Inspection Report Summary
The most recent inspection on May 8, 2025, found multiple deficiencies related to resident assessments, medication availability and documentation, psychotropic medication reviews, and service agreements. Earlier inspections showed a pattern of similar issues with resident care documentation and medication management, as well as recurring fire and life safety deficiencies such as missing emergency testing documentation, inadequate staff training, and electrical hazards. Complaint investigations in January 2022 substantiated concerns about fall investigations, infection control, and staffing levels. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history indicates ongoing challenges with regulatory compliance, with no clear improvement trend over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Follow-Up
Deficiencies: 6
Date: May 8, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey to verify correction of previously cited deficiencies.
Findings
The facility was found to have multiple ongoing deficiencies including failure to conduct 90-day assessments, medication availability issues, incomplete medication destruction logs, lack of six-month psychotropic medication reviews, incomplete negotiated service agreements, and inconsistent documentation of resident care assessments.
Deficiencies (6)
Failure to conduct 90-day assessments for six of eight sampled residents including physical evaluations.
Medications not available to residents as prescribed, including PRN diclofenac sodium and other medications.
Medication destruction logs lacked two signatures for each medication, only one signature for non-narcotic medications.
Psychotropic medications taken longer than six months without required six-month reviews.
Negotiated Service Agreements did not clearly reflect residents' needs or describe services to be provided.
Resident care assessments for changes in physical and mental conditions were not consistently documented for six of eight sampled residents.
Report Facts
Sampled residents: 8
Residents with missing 90-day assessments: 6
Residents with incomplete NSAs: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debbie Henscheid | Administrator | Named as facility administrator |
| Mina Ramirez | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Life Safety
Deficiencies: 8
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire safety codes and regulations.
Findings
The facility was found deficient in multiple fire and life safety areas including lack of written relocation agreements, missing documentation for emergency generator testing, insufficient spare sprinklers, missing sprinkler escutcheons, prohibited use of multi-plug adapters and relocatable power taps, and gaps in emergency egress and relocation drills.
Deficiencies (8)
Facility could not provide the written agreements for the two required relocation locations.
No documented monthly load testing was provided for the Emergency Power Supply System (EPSS) generator sets.
No documentation was provided for the testing of Fire/Smoke dampers within the last four years.
Only three 155-degree spare sprinkler pendants were available instead of the required six.
Missing escutcheon from the flush mounted sprinkler pendant in the Assisted Living dining room closet.
Use of multi-plug adapters identified in rooms #100, #122, and #126 to supply power to various devices.
Use of relocatable power taps to supply power to medical devices in rooms #115 and #126.
Emergency egress and relocation drills had a gap from June 2024 to October 2024, not meeting the required bi-monthly frequency.
Report Facts
Spare sprinklers required: 6
Spare sprinklers found: 3
Emergency egress and relocation drills frequency: 6
Gap in drills: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeremy Wilson | Survey Team Leader | Named as survey team leader conducting the fire life safety and sanitation licensure survey |
| Debbie Henscheid | Administrator | Named as facility administrator |
Inspection Report
Life Safety
Deficiencies: 12
Date: Apr 24, 2023
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire safety codes and regulations.
Findings
Multiple deficiencies were identified related to emergency generators, fire suppression systems, fire doors, emergency lighting, staff training, electrical installations, prohibited electrical applications, medical gas safety, and emergency drills. Several required tests and documentation were missing or incomplete.
Deficiencies (12)
No documented monthly load testing, weekly inspections, or four-hour load test for level 1 emergency power supply system generator.
No documented full trip testing of the dry suppression system since 2019; missing escutcheon in activity room closet; blocked pendant in maintenance storage.
No documented testing of fire dampers in the past four years.
No documented annual fire door testing for two-hour separation occupancy or doors to protected stairwells and elevator shafts.
No documented monthly and annual emergency lighting testing as required.
No documented testing for alcohol-based hand rub dispensers each time a refill is replaced.
No documentation of bi-monthly review for staff training on the disaster plan.
Missing approved coverings on electrical connections in multiple locations; open junction box and missing switch cover.
Use of extension cords and multiple plug adapters prohibited but found in Health and Wellness office.
Use of relocatable power taps to supply power to appliances prohibited but found in housekeeping.
No documented ongoing education program for staff on oxygen risks and no policy for medical gas ignition source elimination.
Emergency egress and relocation drills not conducted as required; gap of four months with only four drills in past year and only one during night shift.
