Inspection Reports for Heritage Assisted Living and Memory Care
622 Filer Avenue West, ID, 83301
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 28, 2024, identified multiple fire and life safety deficiencies related to ventilation, prohibited electrical devices, and oxygen cylinder storage. Earlier inspections showed a pattern of safety and training issues, including missing staff training documentation, improper use of extension cords and power taps, and maintenance concerns. Prior reports also noted deficiencies in resident care documentation, privacy breaches, and staffing challenges, though no enforcement actions or fines were listed in the available reports. Complaint investigations included one with incomplete staff documentation, but substantiation was not specified, and most complaints were unsubstantiated. The facility’s inspection history reflects ongoing challenges with safety compliance and staff training, with similar issues recurring over time.
Deficiencies (last 4 years)
Deficiencies (over 4 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
12
9
6
3
0
Inspection Report
Life Safety
Deficiencies: 5
Date: Aug 28, 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 inspection identified multiple fire and life safety deficiencies including a 4-inch gap in the kitchen ventilation hood filtration system, prohibited use of multi-plug adapters and extension cords in resident rooms, use of a relocatable power tap to power a refrigerator, and improper storage of liquid oxygen cylinders within a single smoke compartment.
Deficiencies (5)
Ventilation hood filtration system had a 4-inch gap between filter panels allowing grease laden vapors to bypass filtration, increasing fire risk.
Use of multi-plug adapter to power oxygen concentrator and other devices in Room #29; multi-plug adapters are prohibited.
Use of extension cord to power miniature refrigerator in Room #48; extension cords are prohibited.
Use of relocatable power tap to power miniature refrigerator in Room #9; appliances powered by RPT are prohibited.
Storage of 20 E-cylinder liquid oxygen cylinders (approx. 460-500 cubic feet) within a single smoke compartment, not in accordance with NFPA 99 standards.
Report Facts
Oxygen cylinder quantity: 20
Oxygen volume: 460
Oxygen volume: 500
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 12, 2023
Visit Reason
The inspection was a health care licensure and follow-up survey to verify compliance with regulatory requirements.
Findings
Nine of ten staff reviewed did not have developmental disability training despite the facility providing services to residents with developmental disabilities. The administrator stated the training had not yet been completed.
Deficiencies (1)
Nine of ten staff, whose records were reviewed, did not have developmental disability training.
Inspection Report
Life Safety
Deficiencies: 9
Date: Sep 19, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with applicable safety codes and regulations.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code, including lack of documentation for staff training on oxygen safety and emergency plans, missing sensitivity testing for smoke detectors, insufficient relocation agreements, obstructed electrical panels, improper use of extension cords and power taps, missing emergency generator maintenance documentation, and damaged laundry room flooring.
Deficiencies (9)
Facility could not produce documentation showing staff are trained periodically on safety guidelines, usage requirements and risks associated with oxygen handling.
Facility lacked documentation for periodic staff training or bi-monthly in-service training on emergency plan roles and responsibilities.
Two smoke detectors failed sensitivity testing with no documentation of replacement or follow-up testing.
Facility had only one relocation agreement instead of the required two, and the agreement was undated and with a sister facility.
Three electrical panels in the basement were obstructed with storage items.
An extension cord was in use in the garden room and nursing office.
A refrigerator and an ice maker were plugged into Relocatable Power Taps, which is prohibited.
Facility could not produce documentation for weekly inspections, monthly load tests, or battery conductivity testing of the emergency generator in the past 12 months.
Both laundry rooms had damaged flooring that is no longer washable.
Report Facts
Relocation agreements required: 2
Smoke detectors failed sensitivity testing: 2
Electrical panels obstructed: 3
Inspection Report
Original Licensing
Deficiencies: 9
Date: Dec 15, 2021
Visit Reason
The inspection was conducted as an initial licensure survey for Heritage Assisted Living and Memory Care facility.
Findings
The inspection identified multiple deficiencies including failure to report and investigate an allegation of exploitation, privacy breaches due to the call system, poor housekeeping and maintenance, unsafe self-administration of medication, incomplete resident care records, lack of behavior documentation and plans, and insufficient staffing leading to unmet resident needs.
Deficiencies (9)
Failure to report an allegation of exploitation to Adult Protection after Resident #6 reported missing money.
Failure to conduct an investigation within 30 days after Resident #6 reported missing money.
Use of a two-way intercom call system allowing staff to listen to residents without their knowledge, breaching privacy.
Facility not maintained in a clean, safe, and orderly manner with multiple maintenance and cleanliness issues observed.
Residents #2 and #5 self-injected insulin without nurse assessments to ensure safety; Resident #5 changed insulin dose without assessment.
Incomplete documentation of change of condition assessments for residents.
Failure to evaluate Resident #6's behaviors of yelling, cursing, and refusing showers.
Failure to develop a behavior plan with specific interventions for Resident #6.
Insufficient staffing leading to long wait times for call lights, unmet resident needs, and difficulty assisting residents.
Report Facts
Residents assisted by medication technicians: 53
Inspection date: Dec 15, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bianca Acevedo | Administrator | Named in relation to failure to report exploitation and staffing issues. |
| Tom Moss | Survey Team Leader | Leader of the inspection team. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 20, 2021
Visit Reason
The inspection was conducted as a health care complaint investigation at Heritage Assisted Living and Memory Care.
Complaint Details
The visit was complaint-related as a health care complaint investigation. Substantiation status is not stated.
Findings
The facility failed to ensure staff documentation was completed, specifically missing documentation of self-harm behaviors and communications with family and hospice prior to an immediate discharge for Resident #1.
Deficiencies (1)
The facility did not ensure staff documentation was completed, including missing documentation of self-harm behaviors and communications with family and hospice prior to an immediate discharge.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bianca Acevedo | Administrator | Named as the facility administrator during the complaint investigation. |
| Veronica LeMaster | Survey Team Leader | Led the health care complaint investigation survey. |
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