8 CMS Surveys
Inspection Report — Nov 20, 2025
Routine
Date: Nov 20, 2025
Visit Reason
A routine health care licensure survey was conducted to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to involve residents' representatives in care planning, failure to act on grievances regarding missing personal items, failure to implement physician orders for symptom management, and failure to ensure drug regimens were free from unnecessary medications.
Deficiencies (4)
F 0553 Allow resident to participate in the development and implementation of his or her person-centered plan of care: the facility failed to ensure residents' representatives were provided the opportunity to participate in the development of the resident's care plan, resulting in a delayed initial care conference beyond regulatory timeframes.
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: the facility failed to ensure grievances were acted upon when staff were made aware of residents' missing items, including ear amplifiers, shoes, socks, and underwear, which were not replaced or resolved.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: the facility failed to implement a physician's order for Haldol prescribed for symptom management during end-of-life care, potentially resulting in untreated symptoms.
F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs: the facility administered Keflex beyond the prescribed duration without documented physician authorization or clinical justification, increasing the risk of adverse outcomes including multi-drug resistant organisms.
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Inspection Report — Sep 12, 2025
Routine
Date: Sep 12, 2025
Visit Reason
A health care licensure and follow-up survey was conducted to evaluate compliance with state and federal regulations regarding resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident environment cleanliness, abuse prevention, transfer documentation, accurate assessments, medication monitoring and administration, dental care, hydration, food safety, staff licensing, and infection control practices. These deficiencies posed potential risks for resident harm, infection, and inadequate care.
Deficiencies (15)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: Resident #2's room had persistent foul urine odor and unclean conditions despite increased cleaning frequency.
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect: Resident-to-resident abuse occurred causing harm to Resident #87; immediate actions were taken but further interventions were lacking.
F 0610 Respond appropriately to all alleged violations: Facility failed to implement effective interventions to prevent further resident-to-resident abuse involving Residents #87 and #113.
F 0628 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies: Pertinent medical information was not documented as provided to receiving hospitals for Residents #4 and #79 during transfers.
F 0641 Ensure each resident receives an accurate assessment: Resident #10's Minimum Data Set (MDS) assessments failed to include diagnoses of dementia and anxiety despite medical documentation.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident #17's anticoagulant therapy monitoring was incomplete; signs and symptoms of complications were not documented as required.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube: Resident #72 was administered the incorrect nutritional supplement via feeding tube.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: Resident #29 was not receiving continuous oxygen therapy as ordered, resulting in dangerously low oxygen saturation.
F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: Pharmacy recommendations to discontinue unnecessary medications for Resident #90 were not acknowledged or acted upon.
F 0760 Ensure that residents are free from significant medication errors: RN failed to obtain an apical pulse prior to administering digoxin to Resident #50, risking adverse effects.
F 0790 Provide routine and 24-hour emergency dental care for each resident: Resident #68 had a broken tooth causing pain but no dental appointment was scheduled in a timely manner.
F 0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration: Resident #3 was observed coughing during lunch without a hydration beverage available.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: Facility failed to ensure proper hand hygiene, food storage, and cleaning of equipment including ice machines and cooking skillets; expired food items were found.
F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws: RN #1 worked multiple shifts with an expired nursing license before reassignment.
F 0880 Provide and implement an infection prevention and control program: Cross-contamination risk occurred during medication administration; food and drink were stored in medication carts; sterile technique was not followed during LVAD dressing change for Resident #2.
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Inspection Report — Sep 12, 2025
Routine
Date: Sep 12, 2025
Visit Reason
A 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 environment cleanliness, abuse prevention, transfer documentation, assessment accuracy, medication monitoring and administration, dental care, hydration, food safety, staff licensure, and infection control practices. These deficiencies posed potential risks for resident harm, infection, and inadequate care.
Deficiencies (15)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: Resident #2's room had persistent foul urine odor and unclean conditions despite increased cleaning frequency.
F 0600 Protect each resident from all types of abuse: The facility failed to protect Resident #87 from abuse by Resident #113, resulting in physical harm and placing all residents at risk.
F 0610 Respond appropriately to all alleged violations: The facility failed to implement effective interventions to prevent further resident-to-resident abuse involving Residents #87 and #113.
F 0628 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies: Pertinent medical information was not documented as provided to receiving hospitals for Residents #4 and #79 during transfers.
