess compliance with regulatory requirements and address specific complaints.
Findings
The facility operated without a licensed administrator for 25 days, failed to consistently track and intervene in resident-to-resident incidents, did not complete required quarterly assessments for most sampled residents, and failed to consistently assess residents after changes in condition. Additionally, medication technicians administered PRN medications without proper nurse consultation, and the facility lacked a Certified Food Protection Manager at the time of survey.
Complaint Details
The visit included a complaint investigation component as indicated by the survey type and findings related to resident-to-resident altercations and lack of proper nursing assessments.
Deficiencies (5)
| Description |
|---|
| Facility operated without a licensed administrator from 2/22/24 through 3/17/24. |
| Facility did not consistently track and trend patterns of incidents nor develop effective interventions to prevent recurrences of resident-to-resident physical altercations. |
| Registered Nurse did not perform quarterly assessments within 90 days of survey entrance for 8 of 9 sampled residents. |
| Facility nurse did not consistently assess residents after changes in condition and medication technicians administered PRN medications without nurse consultation. |
| Facility did not have a Certified Food Protection Manager at the time of survey; dietary manager's certification had expired. |
Report Facts
Days without licensed administrator: 25
Sampled residents missing quarterly assessments: 8
Sample size for quarterly assessments: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Summer Redwine | Administrator | Named as the facility administrator at time of survey. |
| Teresa McClenathan | Survey Team Leader | Named as survey team leader conducting the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 10
Dec 29, 2023
Visit Reason
The inspection was conducted as a health care complaint investigation triggered by allegations of abuse involving Resident #2 and other concerns related to resident care and safety.
Findings
The investigation found multiple deficiencies including failure to include all required elements in the abuse/neglect/exploitation policy, delayed administrator notification of abuse allegations, incomplete investigations, failure to protect residents from alleged abusers, lack of corrective actions after incidents, inadequate nursing assessments for changes in resident conditions, incomplete resident service agreements, and insufficient documentation of resident care and behavior evaluations.
Complaint Details
The complaint investigation was substantiated with findings of abuse allegations involving Resident #2 and multiple failures in policy, investigation, resident protection, nursing assessments, and documentation.
Deficiencies (10)
| Description |
|---|
| The facility's abuse/neglect/exploitation policy did not include all required elements such as education, reporting procedures, investigation steps, and interventions to prevent further abuse. |
| Administrator was not informed timely about an abuse allegation involving Resident #2. |
| Administrator did not conduct thorough investigations into abuse allegations, only interviewing the alleged abuser and the resident. |
| Resident #2 was not protected from the alleged abuser who continued working with residents during the investigation. |
| Administrator failed to implement corrective actions after multiple resident falls and injuries. |
| Facility nurse did not conduct nursing assessments for residents with changes in condition, including bruises, falls, and pain complaints. |
| Residents' service agreements (NSA's) did not clearly reflect residents' needs or describe services to be provided. |
| Facility lacked a system to ensure the nurse was notified of residents' change of condition. |
| Nursing assessments for changes in resident conditions were not consistently documented. |
| Facility did not evaluate Resident #2's maladaptive behaviors or complete behavior evaluations. |
Report Facts
Dates of incidents: Abuse allegation on 11/08/23; falls on 11/10/23, 11/15/23, 11/27/23, 12/02/23, 12/23/23; bruising and pain noted on various dates in November and December 2023.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jody Stephen | Administrator | Named in findings related to failure to be informed timely of abuse allegations, failure to conduct thorough investigations, failure to protect residents, and failure to implement corrective actions. |
| Megan Rideout | Survey Team Leader | Led the health care complaint investigation survey. |
Inspection Report
Follow-Up
Deficiencies: 16
May 5, 2023
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to verify compliance with previous citations and assess current regulatory adherence.
Findings
Multiple deficiencies were identified including incomplete criminal history and background checks for employees, failure to conduct timely investigations of resident incidents, inadequate notification to licensing agency of falls, inconsistent completion of change of condition assessments, medication administration issues, incomplete psychotropic medication reviews, unsigned service agreements, missing resident care records, undocumented dietary substitutions, incomplete staff schedules, insufficient certified personnel during night shifts, and incomplete orientation training for employees.
