Inspection Report Summary
The most recent inspection on April 23, 2025, identified two deficiencies related to employee background checks and medication refrigerator temperature control. Earlier inspections showed a pattern of deficiencies involving facility maintenance, medication management, staffing, and fire and life safety compliance. Complaint investigations substantiated issues with housekeeping, medication errors, and failure to provide written responses to complaints, including a notable case involving an unsecured resident at risk of elopement. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows ongoing challenges with regulatory compliance, with some issues persisting over time and no clear pattern of overall improvement.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
17.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
118% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
56 residents
Based on a October 2023 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 23, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey to verify compliance with previous requirements and regulations.
Findings
Two deficiencies were identified: failure to complete Idaho State Police background checks for employees prior to working alone with residents, and failure to maintain medication refrigerator temperatures within the required range for insulin storage.
Deficiencies (2)
Two employees did not have Idaho State Police background checks completed prior to working alone with residents.
Medication refrigerator temperatures were not maintained between 38 and 45 degrees F daily, with documented instances below 38 degrees in March and April 2025.
Report Facts
Temperature deviations: 6
Temperature deviations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patrick McNabb | Administrator | Confirmed Idaho State Police background checks were not completed |
| Torrey Bollinger | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Life Safety
Deficiencies: 5
Date: Mar 6, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey at Brookdale Coeur d'Alene facility.
Findings
The facility had multiple non-core deficiencies including lack of clearly marked designated smoking areas, failure to ensure 1-hour fire-resistant construction and compartment containment, use of prohibited relocatable power taps with appliances, missing documentation for annual fuel-fired heating system inspections, and failure to conduct bi-monthly emergency egress and relocation drills between January and June 2023.
Deficiencies (5)
No smoking area was clearly marked or identified despite smoking policy permitting smoking in designated areas.
Facility failed to ensure 1-hour construction and compartment containment per NFPA 101; fire suppression system impairment caused damage and removal of fire resistive properties; facility placed on Fire Watch until repairs completed.
Use of relocatable power tap to power microwave and coffee maker in Room 223, which is prohibited.
Facility could not provide documentation of annual inspections for fuel-fired heating systems.
Facility did not hold emergency egress and relocation drills on a bi-monthly basis; drills missing from January 2023 to June 2023.
Inspection Report
Follow-Up
Census: 56
Deficiencies: 8
Date: Oct 24, 2023
Visit Reason
The visit was a follow-up survey to assess correction of previously cited non-core deficiencies related to healthcare and facility operations.
Findings
The facility was found to have ongoing issues including unarranged private-duty caregiver services, poor housekeeping and maintenance, inconsistent medication administration, missing provider orders, inadequate nursing assessments, inaccurate admission and discharge registers, insufficient staffing, and improper delegation of medication administration.
Deficiencies (8)
Private-duty caregivers provided basic care services not arranged or coordinated by the facility.
Facility was not maintained in a safe, clean, and orderly manner with stained carpets, dirty floors, urine odors, and overflowing trash cans.
Residents did not consistently receive medications and treatments as ordered, with documented missed doses and incomplete monitoring.
Residents' written, signed medication orders were not obtained or retained in records.
Nursing assessments were not conducted when residents experienced changes in health status, and some assessments were done by nurses without valid licenses.
Admission and discharge register was not up-to-date, with discrepancies in resident counts and inclusion of a deceased resident.
Insufficient staff to meet residents' needs and maintain cleanliness, resulting in missed showers and housekeeping tasks.
Most staff passing medications were not properly delegated by a nurse with a valid nursing license.
Report Facts
Resident census: 56
Resident roster count: 58
Admission and discharge register count: 54
Missed doses of lidocaine: 36
Missed doses of lidocaine: 44
Missed doses of diclofenac: 35
Missed doses of diclofenac: 43
Missed consecutive days of blood pressure medication: 5
Weighings ordered: 10
Weighings completed: 5
Weighings completed: 6
Staff passing medications not delegated: 10
Staff passing medications: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patrick McNabb | Administrator | Named as the facility administrator during the survey. |
| Melvin Lu | Survey Team Leader | Named as the survey team leader conducting the follow-up inspection. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 22
Date: Jan 27, 2023
Visit Reason
The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation at Brookdale Coeur d'Alene.
