Inspection Reports for The Cottages Assisted Living and Memory Care-Boise
6300 N Roe St, Garden City, ID 83714, United States, ID, 83714
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 28, 2023, found deficiencies related to fire and life safety, including non-operational emergency lights, missing documentation of staff emergency training, and incomplete emergency drills. Earlier inspections showed a pattern of issues with safety compliance, resident care, staffing, and documentation, including unsecured environments, incomplete nursing assessments, and lapses in administrator licensing. Inspectors cited concerns with medication management, behavior plans, and insufficient staffing during overnight shifts, with substantiated complaints about administrator licensing gaps and staffing shortages affecting resident care. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history indicates ongoing challenges with compliance, particularly in safety and administrative areas, with no clear trend of improvement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Life Safety
Deficiencies: 3
Date: Jul 28, 2023
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 three through sixteen residents.
Findings
The facility failed to maintain compliance with the 2018 edition of NFPA 101 Life Safety Code, including two non-operational emergency lights and lack of documentation for periodic staff training on the emergency plan. Additionally, the facility did not conduct the required number of emergency egress and relocation drills, with missing drills for several months in two houses.
Deficiencies (3)
Two non-operational emergency lights were found in the hallway between resident room #15 and the linen closet, and at the exit door.
The facility could not produce documentation for periodic staff training or bi-monthly in-service training on the facility emergency plan.
The facility conducted only one required night drill in the past 12 months and was missing bi-monthly drills for several months in House #1 and House #2.
Report Facts
Number of non-operational emergency lights: 2
Number of night drills conducted in past 12 months: 1
Number of required emergency egress and relocation drills per year: 6
Missing drills for House #1: 3
Missing drills for House #2: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Chaney | Survey Team Leader | Named as survey team leader conducting the fire life safety and sanitation licensure survey. |
| Kristin Baisden | Administrator | Named as facility administrator. |
Inspection Report
Follow-Up
Deficiencies: 14
Date: Apr 21, 2023
Visit Reason
The inspection was conducted as a health care licensure and follow-up combined with a complaint investigation to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Complaint Details
The visit included a complaint investigation component as indicated by the survey type 'health care licensure and follow-up + complaint investigation'. Specific substantiation status was not stated.
Findings
The facility was found to have multiple deficiencies including lack of activities offered to residents, absence of a licensed administrator for 24 days, failure to conduct timely investigations of incidents, inadequate interim care plans, unsecured environment leading to resident elopements, incomplete nursing assessments, improper medication refrigerator temperature maintenance, lack of behavior management plans, incomplete psychotropic medication reviews, incomplete resident assessments and service agreements, unsigned NSAs, undocumented change of condition assessments, incomplete behavior evaluations and plans, and incomplete as-worked schedules.
Deficiencies (14)
No activities were offered to residents in Building #1 during observations, despite a calendar showing scheduled activities.
Facility lacked a licensed administrator for 24 days between 3/31/22 to 4/24/22.
Administrator did not conduct investigations within 30 days for incidents involving Resident #4 and Resident #5.
Facility did not provide information on interim care plan for Resident #8, a flight risk.
Facility did not provide a secure environment, allowing Residents #6 and #8 to elope due to an unlocked garage door.
Nursing assessments were not conducted for residents experiencing changes in health status, including Residents #5, #6, and #8.
Medication refrigerator containing morphine and lorazepam was not maintained at required temperatures.
Facility did not attempt non-drug interventions before prescribing psychotropic medications; behavior management plans were missing for Residents #4, #5, and #6.
Six-month psychotropic medication reviews were not completed for 3 of 8 sampled residents.
Comprehensive assessments for Residents #4 and #5 were incomplete, missing demographics and behavior assessments.
Residents' Negotiated Service Agreements did not clearly reflect needs or services and were unsigned for Residents #1 through #5.
Change of condition assessments were not documented for Residents #1 and #2 despite observed health concerns.
Behavior evaluations and plans were incomplete or missing for Residents #1, #2, #3, #5, #6, and #8.
