Inspection Reports for Wellspring Meadows Assisted Living
9873 North Buttercup Lane, Hayden, ID, 83835
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 27, 2023, found deficiencies related to the absence of an activity director, unsecured gates in the memory care building, and inconsistent monitoring of medication refrigerator temperatures. Earlier inspections showed a pattern of issues with secure environments, medication management, and safety equipment, including unsecured oxygen cylinders and missing fire safety documentation. Prior reports also noted deficiencies in resident evaluations, staffing levels, and failure to notify licensing of reportable incidents. Complaint investigations were not listed in the available reports. The facility’s inspection history indicates ongoing challenges with environmental security and medication practices, with no clear pattern of improvement or worsening over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jul 27, 2023
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility lacked an activity director resulting in no activities being offered to residents during the survey period. The memory care building did not provide a secure environment as gates were left open and did not latch properly. Additionally, the medication refrigerator temperatures were not consistently monitored or maintained within the required range, with documented temperatures below the acceptable range.
Deficiencies (3)
No activities were offered to residents due to vacancy of the activity director position.
The memory care building did not provide a secure environment; gates were left open and did not latch properly.
Medication refrigerator temperatures were not monitored daily and were not maintained between 38 and 45 degrees F, with documented temperatures at 36 degrees F.
Report Facts
Temperature monitoring omissions: 9
Temperature recorded: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kurt Neely | Administrator | Provided explanation for lack of activities and plans to address gate security |
| Bradley Perry | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Life Safety
Deficiencies: 8
Date: Feb 28, 2020
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey of Wellspring Meadows Assisted Living facility.
Findings
Multiple deficiencies were identified related to fire safety equipment, emergency lighting, exit door locks, fire drills, secure environment, and building character across the two houses (Buttercup and Syringa). Documentation for required inspections and tests was missing, and physical safety issues such as unsecured oxygen cylinders and obstructed sprinklers were noted.
Deficiencies (8)
Syringa house lacked a specialized wrench for fire sprinklers and had only 4 spare sprinklers instead of the required 6; boxes obstructed a sprinkler in the Administrator's office; no documentation for monthly visual inspections of fire sprinkler gauges and control valves.
No documentation for an annual fire alarm inspection; last known inspection was on 9/5/2017.
Unsecured oxygen cylinder under the sink at the staff washing station in the Syringa house.
Emergency light across from resident room #15 in Buttercup house was non-operational; no documentation for a 90 minute annual test of emergency lighting.
Both buildings had non-single operational locking arrangements on front and rear doors; Buttercup house had magnetic locks with keypad override and a deadbolt; Syringa house had magnetic locks with keypad override and a deadbolt at rear exit; no delayed egress component at either house.
Missing fire drills in Buttercup house on third shift second, third, and fourth quarters 2019 and on first and second shifts fourth quarter 2019; Syringa house missing fire drills on third shift all four quarters 2019 and first and second shifts fourth quarter 2019.
Magnetic lock on rear yard door at Buttercup house was not engaged and door could be opened without keypad override; gate on west end of secured yard was left unlocked and wide open.
Multiple penetrations observed in mechanical/electrical rooms where wires and pipes run through walls and ceilings at both houses.
Report Facts
Fire drills missing: 7
Spare fire sprinklers: 4
Inspection Report
Follow-Up
Deficiencies: 8
Date: Aug 9, 2019
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to assess compliance with regulations and verify correction of previously cited deficiencies.
Findings
The facility was found deficient in multiple areas including failure to evaluate residents' behaviors, unsecured environments, lack of change of condition assessments by the RN, medication order and treatment errors, missing psychotropic medication reviews, failure to notify licensing of reportable incidents, unsecured medical gases, and insufficient personnel to provide required assistance.
Deficiencies (8)
The facility did not evaluate residents' behaviors including inappropriate grabbing and hoarding behaviors.
Residents with cognitive impairments were observed sitting unsupervised on unsecured front patios and the facility's buildings and yards were not secure.
The RN did not conduct change of condition assessments for several residents after falls and medication errors.
Medication orders and treatments were not properly followed, including administration without orders, missing adaptive equipment, unavailable medications, and incorrect diets.
Psychotropic medication reviews were not conducted every six months and behavioral updates were not provided to the physician for over a year.
The facility failed to notify Licensing and Certification of reportable incidents involving bruising of unknown origin in multiple residents.
Oxygen cylinders were observed unsecured in multiple rooms in the facility.
Insufficient personnel were scheduled to provide required two-person assistance during transfers, resulting in residents being left alone multiple times per month during night shifts.
Report Facts
Residents with bruising: 5
Oxygen cylinders unsecured: 5
Falls: 4
Times residents left alone: 2
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