Inspection Reports for Hearthstone Village, LLC
402 West 3rd Avenue, ID, 83840
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 17, 2025, identified multiple deficiencies related to employee background checks, medication management, unsafe smoking practices, housekeeping, staffing, and failure to properly investigate abuse allegations. Earlier inspections showed similar issues with medication administration, documentation, staffing certifications, and fire and life safety compliance, including outdated fire safety equipment inspections and prohibited electrical equipment use. Complaint investigations found substantiated failures in abuse investigations and incident reporting, while other complaints were not listed as substantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The pattern of deficiencies suggests ongoing challenges with regulatory compliance, particularly in medication management, staff training, and safety procedures, with no clear indication of sustained improvement over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
21 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
166% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Deficiencies: 31
Date: Sep 17, 2025
Visit Reason
The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation to assess compliance with regulatory requirements and investigate specific complaints.
Complaint Details
The visit was complaint-related and included investigation of allegations of abuse, neglect, and failure to follow abuse and neglect policies. The facility failed to complete investigations and documentation for multiple incidents involving residents, including falls, altercations, and choking incidents.
Findings
The facility was found to have multiple deficiencies including incomplete criminal background checks for employees, unsafe smoking practices, poor housekeeping and maintenance, unsecured toxic chemicals, medication administration errors, incomplete medication orders, lack of nursing assessments after incidents, inadequate documentation and monitoring of medication storage, expired supplies, insufficient staffing and training, failure to conduct proper investigations of abuse allegations, and failure to conduct fire drills during sleeping hours.
Deficiencies (31)
Three of six employees did not have a Department Criminal History and Background Check.
One of three employees did not have the Idaho State Police Background Check.
Facility did not have a designated smoking area clearly marked and improper disposal of smoking materials.
Facility was not maintained in a clean, safe and orderly manner with issues such as weeds, broken furniture, and missing paint.
Toxic chemicals were stored in an unlocked area accessible to cognitively impaired residents.
Residents' medications were not given as ordered due to unavailability.
Medication orders were not current, signed, or dated in residents' care records.
Nursing assessments were not conducted after residents experienced changes in health status or incidents.
Medication refrigerator temperatures were not monitored and documented daily.
PRN medications were not available in the facility for residents.
Expired urinalysis reagent test strips were used on residents.
Medication destruction log did not document method of destruction.
Non-drug interventions were not attempted prior to psychotropic medication use for maladaptive behaviors.
Psychotropic medication reviews lacked updated behavioral data.
Comprehensive assessments were not completed prior to admission for some residents.
Residents' Negotiated Service Agreements did not clearly reflect needs or services.
Facility records were incomplete and inaccurate for personnel and fire life safety.
Residents' care records lacked documented caregiver notes.
Medication technicians did not conduct hand hygiene between residents during medication pass.
Fire drills were not conducted during night sleeping hours as required.
Menu substitutions were not documented or maintained.
Insufficient staff scheduled during all hours to meet residents' needs.
Staff lacked evidence of CPR or First Aid certification.
Staff lacked training on reporting allegations of abuse, neglect, and exploitation.
Staff lacked dementia training.
Staff lacked annual job-related continued training.
Medication technician lacked approved medication assistance course certification.
Medication orders for Resident #1 were not implemented correctly.
Facility did not follow Abuse and Neglect Policy; investigations and documentation were incomplete or missing.
Administrator did not complete investigations and written reports within required timeframes for incidents and allegations.
Administrator did not implement immediate corrective actions after accidents and incidents.
Report Facts
Employees lacking Department Criminal History and Background Check: 3
Employees lacking Idaho State Police Background Check: 1
Medication refrigerator temperature logs: 16
Expired urinalysis reagent test strips: 1
Fire drills conducted: 6
Falls experienced by Resident #4: 4
Falls experienced by Resident #6: 2
Staff lacking CPR or First Aid certification: 5
Staff lacking dementia training: 5
Staff lacking annual continued training: 5
Inspection Report
Life Safety
Deficiencies: 11
Date: Feb 3, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with fire safety codes and related regulations.
Findings
The facility was found to have multiple deficiencies including outdated relocation agreements, failure to conduct monthly inspections of fire extinguishers and fire suppression systems, use of prohibited multi-plug adapters and relocatable power taps, incomplete emergency drill documentation, and missing annual servicing of fire extinguishers.
Deficiencies (11)
Provided relocation agreements were outdated and not reviewed annually.