As-worked schedules did not document times the facility nurse or maintenance supervisor were present.
Report Facts
Days without licensed administrator: 24
Medication refrigerator temperature deviations: 18
Medication refrigerator temperature deviations: 20
Medication refrigerator temperature deviations: 3
Residents sampled for psychotropic medication review: 8
Residents with unsigned NSAs: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Ellis | Administrator | Confirmed facility lacked licensed administrator for 24 days and stated investigations and behavior management plans were incomplete. |
| Michael Oldfield | Survey Team Leader | Led the health care licensure and follow-up plus complaint investigation survey. |
Inspection Report
Life Safety
Deficiencies: 7
Date: Mar 30, 2022
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey for The Cottages of Boise.
Findings
Multiple deficiencies were found related to fire and life safety standards, including lack of documented quarterly waterflow alarm testing since 2018, insufficient control valve documentation, a smoke detector failure with no documented replacement, overdue 5-year internal obstruction inspections, lack of emergency light testing since October 2021, overdue full flow trip testing last conducted in May 2018, and no documented fire drills since February 2021.
Deficiencies (7)
No documented quarterly waterflow alarm testing completed since 2018.
Control valve documentation not being performed at least monthly; PIV windows faded and insufficient for valve position viewing.
Smoke detector failure in building 1, room 9 with no documented replacement.
Fire suppression systems past due for 5-year internal obstruction inspection.
No documented emergency light testing conducted since October 2021.
Fire suppression system past due for full flow trip testing; last conducted May 2018.
No documented fire drills since February 2021 (repeat deficiency).
Report Facts
Years since last quarterly waterflow alarm testing: 4
Years since last full flow trip testing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Smith | Administrator | Named as facility administrator |
| Sam Burbank | Survey Team Leader | Conducted fire life safety and sanitation licensure survey |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 9, 2022
Visit Reason
The inspection was conducted as a health care complaint investigation to assess compliance with facility administrator licensing and staffing requirements.
Complaint Details
The visit was triggered by a health care complaint investigation. The report details substantiated issues with administrator licensing gaps and insufficient staffing impacting resident care.
Findings
The facility lacked a licensed administrator for three separate periods over six months, resulting in unreported incidents and difficulties in reporting issues. Additionally, staffing was insufficient, especially during overnight shifts, leading to unmet resident care needs such as missed showers and caregivers leaving buildings unattended.
Deficiencies (2)
The facility did not have a licensed administrator for three different periods in the last six months, causing difficulties in reporting incidents and lack of investigations.
The facility did not schedule sufficient staff during all hours, particularly overnight, resulting in caregivers leaving buildings unattended and unmet resident care needs.
Report Facts
Days without licensed administrator: 27
Days without licensed administrator: 26
Days without licensed administrator: 17
Showers documented: 2
Showers documented: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Smith | Administrator | Current administrator who began working on 11/29/21 and was unaware of prior issues |
| Stacey Brown | Survey Team Leader | Led the health care complaint investigation |
Inspection Report
Follow-Up
Deficiencies: 3
Date: May 13, 2021
Visit Reason
The visit was a health care licensure and follow-up survey to assess compliance with prior deficiencies and regulatory requirements.
Findings
The facility failed to provide a secure environment as an unsampled resident knew and used door codes to exit and re-enter. The facility nurse did not timely assess residents after changes in condition, and a night shift caregiver worked alone without current CPR certification.
Deficiencies (3)
Facility did not provide a secure environment due to an unsampled resident knowing and using door codes to exit and re-enter.
Facility nurse did not assess residents promptly after changes in condition, including choking, falls, and skin issues.
Night shift caregiver worked alone without current CPR certification.
Report Facts
Previous citation date: Sep 6, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Virginia Thornley | Administrator | Administrator acknowledged resident knew door codes and caregiver lacked CPR certification |
| Melvin Lu | Survey Team Leader | Led the health care licensure and follow-up survey |
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