F 0641 Ensure each resident receives an accurate assessment: Resident #10's Minimum Data Set assessments did not include diagnoses of dementia or anxiety despite medical documentation.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident #17's anticoagulant therapy monitoring was incomplete as signs and symptoms were not documented on several dates.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube: Resident #72 was administered the incorrect nutritional supplement via feeding tube.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: Resident #29 was not receiving continuous oxygen therapy as ordered, resulting in low oxygen saturation.
F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: Pharmacy recommendations to discontinue unnecessary medications for Resident #90 were not acknowledged or acted upon.
F 0760 Ensure that residents are free from significant medication errors: RN #3 administered digoxin to Resident #50 without assessing the apical pulse as required.
F 0790 Provide routine and 24-hour emergency dental care for each resident: Resident #68 had a broken tooth causing pain but did not receive timely dental care or appointment scheduling.
F 0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration: Resident #3 was observed without a beverage during lunch and was coughing until provided a drink.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: The facility failed to ensure proper hand hygiene, food storage, and cleaning of equipment including ice machines and cooking skillets; expired food items were found.
F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws: RN #1 worked multiple shifts with an expired nursing license before being reassigned.
F 0880 Provide and implement an infection prevention and control program: The facility failed to prevent cross-contamination during medication administration, stored food improperly in medication carts, and did not use sterile technique during a dressing change for Resident #2 with an LVAD.
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Inspection Report — Jun 28, 2024
Routine
Date: Jun 28, 2024
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with state and federal regulations.
Findings
The survey identified multiple deficiencies including failure to maintain residents' dignity during dining, lack of advance directive documentation, failure to notify physicians of weight changes, unsafe and unclean environment, inadequate grievance investigation, sexual abuse incident, incomplete transfer documentation, incomplete care plans, medication errors, improper use of bed rails, inaccurate census posting, medication labeling issues, and unsanitary food service practices.
Deficiencies (16)
.000 Honor the resident's right to a dignified existence: residents seated at the same table were served meals at different times, causing potential psychosocial harm.
.000 Honor the resident's right to request, refuse, and/or discontinue treatment: failed to ensure residents and representatives received assistance to formulate advance directives; documentation missing for multiple residents.
.000 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: failed to notify physician of resident weight changes as ordered for 2 residents, placing them at risk.
.000 Honor the resident's right to a safe, clean, comfortable and homelike environment: facility failed to ensure equipment was clean and free of dried substances, risking cross-contamination.
.000 Honor the resident's right to voice grievances: failed to investigate and take prompt corrective action on a resident's grievance regarding missing medication, risking psychological harm.
.000 Protect each resident from all types of abuse: sexual abuse occurred when one resident inappropriately touched another; facility took corrective actions and was in substantial compliance at survey time.
.000 Not transfer or discharge a resident without an adequate reason: failed to document pertinent medical information provided to receiving hospitals for multiple residents.
.000 Develop and implement a complete care plan: failed to document dentures and oxygen orders for a resident, risking inadequate care.
.000 Provide appropriate treatment and care according to orders: failed to implement physician's order for bed side rails and failed to administer bowel medications as ordered.
.000 Provide safe and appropriate respiratory care: oxygen tubing and nasal cannula were found lying on the floor, risking infection.
.000 Try different approaches before using a bed rail: failed to assess risks, review benefits, obtain consent, and document alternatives for bed rail use for two residents.
.000 Post nurse staffing information every day: failed to post accurate census information daily for each shift.
.000 Ensure a licensed pharmacist perform a monthly drug regimen review: failed to recognize and report medication irregularities related to PRN psychotropic medication for a resident.
.000 Ensure drugs and biologicals are labeled and stored properly: expired medications found in storage room and undated insulin pens in medication cart.
.000 Procure food from approved sources and store, prepare, distribute, and serve food safely: multiple food safety violations including improper hand hygiene, food stored on floor, undated and expired food items, improper clothing and hair restraints, and inadequate cleaning schedules.
.000 Arrange for provision of hospice services: failed to coordinate care and delineate responsibilities between facility and hospice agency for a resident receiving hospice.
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Inspection Report — Jun 28, 2024
Routine
Date: Jun 28, 2024
Visit Reason
A routine health care licensure and follow-up survey was conducted to assess compliance with state and federal regulations.