Complaint Details
The complaint investigation included issues such as lack of housekeeping for four months, stained carpets, medication issues, and food complaints. The administrator failed to provide written responses to these complaints.
Findings
Multiple deficiencies were identified including lack of required criminal background checks for employees, absence of a licensed administrator for a period, failure to provide written responses to complaints, unsafe and unclean facility conditions, medication administration errors, incomplete resident care records, and inadequate staff training and certification documentation.
Deficiencies (22)
One of ten employees did not have a Department Criminal History and Background Check.
Facility administrator did not have a Department Criminal History and Background Check completed within three years of hire date.
Eight of eight employees required to have State Police background checks did not have them completed.
Facility lacked a licensed administrator to oversee day-to-day operations between 10/20/22 and 11/18/22.
Administrator did not provide written responses to resident complaints within thirty days.
Licensing agency was not notified of administrator changes timely.
Facility was not maintained in a safe, clean, and orderly manner; stained carpets and unsafe exterior conditions observed.
Resident medication orders were not properly followed; diet orders not implemented; communication with providers lacking.
Residents lacked signed physician orders for multiple medications; discontinuation orders not obtained.
Nursing assessments were not conducted when residents experienced changes in health status.
Medication refrigerator temperatures were frequently out of the required range.
Residents' Negotiated Service Agreements did not reflect current needs or services provided.
Residents' care records were incomplete, not current, and documentation errors were not corrected.
Resident assessments were performed but not documented properly.
Admission and discharge register was not up-to-date or accurate.
Personnel records lacked documentation of orientation, infection control training, CPR, first aid certifications, and medication technician certification.
As-worked schedules did not document times staff were at the facility and lacked last names.
Facility did not have a certified food protection manager.
Weekly menu was not posted with the current week's menu for seven days.
Therapeutic menus were not signed and dated by a registered dietitian and were not provided during meal observations.
Staff lacked specialized training for caring for residents with dementia and mental illness.
Two of five staff who passed medications were not delegated by the current facility nurse.
Report Facts
Residents documented on admission and discharge register: 78
Residents listed on census report: 35
Corrected census report residents: 50
Residents on facility roster: 55
Weight loss of Resident #3: 62
Medication refrigerator out-of-range temperature occurrences: 15
Medication refrigerator out-of-range temperature occurrences: 18
Medication refrigerator out-of-range temperature occurrences: 24
Medication refrigerator out-of-range temperature occurrences: 12
Resident #4 medication refusals: 29
Employees without orientation or infection control training: 8
Employees without required continued training: 4
Employees without CPR or first aid certification: 6
Medication technicians without certification: 1
Staff lacking specialized dementia/mental illness training: 3
Staff passing medications without delegation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Smith | Administrator | Facility administrator during inspection; involved in findings related to licensing and complaint responses. |
| Stacey Brown | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey. |
Inspection Report
Life Safety
Deficiencies: 11
Date: Sep 27, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire and life safety codes and regulations.
Findings
Multiple deficiencies were identified including missing or incomplete relocation agreements, lack of documentation for fire and life safety records and inspections, physical safety hazards such as unsealed penetrations and blocked fire suppression equipment, electrical safety violations, unsecured oxygen cylinders, structural hazards like a collapsing front awning, inadequate emergency drills documentation, and unclear designated smoking areas.
Deficiencies (11)
Relocation agreement is for only one location and not dated or signed; facility must have at least two relocation agreements reviewed annually.
Facility could not provide documentation for fire and life safety records including ABHR dispenser testing, fuel-fired heating inspections, fire alarm inspections, and emergency egress and relocation drills.