Report Facts
Survey Date: Apr 24, 2023
Response Due Date: May 24, 2023
Number of emergency egress drills required per year: 6
Number of emergency egress drills documented in past 12 months: 4
Months gap in emergency drills: 4
Number of drills during night shift: 1
Inspection Report
Follow-Up
Deficiencies: 12
Date: Apr 27, 2022
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to develop and implement adequate policies for abuse and neglect, failure to notify Adult Protection and law enforcement of alleged exploitation, incomplete nursing assessments, medication administration errors, lack of psychotropic medication reviews, inadequate behavior evaluations, incomplete resident service agreements, and insufficient documentation by medication technicians.
Deficiencies (12)
Administrator did not ensure a policy and procedure for abuse, neglect and exploitation was developed and implemented, missing key components and failing to notify Adult Protection following an alleged incident.
Administrator did not notify adult protection and law enforcement after Resident #6 reported $800 missing from their room.
Facility nurse did not conduct complete 90-day assessments for sampled residents including physical evaluations.
Residents did not receive medications and treatments as ordered, including incorrect doses and missed physician orders.
Facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status.
Facility did not have current six-month psychotropic medication reviews with behavior updates for residents taking such medications.
Facility did not evaluate maladaptive behaviors for Resident #11 who repeatedly yelled and slapped another resident.
Residents' Negotiated Service Agreements did not clearly reflect needs or describe services to be provided.
Medication technicians did not document assistance with medications and treatments, missing multiple oxygen saturation and blood glucose level recordings.
Facility did not develop a behavior plan with at least one intervention for each maladaptive behavior.
Facility did document behaviors but failed to document incidents of maladaptive behaviors as reported by staff.
Four of seven medication technicians lacked documentation of an Idaho Board of Nursing approved medication assistance course.
Report Facts
Missing oxygen saturation documentation: 44
Missing blood glucose documentation: 34
Medication technicians without approved training: 4
Residents with incomplete 90-day assessments: 10
Residents with incomplete NSAs: 10
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 4
Date: Jan 6, 2022
Visit Reason
The inspection was conducted as a health care complaint investigation regarding the facility's handling of resident falls and infection control practices.
Complaint Details
The visit was triggered by complaints related to resident falls and infection control. The investigation found multiple failures including lack of timely investigations, failure to notify licensing, improper mask use, and insufficient staffing.
Findings
The facility failed to conduct timely investigations of resident falls, did not notify the licensing agency within one business day of falls requiring hospital assessment, did not follow CDC recommendations for mask usage, and did not schedule sufficient staff to meet residents' needs.
Deficiencies (4)
The administrator did not conduct an investigation within 30 days when residents experienced falls.
The facility did not notify Licensing and Certification within one business day when residents experienced falls requiring hospital assessment.
The facility did not follow CDC recommendations for mask wearing to prevent transmission of infectious disease.
The facility did not schedule sufficient staff during all hours, resulting in delayed assistance after falls and insufficient care coverage.
Report Facts
Resident falls: 13
Resident falls: 16
Residents on two floors during night shift: 53
Staff members reporting insufficient staffing: 11
Falls requiring EMS assistance: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jon Potter | Administrator | Named as the administrator who did not conduct timely investigations of falls |
| Veronica LeMaster | Survey Team Leader | Led the health care complaint investigation survey |
Inspection Report
Life Safety
Deficiencies: 7
Date: Dec 1, 2021
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code, including lack of staff training on oxygen safety, missing documentation for inspections of fire suppression systems, unsecured gas cylinders, malfunctioning elevator fire doors, outdated relocation agreements, and absence of safety barriers on a gas fireplace.
Deficiencies (7)
Facility could not produce documentation showing staff are trained periodically on safety guidelines, usage requirements and risks associated with handling and use of oxygen.
Facility could not produce documentation to show weekly visual inspections of dry suppression system gauges and monthly visual inspections of secured control valves were completed.
Observation revealed a large unsecured helium tank in the activities closet and four unsecured carbon dioxide cylinders in the kitchen.
Elevator fire doors on first and third floors did not self-close properly when released from magnetic hold-open devices.
Facility could not produce documentation for periodic instruction or bi-monthly staff review of duties and responsibilities under the Emergency Action Plan.
Relocation agreements with two separate locations were not updated annually; last review was in 2011.
Two-sided gas fireplace in living/dining areas lacked safety barriers on either side.
Report Facts
Number of relocation agreements: 2
Year of last relocation agreement update: 2011
Number of unsecured carbon dioxide cylinders: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Chaney | Survey Team Leader | Led the fire life safety and sanitation licensure survey. |
| Jon Potter | Administrator | Facility administrator named in the report header. |
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