Inspection Report Summary
The most recent inspection on October 10, 2025, found multiple deficiencies including incomplete nursing assessments, inaccurate resident care documentation, unresolved fire suppression system issues, and medication handling concerns. Earlier inspections showed a pattern of fire and life safety deficiencies, particularly related to combustible overhangs lacking fire suppression, as well as staffing shortages and documentation problems. Prior complaint investigations substantiated insufficient staffing during night shifts, affecting medication administration and resident assistance. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s deficiencies appear persistent over time, with some issues remaining uncorrected despite follow-up surveys.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Follow-Up
Deficiencies: 6
Date: Oct 10, 2025
Visit Reason
The inspection was a health care licensure and follow-up survey to evaluate compliance with previously identified deficiencies and assess current facility operations.
Findings
The facility was found deficient in multiple areas including failure to conduct nursing assessments after resident health changes, incomplete and inaccurate resident care documentation, inadequate negotiated service agreements, improper medication handling without hand hygiene, incomplete as-worked schedules, and unresolved fire suppression system deficiencies previously cited.
Deficiencies (6)
Facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status.
Residents' Negotiated Service Agreements did not clearly reflect resident needs or describe services to be provided.
Facility staff documentation was not completed by the staff making observations; medication technicians charted for caregivers.
Facility's as-worked schedule did not document dates and exact times the administrator or nurse were at the facility.
Medication technician handled residents' oral medications without hand hygiene and continued medication passes after dropping a tablet on the floor.
Facility lacked fire suppression protection of combustible overhangs, a previously cited deficiency still unresolved.
Report Facts
Medication passes observed: 4
Dates of resident falls: Resident #1 had falls on 3/19/25, 3/22/25, and 3/28/25
Dates of resident symptoms: Resident #5 had diarrhea and stomach pain on 3/7/25, worsening cough and runny nose on 4/11/25
Previous citations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yvette Serrano | Administrator | Named as administrator who stated components were not included in NSAs and waiting for fire suppression estimate |
| Jenny Walker | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as a health care complaint investigation to assess staffing sufficiency and compliance with medication technician requirements during night shifts.
Complaint Details
The investigation was triggered by a complaint regarding insufficient staffing, specifically the absence of medication technicians on night shifts and inadequate staff to assist residents requiring two-person transfers.
Findings
The facility did not schedule sufficient staff during all hours, particularly on night shifts where there was no medication certified staff or delegated medication passers on multiple occasions. Residents requiring two-person assistance for transfers were at risk due to insufficient staffing.
Deficiencies (1)
The facility did not schedule sufficient staff during all hours, including lack of medication certified staff and inadequate staffing for residents requiring two-person transfers.
Report Facts
Occurrences without medication certified staff: 9
Occurrences with only one staff member per house: 27
Dates of as-worked schedules reviewed: 23
Dates of as-worked schedules reviewed: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yvette Serrano | Administrator | Stated knowledge about medication technician requirements and staffing issues. |
| Jenny Walker | Survey Team Leader | Led the health care complaint investigation survey. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
The visit was a follow-up survey to verify correction of previously identified fire and life safety deficiencies related to fire suppression protection of combustible overhangs.
Findings
The facility was found to still lack fire suppression protection of combustible overhangs, a deficiency previously identified on March 30, 2024, and during a building evaluation on May 25, 2022. This deficiency remains uncorrected and is cited in accordance with NFPA 13 standards.
Deficiencies (1)
Lack of fire suppression protection of combustible overhangs as required by NFPA 13, Chapter 8, 8.15.1.2.18.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sam Burbank | Survey Team Leader | Named as the survey team leader conducting the fire life safety non-core follow-up survey. |
Inspection Report
Original Licensing
Deficiencies: 3
Date: Mar 13, 2024
Visit Reason
The inspection was conducted as an initial licensure survey for Pinehurst Senior Community.
Findings
The facility failed to notify Licensing and Certification within one business day of resident falls requiring hospital assessments, did not have updated admission agreements for four of seven residents after ownership change, and had discrepancies between medication orders and medication container labels for multiple residents.
Deficiencies (3)
Failure to notify Licensing and Certification within one business day of resident falls requiring hospital assessments.
Four of seven residents lacked new admission agreements following change in ownership.
Medication container labels did not match provider orders, including conflicting orders and missing labels for medications.
Report Facts
Residents without new admission agreements: 4
Resident falls requiring notification: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yvette Serrano | Administrator | Administrator stated she was not aware incidents needed to be reported to Licensing and Certification. |
| Melvin Lu | Survey Team Leader | Led the health care initial licensure survey. |
Inspection Report
Life Safety
Deficiencies: 9
Date: Feb 29, 2024
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with the 2018 edition of NFPA 101 Life Safety Code and related standards for existing residential board and care occupancies.
Findings
The facility did not maintain compliance with multiple fire and life safety standards including combustible overhangs without fire suppression, missing documentation for smoke detector sensitivity tests and sprinkler system assessments, inadequate smoking area signage, missing oxygen precaution signs in resident rooms, missing delayed egress signage on exit doors, use of non-grounded electrical extension cords, and lack of documentation for annual inspection of fuel-fired heating devices.
Deficiencies (9)
Combustible overhangs exceeding 48 inches in depth without fire suppression system protection.
No documentation for a 5-year sensitivity test of smoke detectors.
Attic access panel in pantry ceiling was ajar creating large penetrations.
No documentation for 5-year assessment of sprinkler system piping and calibration/replacement of gauges.
Smoking policy does not specify designated outside smoking area; no signage indicating designated smoking area near ashtrays.
Only one of three resident rooms with oxygen use had required 'Oxygen in Use, No Smoking' signage.
Two of three exit doors lack required delayed egress signage.
Use of non-grounded 'zip' style extension cord and grounded extension cord to power decorative lights.
No documentation of annual inspection for two gas fireplaces and central boiler.
Report Facts
Number of gas fireplaces: 2
Number of resident rooms with oxygen use: 3
Number of exit doors lacking delayed egress signage: 2
Number of non-combustible ashtrays observed: 2
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