Multiple fire and life safety code violations including prohibited transfer grilles, stairwell door not self-closing and latching, missing annual fire alarm inspection and sensitivity testing, unsealed kitchen ceiling penetration, blocked fire suppression activation devices, missing placard for Class K fire extinguisher, and corridor door not self-closing and latching.
Open electrical junction boxes and broken outlet cover present.
Use of extension cords and multiple plug adapters prohibited but found in use.
Use of relocatable power taps prohibited with medical appliances but found in use powering oxygen concentrator.
Unsecured oxygen cylinders found in resident rooms.
No documentation for annual fuel-fired heating inspection for gas furnaces and fireplace.
Front awning collapsing due to damage and dry rot; only caution tape present with free resident access and no protective guards.
Emergency egress and relocation drills insufficiently documented; only five drills documented with incomplete evacuation details and limited shift coverage.
No clearly marked designated smoking areas despite policy permitting smoking; ashtrays present without signage.
Report Facts
Number of documented emergency drills: 5
Number of relocation agreements required: 2
Size of unsealed kitchen ceiling penetration (inches): 24
Number of unsecured oxygen cylinders: 2
Number of French doors with free resident access to collapsing awning: 3
Inspection Report
Follow-Up
Deficiencies: 12
Date: Oct 22, 2021
Visit Reason
The inspection was a follow-up visit combined with a complaint investigation to assess compliance with previously cited deficiencies and to investigate specific complaints.
Complaint Details
The visit included a complaint investigation component; however, the substantiation status is not explicitly stated in the report.
Findings
The facility had multiple deficiencies including failure to monitor incident patterns, inadequate housekeeping, incomplete nursing assessments, medication administration errors, lack of psychotropic medication reviews, incomplete resident service agreements, behavior documentation issues, incomplete staff schedules, and failure to follow CDC COVID-19 infection control recommendations. Additionally, the facility operated without a licensed administrator for 34 days.
Deficiencies (12)
The administrator did not monitor patterns of incidents nor develop interventions to prevent recurrences.
The facility was not maintained in a clean, safe and orderly manner with soiled carpets, odors, full garbage cans, and soiled laundry in multiple resident rooms.
The facility nurse did not complete change of condition assessments for residents' wounds.
Residents did not receive medications as ordered, including incorrect dosing of Coumadin and missed doses of Lexapro.
The facility nurse did not assess residents' ability to self-administer medications.
Psychotropic medication reviews were not completed as required for residents.
Resident service agreements (NSAs) were incomplete, missing required components, and not signed by all responsible parties.
Behavior documentation was incomplete, missing documentation of suicidal thoughts and resident interactions.
The facility's as-worked staff schedules were incomplete, missing last names and exact times for all staff.
The facility did not follow CDC recommendations for COVID-19 infection control; staff were observed wearing masks improperly.
The Business Office Manager was passing medications without a medication assistance certification.
The facility failed to retain a licensed administrator overseeing day-to-day operations for 34 days.
Report Facts
Days without licensed administrator: 34
Medication missed days: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Madsen | Administrator | Named in relation to monitoring incident patterns, medication order oversight, and licensing status. |
| Mindy Ritz | Facility Administrator (former) | Named in relation to lapse of administrator and licensing issues. |
| Jenny Walker | Survey Team Leader | Led the inspection team for the follow-up and complaint investigation. |
Inspection Report
Life Safety
Deficiencies: 8
Date: Apr 1, 2021
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 deficiencies related to fire and life safety standards, including lack of written relocation agreements, blocked electrical panels, unsafe use of extension cords and power taps, non-compliance with NFPA 101 Life Safety Code requirements, blocked fire extinguishers, non-operational emergency lighting, and missing documentation for required inspections and testing.
Deficiencies (8)
Facility could not produce any written relocation agreements as required.
Marketing Director's office had a portable space heater in use.
Operational gas fireplaces in common areas did not have safety barriers.
Facility had multiple blocked electrical panels in mechanical/electrical rooms.