Deficiencies (16)
| Description |
|---|
| One of ten employees did not have a Department Criminal History and Background Check completed. |
| Use of a previous Criminal History and Background Check outside the three-year window for one employee. |
| Two employees did not have Idaho State Police background checks completed as required. |
| Administrator did not conduct investigations within 30 days for multiple resident incidents. |
| Facility failed to notify Licensing and Certification within one business day of resident falls requiring assessment. |
| Change of condition assessments were not consistently completed for residents with falls or hospice admission. |
| Facility nurse did not assess resident's ability to self-administer medication after hospice admission and medications were not audited properly. |
| Medication refrigerator temperatures were not monitored and documented daily as required. |
| Psychotropic medication reviews were not completed for residents on such medications longer than six months. |
| Residents' Negotiated Service Agreements did not accurately reflect needs or services provided. |
| Negotiated Service Agreements were not signed and dated by residents or their legal representatives. |
| Pre-admittance assessments were conducted but not retained in resident care records. |
| Dietary substitutions were not documented as required. |
| As-worked staff schedules did not include all staff, last names, or exact times, and memory care schedules were not maintained. |
| Three of eight sampled staff did not have current certification and worked alone during night shifts. |
| Four of ten employees did not complete required sixteen hours of orientation training within thirty days of hire. |
Report Facts
Employees without Department Criminal History and Background Check: 1
Employees without Idaho State Police background check: 2
Resident falls not investigated within 30 days: 3
Resident falls not reported within one business day: 2
Residents with incomplete change of condition assessments: 2
Days medication refrigerator temperatures logged: 10
Days medication refrigerator temperatures logged: 14
Staff without current certification: 3
Employees with incomplete orientation training: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jody Stephen | Administrator | Confirmed multiple deficiencies including incomplete investigations and training documentation |
| Michael Oldfield | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 22, 2022
Visit Reason
The inspection was conducted as a health care complaint investigation regarding an incident where a facility nurse left the memory care unit unattended during a night shift on 5/13/22.
Findings
The administrator failed to complete an investigation after a nurse left early, resulting in residents being unattended and a resident found with feces on their clothing. Staff reported unanswered call lights since 4:00 AM.
Complaint Details
The complaint investigation found that the administrator did not complete an investigation following the incident of unattended residents and unmet care needs on 5/13/22.
Deficiencies (1)
| Description |
|---|
| Administrator did not complete an investigation after a nurse left the memory care unit unattended on 5/13/22, resulting in resident neglect. |
Report Facts
Facility License Number: RC-1024
Survey Date: 07/22/2022
Response Due Date: 08/21/2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jody Stephen | Administrator | Named in relation to failure to complete investigation |
| Teresa McClenathan | Survey Team Leader | Led the complaint investigation |
Inspection Report
Life Safety
Deficiencies: 8
Feb 14, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire safety codes and related regulations.
Findings
Multiple deficiencies were identified including outdated relocation agreements, missing documentation for fire and life safety inspections, uncovered live electrical connections, unsecured medical gas cylinders, lack of required inspections for fire suppression and fuel-fired heating systems, overdue fire extinguisher maintenance, missing emergency preparedness training records, and failure to conduct required emergency evacuation drills.
Deficiencies (8)
| Description |
|---|
| Relocation agreements are outdated and with administrators no longer in service. |
| Missing documentation for fire life safety inspections including fire suppression quarterly inspections, fuel-fired heating inspection, annual fire alarm inspection, semi-annual hood inspection, and UL testing for dry system pendants. |
| Exposed live wiring in rear mechanical and fire alarm room electrical disconnect panel due to missing cover. |
| Use of multiple plug adapters prohibited; rooms 110 and 225 using 3-1 MPAs; microwave plugged into one of the MPAs in room 225. |
| No documented inservice for staff qualifications on oxygen risks; multiple unsecured oxygen cylinders in various rooms and storage areas; oxygen storage room not properly signed. |
| No documentation for annual fuel-fired heating inspection. |
| No documentation for annual fire alarm inspection and sensitivity testing; missing inspections for fire suppression system components; overdue fire extinguisher maintenance and inspections; missing emergency preparedness training and resident training documentation; no testing documentation for Alcohol Based Hand Rub dispensers; room 248 door not latching properly; unsealed wall penetration in mechanical room. |
| Emergency egress and relocation drills not conducted to designated assembly points as required. |
Report Facts
Unsecured oxygen cylinders: 8
Unsealed wall penetration size: 3
Unsealed wall penetration size: 12
LOX liberators volume: 42
Inspection Report
Follow-Up
Deficiencies: 7
Nov 10, 2021
Visit Reason
The inspection visit was conducted as a follow-up to previous healthcare core deficiencies and a complaint investigation to verify correction of cited issues.