Findings
The survey identified multiple deficiencies including failure to maintain residents' dignity during dining, incomplete advance directive documentation, failure to notify physicians of weight changes, unsafe and unsanitary environment, inadequate grievance investigation, sexual abuse incident, incomplete transfer documentation, incomplete care plans, medication errors, respiratory equipment sanitation issues, improper use of bed rails, inaccurate census posting, medication labeling and storage issues, and food safety violations.
Deficiencies (18)
.000 Honor the resident's right to a dignified existence: residents seated at the same table were served meals at different times, causing potential psychosocial harm.
.000 Honor the resident's right to request, refuse, and/or discontinue treatment: failed to ensure residents and representatives received assistance to formulate advance directives; documentation was incomplete for multiple residents.
.000 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: failed to notify physician of significant weight changes for residents #12 and #48 as ordered.
.000 Honor the resident's right to a safe, clean, comfortable and homelike environment: facility failed to maintain cleanliness of equipment and environment, including dirty lifting devices and vital sign machines.
.000 Honor the resident's right to voice grievances: failed to investigate and resolve a grievance regarding missing medication for Resident #16.
.000 Protect each resident from all types of abuse: Resident #42 inappropriately touched Resident #63; facility took corrective actions and separated residents.
.000 Not transfer or discharge a resident without an adequate reason: failed to document pertinent medical information provided to receiving hospitals for residents #8, #42, and #54.
.000 Develop and implement a complete care plan: Resident #27's care plan lacked documentation of dentures and oxygen order was missing; half side rails ordered but not in place.
.000 Provide appropriate treatment and care according to orders: Resident #27's physician ordered half side rails which were not in place; Resident #53's bowel medications were not administered as ordered.
.000 Provide safe and appropriate respiratory care: Resident #27's oxygen tubing and nasal cannula were observed lying on the floor, risking contamination.
.000 Try different approaches before using a bed rail: failed to document risk/benefit analysis, alternatives attempted, and obtain consent for bed rails for Residents #47 and #56.
.000 Post nurse staffing information every day: census information was not posted daily as required.
.000 Ensure a licensed pharmacist perform a monthly drug regimen review: pharmacist failed to review and report on PRN psychotropic medication for Resident #16.
.000 Implement gradual dose reductions and limit PRN psychotropic medications: Resident #16 received PRN quetiapine without stop date and frequent use without documented review.
.000 Ensure drugs and biologicals are labeled and stored properly: expired medications found in storage room; insulin pens undated in medication cart.
.000 Procure food from approved sources and store, prepare, distribute, and serve food safely: multiple food safety violations including improper hand hygiene, food stored on floor, undated opened food items, unrestrained hair, and unsanitary kitchen conditions.
.000 Ensure cleaning schedules are maintained and physical facilities cleaned regularly: cleaning schedules incomplete or not used; dirt and residue observed on kitchen ceilings and equipment.
.000 Arrange for provision of hospice services: failed to delineate responsibilities between facility and hospice agency for Resident #56.
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Inspection Report — May 8, 2023
Routine
Date: May 8, 2023
Visit Reason
A routine licensure and certification survey was conducted to evaluate compliance with Idaho Residential Assisted Living Facility regulations.
Findings
The facility was found deficient in multiple areas including medication self-administration documentation, resident rights, notification of changes in condition, abuse prevention and investigation, care planning, nursing staffing, dietary services, and infection control related to food safety. Immediate jeopardy was identified for serving unpasteurized eggs not fully cooked, which was later abated.
Deficiencies (29)
.0554 Allow residents to self-administer drugs: the facility failed to assess whether residents #20 and #61 could self-administer their Albuterol inhalers and failed to document self-administration.
.0558 Reasonably accommodate resident needs and preferences: Resident #61's light switch was not within reach, causing potential harm due to darkness and sleep disruption.
.0565 Honor resident's right to organize and participate in resident/family groups: concerns from Food Committee meetings were not documented or addressed, causing resident frustration.
.0580 Immediately notify resident, physician, and family of changes: the facility failed to timely notify family members of changes in condition for Residents #2, #19, and #231.
.0582 Give residents notice of Medicare/Medicaid coverage and potential liability: Residents #58, #66, and #178 were not provided required Medicare Advance Beneficiary Notices.
.0584 Honor resident's right to a safe, clean, comfortable environment: Resident #380 was exposed to unsanitary conditions with a cat litter box in the room not cleaned properly.