Monthly fire extinguisher inspections were not conducted for specified months in House A and House B.
Portable fire extinguisher in House A upstairs office had not been serviced since 2023.
Two penetrations of ceiling membrane in laundry room of House A not in compliance with smoke partition membrane standards.
Facility failed to conduct monthly inspections of fire suppression wet systems gauges and valves as required.
Last fire alarm system inspection and testing was conducted on 10/12/2023; annual inspection required.
Monthly testing of emergency lights was not conducted prior to October 2024; no documentation of last 90-minute annual testing of emergency lighting.
Use of prohibited multi-plug adapters powering lamps, chargers, mini fridges, and fans in House B rooms.
Use of prohibited Relocatable Power Taps (RPT) to supply power to appliances in multiple rooms in House B.
Last fuel-fired heating inspection and testing conducted on 1/27/2023; fireplaces are gas-fired and operating.
Only two documented fire/emergency egress drills on file in 2024-2025; bi-monthly drills with at least two during sleeping hours required.
Report Facts
Facility License Number: RC-922
Number of documented fire drills: 2
Date of last fire alarm inspection: 10/12/2023
Date of last fuel-fired heating inspection: 1/27/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robbe Redford | Administrator | Named as facility administrator |
| Jeremy Wilson | Survey Team Leader | Named as survey team leader conducting fire life safety and sanitation licensure survey |
Inspection Report
Follow-Up
Deficiencies: 9
Date: Jul 28, 2023
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to assess compliance with regulatory requirements and verify correction of previous deficiencies.
Findings
The facility was found to have multiple deficiencies including incomplete criminal background checks for employees, inadequate temperature control in residents' rooms, poor housekeeping and maintenance, medication management issues including unavailable medications and improper documentation, incomplete resident care records, and insufficient personnel certifications.
Deficiencies (9)
One of eight employees did not have a Department Criminal History and Background Check completed.
The facility did not ensure all residents' rooms and common areas remained between appropriate temperatures; some residents lacked air conditioning.
The facility was not maintained in a clean, safe, and orderly manner with trash, mold, and dirt observed in multiple areas.
The facility nurse did not ensure all residents' medications were available and given as ordered, with multiple missed doses documented.
Medication refrigerator temperatures were not maintained or documented daily as required.
Not all ordered as-needed medications were available at the facility.
The facility did not maintain complete, accurate resident records, including inconsistent documentation of medication administration and nurse communications.
Residents' changes of condition assessments were not consistently documented by the facility nurse.
Two of eight sampled direct care staff did not have current first aid or CPR certification.
Report Facts
Employees without background check: 1
Medication refrigerator temperature documentation misses: 12
Medication refrigerator temperature documentation misses: 25
Medication refrigerator temperature documentation misses: 6
Medication doses documented but not received: 4
Medication doses documented but not received: 27
Direct care staff without current first aid/CPR certification: 2
Inspection Report
Life Safety
Deficiencies: 12
Date: Dec 17, 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 and related regulations.
Findings
The facility failed to maintain compliance with multiple fire and life safety standards including improper door locks on exit doors, lack of documentation for emergency lighting and fire alarm system testing, incomplete emergency drill records, absence of required relocation agreements, unsafe plumbing water temperature, and prohibited electrical equipment usage.
Deficiencies (12)
All door locks on exits required two operations to exit when locked due to operational deadbolts.
No documentation for monthly or annual emergency lighting tests; emergency light non-operational between resident rooms #9 and #10.
No documentation for annual fire/smoke alarm inspection or 5-year sensitivity test of smoke detectors.
No documentation for monthly visual inspections of wet suppression system gauges and secured control valves.
No documentation showing staff training on safety guidelines and oxygen handling.
Mechanical/electrical room had holes in ceiling and wall compromising safety.
Emergency drills not performed bimonthly; insufficient night-time drills; incomplete drill documentation.
Natural gas fireplaces in buildings A and B lacked safety barriers.
Only one relocation agreement present instead of required two; last update in 2013.
Hot water temperature in building A was 127°F, exceeding the allowed maximum of 120°F.
Multiple appliances plugged into a Relocatable Power Tap in staff break room, a prohibited use.
Full-sized refrigerator plugged into an extension cord on covered patio, which is prohibited.
Report Facts
Emergency drills performed: 4
Required emergency drills per year: 6
Night-time drills required: 2
Hot water temperature: 127
Relocation agreements required: 2
Relocation agreements present: 1
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