Findings
Multiple deficiencies were found including incomplete background checks for employees, poor housekeeping and maintenance, lack of delegation for medication technicians, failure to assess a resident after falls, failure to report abuse allegations, insufficient staffing, and residents not receiving care according to their negotiated service agreements.
Complaint Details
The visit included a complaint investigation component, but substantiation status is not explicitly stated.
Deficiencies (7)
| Description |
|---|
| One of two employees requiring a state police background check did not have one completed. |
| Facility was not maintained in a clean, safe, and orderly manner with stained carpets, cracked patios, damaged flooring, dirty air ducts, and water-damaged ceiling tiles. |
| Five of five medication technicians were not delegated by the current facility nurse to pass medications. |
| Resident #1 was not assessed by the facility nurse after falls on 7/3/21 and 10/4/21. |
| Administrator failed to report all allegations of abuse to Adult Protection, including an incident where a staff member pushed a resident causing a fall and fractured hip. |
| Facility did not schedule sufficient staff during all hours to meet resident needs; for example, only one staff member was scheduled for the night shift in memory care with 27 residents, some requiring two-person assist. |
| Residents #2, #6, #7, and #8 did not receive showers according to their negotiated service agreements, receiving one shower a week instead of two since August 2021. |
Report Facts
Residents in memory care unit: 27
Residents in assisted living unit: 89
Staff scheduled for night shift: 2
Residents requiring two-person assist: 3
Residents requiring two-person assist: 2
Residents with behavioral issues: 21
Residents with showers scheduled twice a week but only receiving one: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jody Stephen | Administrator | Named in relation to failure to report abuse and awareness of shower schedule issues |
| Mina Ramirez | Survey Team Leader | Led the inspection team for the follow-up and complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 124
Deficiencies: 12
Mar 4, 2021
Visit Reason
The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation at Truewood by Merrill, Boise.
Findings
The facility was found to have multiple deficiencies including inadequate care related to retaining a resident at risk for elopement in an unsecured environment, failure to conduct criminal background checks for employees, inadequate nursing assessments for residents with changes in condition, incomplete medication orders, poor housekeeping and maintenance, and insufficient staff training.
Complaint Details
The complaint investigation focused on Resident #16 who had cognitive impairment and a history of elopement. The resident eloped in August 2020 and again in February 2021 from the unsecured facility, placing them at risk for injury or death. The facility failed to provide a secure environment and adequate supervision despite documented behavior plans and family communications.
Deficiencies (12)
| Description |
|---|
| 1 of 10 employees did not have criminal history background check. |
| 3 of 3 employees who required Idaho State Police background check did not have one. |
| The facility admitted and retained Resident #16 who required a secure environment but was kept in an unsecured facility despite elopement risks. |
| Rooms and hallways had carpets with numerous dark stains and were heavily worn; courtyard had large cracks, debris, open dumpster, broken air conditioner, and accessible chemicals. |
| 3 of 5 medication technicians did not have documentation of delegation in their files. |
| Facility nurse did not assess multiple residents when they had changes of condition, including wounds, falls, skin tears, and weight loss. |
| Residents #1, #3, #4, #9, #15 did not have signed physician medication orders at the time of survey. |
| Facility records were not maintained for three years; communication logs were shredded after 5 to 30 days. |
| Resident care records were not completed by the person providing care; medication technicians documented care provided by others. |
| 10 of 10 staff did not have 16 hours of orientation training documented and signed within 30 days of hire. |
| 7 of 10 staff did not have mental illness training. |
| 7 of 10 staff did not have developmental disability training. |
Report Facts
Total licensed capacity: 124
Employees without criminal history background check: 1
Employees without Idaho State Police background check: 3
Medication technicians without delegation documentation: 3
Residents without signed physician medication orders: 5
Staff without orientation training documented: 10
Staff without mental illness training: 7
Staff without developmental disability training: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa McClenathan | Survey Team Leader, RN | Team leader conducting the survey |
| Melvin Lu | Health Facility Surveyor, RD | Surveyor conducting the survey |
| Gloria Keathley | Health Facility Surveyor, LSW | Surveyor conducting the survey |
| Jenny Walker | Health Facility Surveyor, RN | Surveyor conducting the survey |
| Donna Henscheid | Health Facility Surveyor, LSW | Surveyor conducting the survey |
| Tom Moss | Health Facility Surveyor, LSW | Surveyor conducting the survey |
| Jody Stephen | Administrator | Administrator confirming resident risk and family communications |
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