Inspection Report Summary
The most recent inspection on April 3, 2025, identified deficiencies related to incomplete background checks, inconsistent fire watch policy implementation, and missing pre-admission nursing assessments documentation. Earlier inspections showed a pattern of issues with fire and life safety compliance, resident care including fall prevention and medication administration, and failure to report infectious diseases timely. Inspectors cited recurring themes of safety policy implementation, documentation gaps, and staff training deficiencies. Complaint investigations found one substantiated case involving delayed reporting of COVID-19 cases to the local health district. The facility’s recent inspection results indicate ongoing challenges similar to prior reports, with no clear trend of improvement or worsening.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 3, 2025
Visit Reason
The inspection was conducted as a health care licensure and follow-up survey to verify compliance with facility policies and regulatory requirements.
Findings
The inspection identified deficiencies including failure to complete Idaho State Police background checks for one of four employees, inadequate implementation of the facility's fire watch policy, and failure to document pre-admission nursing assessments for all sampled residents.
Deficiencies (3)
One of four employees did not have the Idaho State Police background check completed prior to working alone with residents.
The administrator did not ensure all facility policies were implemented; staff conducting fire patrol had additional duties and resident room checks were not consistently done every thirty minutes.
The facility nurse did not document pre-admission nursing assessments for ten of ten sampled residents as required.
Report Facts
Employees reviewed: 4
Residents sampled: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tirsa Saravia | Administrator | Named in relation to failure to ensure background checks and policy implementation |
| Mina Ramirez | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Life Safety
Deficiencies: 14
Date: Aug 22, 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 the facility.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code and related standards, including issues with Alcohol Based Hand Rub dispenser inspections, self-closing doors being propped open, lack of staff training documentation, missing inspections of suppression system gauges, outdated sprinkler pendants, missing policies on ignition sources, and other fire safety and emergency preparedness deficiencies.
Deficiencies (14)
Facility could not produce documentation for testing/inspecting Alcohol Based Hand Rub dispensers each time they are refilled.
Maintenance shop/storage room door was self-closing but had been chocked open with a door wedge.
Door from kitchen to dining room held open by magnetic device but was not self-closing as required.
Facility could not produce documentation for periodic staff training or bi-monthly in-service training on emergency plan roles and responsibilities.
Facility could not produce documentation showing weekly visual inspections of dry suppression system gauges and monthly inspections of wet suppression system gauges/control valves.
Sprinkler pendants in walk-in refrigerator and freezer dated 2005, requiring replacement/testing.
No policy or procedure for elimination of ignition sources and misuse of flammable substances per NFPA 99.
Door to resident room #213 would not latch when fully closed.
Relocatable Power Tap (RPT) plugged in succession creating prohibited 'daisy chain' at multiple locations.
Only two of six residents using oxygen had required 'Oxygen in Use, No Smoking' signage; repeat deficiency.
Facility emergency preparedness plan lacked written plan including responsibilities and point of assembly for drills.
Facility had only one relocation agreement instead of required two; last update in 2017.
Designated smoking areas not specified in facility smoking policy.
Natural gas fireplaces on main floor and basement not equipped with safety barriers.
Report Facts
Residents utilizing oxygen: 6
Relocation agreements required: 2
Relocation agreements present: 1
Sprinkler pendants age: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendi Gailey | Administrator | Named as facility administrator. |
| Linda Chaney | Survey Team Leader | Named as survey team leader conducting the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to report individuals with infectious diseases to the local health district.
Complaint Details
The complaint investigation found that the facility did not report positive COVID-19 test results for Resident #2 and Resident #3 to the local health district until March 1, 2022, despite positive tests occurring on 12/28/21 and 1/3/22 respectively.
Findings
The facility failed to report positive COVID-19 cases of residents to the local health district in a timely manner, with confirmation that reporting was delayed until March 1, 2022.
Deficiencies (1)
The facility did not report individuals with an infectious disease to the local health district authority as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendi Gailey | Administrator | Named in relation to confirming failure to report positive COVID-19 test results. |
| Melvin Lu | Survey Team Leader | Led the health care complaint investigation. |
Inspection Report
Follow-Up
Deficiencies: 8
Date: Aug 20, 2021
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with corrective actions and regulatory requirements.
Findings
The facility failed to implement appropriate corrective actions to prevent resident falls, maintain a secure memory care environment, and ensure licensed nurse assessments after changes in resident conditions. Additional deficiencies included medication administration errors, lack of behavior updates on psychotropic medication reviews, inconsistent resident care documentation, incomplete staff schedules, and inadequate menu and diet planning.
Deficiencies (8)
Failure to ensure appropriate corrective actions to prevent recurrence of falls for multiple residents.
Failure to maintain a safe and secure environment in the memory care unit, resulting in resident elopements.
Licensed nurse did not assess residents after changes in condition, including wounds and symptoms like nausea and diarrhea.
Residents did not receive medications and therapeutic diets as ordered, with multiple missed doses documented.
Lack of behavior updates on six-month psychotropic medication reviews for residents on long-term psychotropic medications.
Inconsistent documentation of resident care records, including unusual occurrences and change of condition assessments.
As-worked staff schedules did not document dates, times, or staff positions accurately.
Menu and diet planning deficiencies, including lack of registered dietitian signature, missing portion sizes, and failure to modify menus for therapeutic diets.
Report Facts
Missed medication doses: 15
Missed medication doses: 9
Missed medication doses: 7
Missed medication doses: 5
Resident falls: 5
Resident elopements: 3
Residents experiencing nausea, vomiting, diarrhea: 7
Psychotropic medication reviews missing behavior updates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wendi Gailey | Administrator | Named in relation to failure to ensure corrective actions and secure environment |
| Stacey Brown | Survey Team Leader | Led the health care licensure and follow-up survey |
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