Inspection Reports for Post Falls Ops, LLC, dba Guardian Angel Homes
1070 East Mullan Avenue, ID, 83854
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 6, 2025, identified multiple deficiencies related to fire and life safety, including overdue testing of sprinkler heads and smoke detectors, compromised smoke partitions, and improper use of power sources for medical devices. Earlier inspections showed a pattern of deficiencies in nursing assessments, medication management, infection control, and fire safety compliance. Inspectors cited issues such as incomplete nursing and medication documentation, expired medications, kitchen sanitation problems, and missing safety system inspections. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports, and complaint investigations were either not substantiated or not clearly stated. The facility’s inspection history reflects ongoing challenges with regulatory compliance, with no clear trend of improvement or worsening over time.
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
Life Safety
Deficiencies: 6
Date: Feb 6, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to evaluate compliance with fire and life safety standards for the facility buildings.
Findings
Multiple deficiencies were identified including overdue UL testing of sprinkler heads, lack of smoke detector sensitivity testing since 2017, ceiling membrane penetrations compromising smoke partitions, gaps in hood assembly filters allowing grease vapors to bypass filtration, use of prohibited multi-plug adapters and extension cords, and use of relocatable power taps to power medical devices.
Deficiencies (6)
UL testing of fast response sprinkler heads was overdue and no documentation was provided to confirm testing compliance.
Smoke detector sensitivity testing for several buildings was not identified since 2017.
A 6" by 8" penetration of the ceiling membrane in the laundry room compromised smoke partition continuity.
A 1" gap between panels of UL listed hood assembly filters allowed grease laden vapors to bypass filtration.
Use of multi-plug adapters and extension cords to supply power to devices in multiple rooms was identified and is prohibited.
Oxygen concentrators in two rooms were powered by relocatable power taps, which is prohibited.
Inspection Report
Follow-Up
Deficiencies: 10
Date: Aug 23, 2024
Visit Reason
The inspection was a health care licensure and follow-up survey conducted to assess compliance with regulatory requirements and to verify correction of previously cited deficiencies.
Findings
The facility was found to have multiple deficiencies including incomplete nursing assessments, medication labeling and administration errors, medication storage issues, lack of availability of PRN medications, accumulation of expired medications, incomplete psychotropic medication reviews, outdated negotiated service agreements, and incomplete resident care documentation.
Deficiencies (10)
One of ten employees worked alone for at least seven shifts before the facility obtained their completed Department Criminal History and Background Check.
The facility RN did not complete initial or timely quarterly nursing assessments for multiple residents.
Medication labels were not up-to-date with providers' orders, causing discrepancies in dosing instructions.
Residents did not receive medications as ordered, including missed doses and delays in starting new medications.
Medication refrigerator temperatures were not maintained between 38 and 45 degrees Fahrenheit, with documented lows of 32 degrees.
Not all residents' as-needed (PRN) medications were available as prescribed.
Accumulation of unused, discontinued, or expired medications for more than 30 days was observed.
Residents were taking psychotropic medications for longer than six months without required six-month medication reviews.
Negotiated Service Agreements were not consistently updated to reflect significant changes in residents' health status.
Resident care documentation requirements were not consistently met, including incomplete preadmission assessments and failure to document unusual events.
Report Facts
Temperature log deviations: 44
Missed medication doses: 61
Expired medications duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dakota Klinkefus | Administrator | Confirmed employee worked alone before background check was obtained; stated need for improved medication and documentation systems |
| Melvin Lu | Survey Team Leader | Led the health care licensure and follow-up survey |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 28, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to infection control issues in the facility kitchen.
Complaint Details
The visit was triggered by a complaint related to infection control deficiencies; substantiation status is not stated.
Findings
The facility failed to maintain sanitary controls in the kitchen, including improperly mixed sanitizing solution, improperly washed knives, and food debris on the floor of the walk-in refrigerator and freezer. A complete food inspection was conducted during the complaint investigation.
Deficiencies (1)
The facility did not maintain sanitary controls in the kitchen per infection control precautions, including improperly mixed sanitizing solution, improperly washed knives, and food debris on the floor of the walk-in refrigerator and freezer.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dakota Klinkefus | Administrator | Named as facility administrator in the report header. |
| Bradley Perry | Survey Team Leader | Named as survey team leader conducting the complaint investigation. |
Inspection Report
Life Safety
Deficiencies: 7
Date: Apr 2, 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 for existing buildings licensed for seventeen or more residents and multi-story buildings.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code, including missing documentation for a 3-year full-trip test of the dry suppression system, missing sensitivity testing data for smoke alarm systems, outdated annual fire alarm inspection, overdue semi-annual kitchen hood cleaning, non-operational emergency lighting in specific areas, lack of safety barriers on operational gas fireplaces, and missing documentation of annual inspection for operational gas fireplaces.
Deficiencies (7)
Facility could not produce documentation for a 3-year, full-trip test of the dry suppression system.
Documentation for sensitivity testing and/or sensitivity data for addressable smoke alarm systems could not be produced at the time of the survey.
Last known annual fire alarm inspection was on 10/18/2019.
Semi-annual cleaning of the kitchen hood was last completed on 7/10/20.
Emergency lighting was non-operational in the 'Tudor' building dining room and the 'Inn' building hallway near the salon.
Operational gas fireplaces and heat producing built-in electric fireplaces did not have safety barriers.
Facility could not produce documentation to show operational gas fireplaces had been inspected in the past 12 months.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Feb 28, 2020
Visit Reason
The inspection was a health care licensure and follow-up survey to assess compliance with state regulations and verify correction of previous deficiencies.
Findings
The facility was found deficient in several areas including failure to complete Idaho State Police background checks prior to employees working alone, incomplete 90-day nursing assessments lacking physical assessments, failure to provide behavioral updates to physicians for certain residents, and insufficient personnel training in CPR and First Aid for caregivers working alone.
Deficiencies (4)
2 of 7 sampled employees did not have documentation of Idaho State Police background checks prior to working alone.
10 of 10 sampled residents' 90-day nursing assessments did not include a physical assessment; nursing assessments were not conducted when 3 residents experienced condition changes.
The facility did not provide behavioral updates to the physician for Residents #2, #4, and #10 to facilitate informed decisions about psychotropic medication.
2 of 8 caregivers did not have documented evidence of CPR or First Aid training prior to working alone.
Report Facts
Sampled employees lacking background checks: 2
Sampled residents without physical assessment in 90-day nursing assessments: 10
Residents with condition changes not assessed: 3
Caregivers lacking CPR or First Aid training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dakota Klinkefus | Administrator | Confirmed background checks were not completed prior to employees working alone and stated caregivers worked alone without CPR or First Aid training. |
| Stacey Brown | Survey Team Leader | Led the health care licensure and follow-up survey. |
| Director of Nursing | Confirmed physical assessments were not included in 90-day nursing assessments. |
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