Inspection Report Summary
The most recent inspection on November 7, 2025, identified deficiencies related to employee background checks, medication administration and storage, documentation of resident care, and staff training on mental illness. Earlier inspections showed a pattern of issues with medication management, documentation, staff training, and fire safety compliance, including missing fire safety procedure documentation and smoke detector problems. Complaint investigations found substantiated deficiencies involving medication errors, lack of a licensed administrator, incomplete records, and infection control lapses during the COVID-19 pandemic. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s deficiencies have persisted over time with recurring themes, indicating ongoing challenges without a clear trend of improvement.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Follow-Up
Deficiencies: 7
Date: Nov 7, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with previous citations and regulatory requirements.
Findings
The facility was found deficient in multiple areas including incomplete background checks for employees, failure to administer medications as ordered, improper medication refrigerator temperature monitoring, lack of availability of PRN medications, incomplete medication destruction logs, inadequate documentation of resident care assessments, and lack of mental illness training for staff.
Deficiencies (7)
Four of five employees did not have Idaho State Police background checks completed prior to working alone with residents.
Resident #10 did not receive medications as ordered, including missed doses of melatonin and unavailable fentanyl patch and Haloperidol.
Medication refrigerator temperatures were out of range multiple days in August, September, and October 2025 with no corrective action taken.
Three of eleven sampled residents did not have their PRN medications available in the facility.
Medication destruction logs did not include the date when medications were destroyed.
Resident care records lacked documentation of assessments following changes in physical or mental health status.
Fifteen of fifteen staff records reviewed did not show mental illness training for caring for residents with mental illness.
Report Facts
Days medication refrigerator temperatures out of range: 5
Days medication refrigerator temperatures out of range: 16
Days medication refrigerator temperatures out of range: 25
Days medication refrigerator temperatures out of range: 6
Days medication refrigerator temperatures out of range: 25
Days medication refrigerator temperatures out of range: 19
Residents with mental illness: 33
Staff records reviewed lacking mental illness training: 15
Inspection Report
Life Safety
Deficiencies: 4
Date: Oct 10, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to evaluate compliance with fire safety standards and related regulations.
Findings
The facility failed to provide a documented Fire Watch procedure for fire suppression system outages, had 30 smoke detectors in the Assisted Living area that failed sensitivity testing without evidence of recalibration or replacement, and prohibited electrical equipment such as multi-plug adapters and relocatable power taps were found in resident rooms.
Deficiencies (4)
Failure to provide documentation of an established Fire Watch procedure for fire suppression system outages exceeding four hours.
Thirty smoke detectors in the Assisted Living side failed sensitivity testing with no evidence of recalibration, cleaning, or replacement.
Use of a multi-plug adapter in room #15, which is prohibited.
Use of a relocatable power tap (RPT) to power an oxygen concentrator in room #112, which is prohibited.
Report Facts
Smoke detectors failed sensitivity testing: 30
Facility license number: RC-1068
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeremy Wilson | Survey Team Leader | Named as survey team leader conducting the fire life safety and sanitation licensure survey |
| Kimberly Messick | Administrator | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 2, 2023
Visit Reason
The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation to assess compliance with facility regulations and address specific complaints.
Complaint Details
The visit was complaint-related and included a follow-up to verify compliance with health care licensure requirements.
Findings
The facility operated without a licensed administrator for 28 days in early 2020, failed to ensure residents received medications as ordered, had incomplete medication disposal records, lacked proper documentation in resident care records, and staff had not received required mental illness training despite residents with mental illness.
Deficiencies (5)
Facility operated without a licensed administrator for 28 days from 1/29/20 through 2/26/20.
Residents did not receive medications as ordered, including missed doses of fluconazole, digestive enzymes, potassium, Nystatin, creams, ointments, donepezil, and vitamin C.
Medication disposal records lacked signatures of both disposing staff and a witness as required.
Resident care records were incomplete; caregiver notes were missing for all sampled residents and some incidents were not documented.
Staff had not received mental illness training despite residents with mental illness in the facility.
Report Facts
Days without licensed administrator: 28
Missed medication doses: 6
Missed medication doses: 3
Missed medication doses: 11
Missed medication doses: 3
Missed medication doses: 5
Missed medication doses: 38
Missed medication doses: 8
Missed medication doses: 22
Staff records reviewed: 10
Resident records sampled: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tyler Drewes | Administrator | Confirmed staff had not had mental illness training on 3/2/2023. |
| Stacey Brown | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey. |
Inspection Report
Life Safety
Deficiencies: 10
Date: Oct 4, 2022
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 multiple fire and life safety code requirements, including lack of documentation for quarterly waterflow alarm testing, smoke detector sensitivity tests, suppression system inspections, alcohol-based hand rub dispenser inspections, staff emergency plan training, fire rated door inspections, written relocation agreements, and emergency generator testing and inspections.
Deficiencies (10)
Facility could not produce documentation for quarterly waterflow alarm testing for third quarter 2022.
No documentation for a 5-year sensitivity test of the smoke detectors.
Facility could not produce documentation for weekly visual inspections of dry suppression system gauges or monthly inspections of wet suppression system gauges and control valves.
Facility could not produce documentation for testing/inspecting Alcohol Based Hand Rub dispensers each time they are refilled.
Facility could not produce documentation for bi-monthly in-service training for staff and residents on emergency plan roles and responsibilities.
Facility was unable to produce documentation for an annual inspection of required fire rated doors between Assisted Living and Independent Living Facilities.
Facility had two verbal relocation agreements but no written agreements for resident relocation in evacuation events.
Facility could not produce documentation for weekly emergency generator inspections for specified weeks in 2021 and 2022.
Facility could not produce documentation for monthly load tests of emergency generator for November 2021 and March 2022.
Facility could not produce documentation for monthly conductivity test of emergency generator battery(s).
Report Facts
Facility License Number: RC-1068
Survey Date: 10/04/2022
Response Due Date: 11/03/2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Jacobson | Administrator | Named as facility administrator |
| Linda Chaney | Survey Team Leader | Named as survey team leader |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 5, 2022
Visit Reason
The inspection was conducted as a health care complaint investigation.
Complaint Details
The visit was triggered by a health care complaint investigation.
Findings
The facility did not meet the standards for the Idaho Food Code. The kitchen inspection failed, and a mandatory re-inspection was required within 10 days.
Deficiencies (1)
The facility did not meet the standards for the Idaho Food Code. Kitchen inspection failed.
Report Facts
Re-inspection timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Torrey Bollinger | Survey Team Leader | Named as Survey Team Leader for the health care complaint investigation. |
| Suzanne Jacobson | Administrator | Named as facility Administrator. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 12, 2021
Visit Reason
The inspection was conducted as a health care complaint investigation regarding infection control practices related to COVID-19 prevention.
Complaint Details
The visit was triggered by a complaint related to infection control practices and COVID-19 prevention. The report does not state substantiation status.
Findings
The facility failed to follow CDC recommendations for infection control, including not screening staff, visitors, and outside agencies for COVID-19 symptoms and not requiring masks. Observations confirmed staff and visitors were not consistently screened or masked, and PPE use was improper.
Deficiencies (1)
The facility did not follow CDC recommendations for infection control related to COVID-19, including failure to screen staff, visitors, and outside agencies for symptoms and failure to require mask use.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Jacobson | Administrator | Confirmed that masks were not always in use as they should be. |
| Gloria Keathley | Survey Team Leader | Led the health care complaint investigation survey. |
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