.0600 Protect residents from abuse and neglect: Residents #53, #60, #63, and #233 experienced abuse or neglect by staff or other residents, including rough care, verbal abuse, and retaliation.
.0609 Timely report suspected abuse, neglect, or injury: the facility failed to report and investigate abuse and injury of unknown origin timely for Residents #19 and #61.
.0610 Respond appropriately to alleged violations: the facility failed to investigate and document allegations of abuse and injury of unknown origin for Residents #19 and #61.
.0622 Not transfer or discharge without adequate reason and documentation: Resident #8 was transferred to hospital without documentation of information sent to receiving facility.
.0637 Assess resident when significant change in condition: Residents #61 and #329 had significant changes in condition but did not have timely comprehensive assessments completed.
.0657 Develop complete care plan within 7 days of assessment: Residents #10, #19, #61, and #329 had care plans that were not updated to reflect current needs, including ADLs, fall prevention, discharge goals, and wound care.
.0677 Provide care and assistance for ADLs: Residents #10, #19, #326, and #40 were not consistently provided bathing, nail care, and oral care as needed.
.0684 Provide appropriate treatment and care: Residents #2, #19, #61, #66, and #327 did not receive timely or complete neurological assessments after falls or head injuries, and physician orders were not always followed.
.0686 Provide appropriate pressure ulcer care: Residents #1, #326, and #329 developed new or worsening pressure ulcers due to inconsistent assessment, documentation, repositioning, and treatment.
.0690 Provide appropriate care for continence and catheter care: Residents #3 and #10 did not receive appropriate catheter care or toileting assistance, increasing risk for urinary tract infections.
.0692 Provide enough food/fluids to maintain health: Resident #64's tube feeding was disconnected and formula spilled, resulting in inadequate nutrition and hydration.
.0695 Provide safe and appropriate respiratory care: Resident #66 received oxygen at 3.5 liters per minute instead of the ordered 2 liters per minute via nasal cannula while awake.
.0725 Provide enough nursing staff and have a licensed nurse in charge on each shift: The facility failed to have a charge nurse on all shifts and staffing was insufficient to meet resident needs.
.0727 Have an RN on duty 8 hours a day, 7 days a week: The facility failed to ensure RN coverage for eight consecutive hours daily on multiple dates.
.0732 Post nurse staffing information daily: Nurse staffing information was not posted daily or retained for review.
.0756 Ensure licensed pharmacist performs monthly drug regimen review: Residents #14 and #31 had missing pharmacist reviews and physician responses to medication irregularities.
.0758 Implement gradual dose reductions and monitor psychotropic medications: Residents #10, #12, #19, and #61 had incomplete monitoring of target behaviors and adverse reactions related to psychotropic medications.
.0800 Provide nourishing, palatable, well-balanced diet: The facility failed to provide diets meeting nutritional and special dietary needs for multiple residents, including mechanical soft, cardiac, and renal diets. Menus were not followed and residents received repetitive or inappropriate foods.
.0804 Ensure food and drink is palatable, attractive, and at safe temperature: Residents reported food was often cold, bland, or unpalatable. Food temperatures were frequently outside safe ranges.
.0806 Ensure food accommodates allergies, intolerances, and preferences: Residents #7, #10, #19, #25, #30, #34, #38, #57, #61, #63, and #66 were not assessed for food preferences or dislikes, and were served foods they disliked or without choices.
.0812 Ensure therapeutic diets are prescribed and followed: Residents #22 and #70 were prescribed renal diets but received regular diets without modifications.
.0812 Immediate Jeopardy - Procure food from approved sources and serve safely: Residents #20 and #53 were served unpasteurized whole shell eggs that were not fully cooked, placing them at risk for foodborne illness. The facility implemented corrective actions and removed the immediacy.
.0842 Safeguard resident-identifiable information and maintain medication records: Resident #20 self-administered her inhaler but documentation of self-administration was incomplete and not consistently recorded in the MAR.
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Inspection Report — May 8, 2023
Routine
Date: May 8, 2023
Visit Reason
A comprehensive survey was conducted to evaluate compliance with Idaho Residential Assisted Living Facility regulations, including resident care, safety, staffing, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medication, inadequate accommodations for resident needs, failure to notify family members timely of changes in condition, abuse and neglect investigations, incomplete assessments and care plans, insufficient staffing and charge nurse coverage, improper food handling and dietary management, and failure to monitor psychotropic medication effects.