Two extension cords were 'daisy chained' together providing power to a TV in the dining room.
Business Manager's office had a refrigerator plugged into a Relocatable Power Tap (RPT).
Facility did not maintain compliance with NFPA 101 Life Safety Code, including missing annual fire/smoke door inspection, blocked exit corridor reducing clearance to 33 inches, non-operational emergency light, lack of documentation for testing of Alcohol Based Hand Rub dispensers, blocked Class K fire extinguisher without required placard, unserviced ABC fire extinguisher, and missing documentation for weekly and monthly inspections of fire suppression system components.
Facility could not produce documentation for an annual inspection of fuel fired heating systems/devices.
Report Facts
Number of relocation agreements required: 2
Corridor clearance: 33
Date of last ABC fire extinguisher service: 201911
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 18
Date: Feb 26, 2021
Visit Reason
The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation at the residential care/assisted living facility.
Complaint Details
The complaint investigation focused on the facility's admission and retention of Resident #5, who had moderate cognitive impairment and a history of wandering, in an unsecured facility. The facility failed to properly assess Resident #5 prior to admission and did not implement adequate safety measures, resulting in the resident eloping from the facility without incident reports or interventions. Staff and family members were unaware or not informed about the elopement incident.
Findings
The facility was found to have multiple deficiencies including failure to complete required background checks, inadequate investigation and reporting of incidents, poor housekeeping and maintenance, incomplete nursing assessments, medication administration errors, and failure to provide adequate supervision and secure environment for residents at risk of elopement. Specifically, Resident #5, who had moderate cognitive impairment and a history of wandering, was admitted and retained in an unsecured facility, placing them at risk for injury or death.
Deficiencies (18)
One of three staff members requiring a state-only criminal history and background check did not have evidence a background check was completed.
The facility admitted and retained Resident #5 who required a secure environment.
The facility did not investigate all incidents and accidents for multiple residents, including falls and an elopement.
The facility did not notify Licensing & Certification of reportable incidents within one business day.
The facility did not implement preventive measures after residents had incidents and accidents.
The facility was not maintained in a safe, clean, and orderly manner with soiled carpets, odors, dirty walls, torn flooring, and maintenance issues.
The facility nurse did not complete 90 day assessments for several residents.
The facility nurse did not complete change of condition assessments for multiple residents, including those with wounds, pain, and decline after falls.
Resident #1 was not receiving Ativan as ordered for 23 days; Resident #6 was underdosed on Gabapentin and missed methotrexate doses; multiple medications were not transcribed to the MAR.
Resident #1 and Resident #8 did not have signed physician orders for certain medications.
Two residents did not have assessments completed prior to self-administering medications.
Residents #1, #2, #3, and #6 did not have completed 6 month psychotropic medication reviews.
Residents #3 and #5 did not have their maladaptive behaviors evaluated.
Negotiated Service Agreements (NSA) were not updated to reflect current resident needs and lacked required components.
Individual care record documentation was not maintained or kept current for each resident.
The facility created their own menu without documenting substitutions to the dietician approved menu.
Multiple cots and a Hoyer lift were stored in a downstairs stairway hall leading to an emergency exit.
Five of seven staff records lacked documentation of mental illness training.
Report Facts
Total licensed capacity: 96
Resident #5's MoCA score: 12
Medication administration duration: 23
Staff records lacking mental illness training documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Edington | Administrator | Named as the facility administrator responsible for admissions and statements regarding Resident #5. |
| Veronica LeMaster | Survey Team Leader, Health Facility Surveyor, RN | Team leader conducting the health care licensure and complaint investigation survey. |
| Gloria Keathley | Health Facility Surveyor, LSW | Surveyor conducting the inspection. |
| Melvin Lu | Health Facility Surveyor, LD | Surveyor conducting the inspection. |
| Jenny Walker | Health Facility Surveyor, RN | Surveyor conducting the inspection. |
| Donna Henscheid | Health Facility Surveyor, LSW | Surveyor conducting the inspection. |
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