Inspection Report Summary
The most recent inspection on July 14, 2025, found deficiencies related to failure to protect residents from abuse and inadequate administrative response to abuse allegations. Earlier inspections showed issues with fire and life safety compliance, unsecured environments, incomplete nursing assessments, and staff background check documentation. The main themes across reports include resident safety concerns, particularly abuse prevention and investigation, as well as environmental and procedural compliance. The July 2025 complaint investigation was substantiated, confirming failures in abuse reporting and protection, while prior complaints were not noted. The inspection history indicates ongoing challenges with resident safety and administrative oversight, with no clear pattern of improvement over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% better than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 14, 2025
Visit Reason
The inspection was conducted as a health care complaint investigation triggered by allegations of abuse involving residents at Harbor Assisted Living.
Complaint Details
The complaint investigation was substantiated, finding that the administrator failed to report and investigate abuse allegations involving Residents #2 and #3, and failed to protect residents from further abuse by caregivers. Caregivers reported witnessing rough and abusive behavior, and the administrator did not take appropriate corrective actions.
Findings
The investigation found that the facility failed to protect residents from abuse, with the administrator not notifying adult protective services, not completing thorough investigations, and failing to protect residents from further abuse. These failures affected 100% of the residents and resulted in abuse.
Deficiencies (5)
The administrator failed to notify adult protective services of an allegation of abuse involving Resident #3 on 5/26/25.
The administrator did not complete an investigation to determine if abuse occurred after a staff member observed forceful handling of Resident #3 resulting in injury.
The administrator was not notified of all allegations of abuse at the facility, as multiple caregivers witnessed abuse but did not report it.
The administrator did not protect residents from potential further abuse after being aware of alleged mistreatment of Resident #1 by a staff member.
The facility failed to protect 2 of 2 sampled residents when the administrator failed to immediately notify APS, complete thorough investigations, and protect residents after alleged abuse by caregivers.
Report Facts
Dates of alleged abuse incidents: May 26, 2025
Dates of caregiver shifts: 11
Resident ages: 91
Resident ages: 75
Inspection Report
Life Safety
Deficiencies: 4
Date: Nov 20, 2024
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 the facility.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101, Chapter 33, including issues with a sprinkler pendant covered in paint, outdated fire suppression system inspections, and lack of smoke detector sensitivity testing documentation. Additionally, the facility failed to maintain proper handling, use, and storage of medical gases, including the absence of required precautionary signage where supplemental oxygen is used.
Deficiencies (4)
Sprinkler pendant above doorway in room #8 was completely covered in non-factory applied paint and must be replaced.
Fire suppression systems were not maintained according to NFPA 25; gauges were not replaced or calibrated within five years and check valves were not internally inspected.
Facility failed to provide documentation of smoke detector sensitivity testing as required every five years.
Facility failed to maintain handling, use, and storage of medical gases in accordance with NFPA 99, including failure to display required precautionary signs where supplemental oxygen is in use.
Report Facts
Facility License Number: RC-1196
Survey Date: 11/20/2024
Response Due Date: 12/20/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Burke | Administrator | Named as facility administrator |
| Jeremy Wilson | Survey Team Leader | Conducted fire life safety and sanitation licensure survey |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Apr 19, 2023
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 to have multiple deficiencies including unsecured exterior environment posing elopement risks, toxic chemicals accessible to cognitively impaired residents, failure to assess residents after changes in condition or falls, lack of comprehensive nursing assessments prior to admission, and incomplete or unsigned Negotiated Service Agreements (NSAs).
Deficiencies (6)
The facility did not provide a secured exterior environment for residents at risk of elopement; the exterior gate was unsecured.
Toxic chemicals were stored in unlocked areas accessible to cognitively impaired residents on multiple occasions.
Facility nurse did not assess residents after changes in condition or falls; documentation of injuries was incomplete.
Three sampled residents did not have comprehensive nursing assessments completed prior to admission.
Residents' Negotiated Service Agreements did not clearly reflect needs or describe services to be provided.
Three resident NSAs were not signed by the residents or their legal guardians.
Report Facts
Number of sampled residents with incomplete nursing assessments: 3
Number of resident NSAs reviewed and found unsigned: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Burke | Administrator | Named as facility administrator who confirmed issues with unsecured gate, chemical storage, and unsigned NSAs. |
| Teresa McClenathan | Survey Team Leader | Led the health care licensure and follow-up survey. |
Inspection Report
Original Licensing
Deficiencies: 2
Date: Dec 31, 2020
Visit Reason
The inspection was conducted as an initial licensure survey for Harbor Assisted Living facility.
Findings
The survey identified two deficiencies related to staff background checks: one staff member did not have a new criminal history and background check after starting work, and one of five employees lacked documentation of required Idaho State Police background checks.
Deficiencies (2)
One staff member completed a Criminal History and Background check on 5/31/2017, but did not complete a new background check after starting work on 10/28/2020, which was over three years old.
One of five current employees required to have Idaho State Police background checks did not have documentation of those checks in their records.
Report Facts
Number of current employees required to have ISP background checks: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Burke | Administrator | Confirmed that the caregiver should have had a Criminal History Background Check completed and that ISP background checks were not completed. |
| Gloria Keathley | Survey Team Leader | Led the initial licensure survey. |
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