Deficiencies (27)
.0554 Self-administration of medication: the facility failed to assess and document residents' ability to self-administer medications, including Resident #20's albuterol inhaler use and documentation.
.0558 Reasonable accommodation: Resident #61's light switch was not within reach, creating potential harm due to darkness and inability to control lighting.
.0565 Resident rights: concerns voiced in Food Committee meetings were not documented or addressed, leading to resident frustration and decreased self-worth.
.0580 Notification of change in condition: the facility failed to immediately notify family members of residents' changes in condition for Residents #2, #19, and #231, placing residents at risk due to lack of advocacy.
.0582 Medicare notices: Residents #58, #66, and #178 were not provided with Medicare Advance Beneficiary Notices when discharge was anticipated, violating policy.
.0584 Sanitary environment: Resident #380 was observed with a cat and unsanitary litter box in the room, risking cross contamination and infection.
.0600 Abuse prevention: Residents #53, #60, #63, and #233 experienced abuse or neglect by staff or other residents, including rough care, verbal abuse, and retaliation, with inadequate facility response.
.0609 Abuse reporting: Resident #61's fall with head injury was not properly assessed or reported, and neurological checks were not documented, risking undetected injury.
.0610 Abuse investigation: the facility failed to thoroughly investigate abuse allegations for Resident #19, including incomplete interviews and documentation.
.0622 Transfer information: Resident #8 was transferred to hospital without documentation of required information sent to receiving facility, risking continuity of care.
.0637 Significant change assessment: Residents #61 and #329 did not have timely comprehensive assessments following significant changes in condition, risking unmet care needs.
.0657 Care plan revision: Residents #10, #19, #61, and #329 had care plans that were not updated to reflect current needs, including ADLs, fall risk, discharge goals, and catheter care.
.0677 Activities of daily living: Residents #10, #19, #326, and #40 did not consistently receive bathing, nail, and oral care as needed, risking hygiene and skin integrity.
.0684 Nursing standards: Residents #2, #19, #61, #66, and #327 did not receive timely neurological assessments or appropriate nursing care following falls or head injuries.
.0686 Pressure ulcer care: Residents #1, #326, and #329 had new or worsening pressure ulcers due to inconsistent assessment, documentation, repositioning, and treatment.
.0690 Urinary care: Residents #3 and #10 did not receive appropriate catheter care or incontinence management, increasing risk of urinary tract infections.
.0692 Nutrition and hydration: Resident #64's tube feeding was disconnected and formula spilled, resulting in inadequate nutrition and hydration per physician orders.
.0695 Respiratory care: Resident #66 received oxygen at 3.5 liters per minute instead of the ordered 2 liters per minute while awake, risking oxygen toxicity.
.0725 Staffing: The facility failed to ensure sufficient nursing staff and charge nurse coverage on all shifts, risking resident care and safety.
.0732 RN coverage: The facility failed to ensure an RN was on duty for eight consecutive hours daily, seven days a week, risking unmet nursing needs.
.0800 Nurse staffing posting: The facility failed to post nurse staffing information daily and maintain records for 18 months, limiting transparency for residents and visitors.
.0803 Medication regimen review: Residents #14 and #31 did not have monthly pharmacist medication reviews or physician responses to pharmacist recommendations, risking medication errors.
.0758 Psychotropic medication monitoring: Residents #10, #12, #19, and #61 did not have resident-specific target behaviors identified or adequately monitored for psychotropic medication effects.
.0800 Food and nutrition: Residents on mechanical soft, cardiac, and renal diets did not receive meals consistent with their prescribed diets; menus were not followed or reviewed by a dietitian; food was often repetitive and not palatable.
.0804 Food temperature and palatability: Residents #7, #13, #19, #25, #30, #34, #61, and #66 reported food was often cold, bland, or unpalatable; food temperatures were frequently outside safe ranges.
.0812 Food safety: Residents #20 and #53 were served unpasteurized eggs that were not fully cooked, placing them at immediate jeopardy of foodborne illness; facility implemented corrective actions to remove immediacy.
.0842 Medication self-administration: Resident #20 self-administered her inhaler but documentation of self-administration was incomplete and not consistently recorded in the MAR.
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Inspection Report — Apr 18, 2023
Date: Apr 18, 2023
Visit Reason
Survey conducted to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during this survey.
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