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Cascadia of Boise

6000 W Denton St, Boise, ID 83704 · For profit - Limited Liability company · 100 certified beds · (208) 629-4383 Medicare & Medicaid certified

Call the home — (208) 629-4383 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$13,049 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $13,049 in federal fines (most recent 2023-09-22)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Urgent care / clinic
6259 W Emerald St · (208) 489-1900 · Call to confirm hours
Pharmacy
999 N Curtis Rd · (208) 367-2167 · Call to confirm hours
Grocery
5907 W Clinton St · (208) 377-0590 · Call to confirm hours
Park
520 N Liberty St · (208) 577-4575 · Typically dawn to dusk
Place of worship
501 N Curtis Rd · (208) 938-8440

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.0%15.6%15.4%better
Long-stay residents who lose too much weight2.3%5.2%5.4%better
Long-stay residents with a catheter left in their bladder0.3%1.2%0.9%better
Long-stay residents with a urinary tract infection2.6%2.0%2.0%worse
Long-stay residents with depressive symptoms1.9%15.1%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.4%3.0%3.3%better
Long-stay residents whose ability to walk worsened6.6%16.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.2%16.3%18.9%worse
Long-stay residents given the seasonal flu vaccine92.5%96.2%95.3%typical
Long-stay residents with pressure ulcers3.0%3.2%4.7%better
Long-stay residents with worsening bladder/bowel control18.7%22.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.3%20.1%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.8%1.4%better
Short-stay residents given the seasonal flu vaccine92.5%86.5%79.4%better
Short-stay residents rehospitalized after admission19.8%17.7%22.6%better
Short-stay residents with an outpatient ER visit15.1%12.3%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.181.171.67worse
Long-stay outpatient ER visits per 1,000 resident days3.051.661.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

54.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 126 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.7%U.S. median 51.5%
Got home and stayed home
8.8%U.S. median 10.7%
Went back to hospital
48.6%U.S. median 56.6%
Met the expected recovery
0.42U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 48.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 105 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.42 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.7%CMS range 45.7–63.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.8%CMS range 6.1–11.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge48.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge40.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge43.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting95.8%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.2%CMS range 2.5–10.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.911.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.43
RN hours/ resident / day
1.34
LPN hours/ resident / day
2.20
Aide hours/ resident / day
3.97
Total nurse hours/ resident / day
0.13
RN hoursweekends
48.0%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 91.0 residents a day — about 91% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.43 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.48 hrs/resident/day on weekends vs 4.16 on weekdays — 16% thinner on weekends. RN hours go from 0.55 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2025-11-19)
6
at the previous standard inspection (2024-08-08)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · G2023-09-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, I&A review, record review, and staff interview, it was determined the facility failed to ensure adequate supervision for residents to prevent falls. This was true for 1 of 3 residents, (Resident #21) whose records were reviewed for falls. This resulted in harm to Resident #21. Findings include: The facility's Accidents and Supervision to Prevent Accidents policy, revised on 10/15/22, stated facilities were obligated to provide adequate supervision to prevent accidents. Adequate supervision was determined by assessing the appropriate level of care and number of staff required, the competency of the staff, and the frequency of supervision needed. This determination was based on the individual resident's assessed needs and identified hazards in the resident's environment. The State Operation Manual, Appendix PP, defined Avoidable Accident as an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-13 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interviews, representative interviews, staff interviews, observations, review of grievances, and review of the three-week nursing schedule, it was determined the facility failed to ensure sufficient staffing was available to meet resident needs according to their plan of care. This failure had the potential to affect all residents residing in the facility if staff were not available to ensure resident needs and safety measures were provided. Findings include: The National Academies of Sciences, Engineering, and Medicine (NASEM) website accessed on 5/13/26, article titled The National Imperative to Improve Nursing Home Quality (2022) documents, inadequate staffing contributes to delayed care, missed care tasks, and reduced resident safety. Staffing must be aligned with resident acuity, not just minimum numbers.A review of facility Grievance Forms, dated 10/3/25 through 5/4/26, showed multiple concerns reported by residents and their representatives related to call light response times, delayed care, untimely medication administration, staff attitude, and unmet care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-13 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interviews, it was determined the facility failed to notify a resident's representative of an accident. This was true for 1 of 3 residents (Resident #20) reviewed for notifications. This deficient practice had the potential to prevent Resident #20 and/or their representative from making timely and informed decisions regarding the resident's medical care. Findings include: The Facility's Fall Response & Management policy, revised 8/21/25, documented facility will notify the provider and resident representative if a resident sustains a fall.Resident #20 was readmitted to the facility on [DATE] with multiple diagnoses including Alzheimer's, dementia, anxiety, kidney disease, and diabetes.The fall report dated 12/16/25, documented Resident #20 was found face down on the floor next to her bed. Upon examination, Resident #20 had a significant bump to the back of the right side of her head and small red mark under her right eye. The I&A report dated 12/16/25, identified…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to follow the physician's order to monitor urinary output. This was true for 1 of 3 residents (Resident #4) whose bowel and bladder records were reviewed. This deficient practice had the potential to affect Resident #4's hydration status when physician ordered monitoring was not completed. Findings include:Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including quadriplegia (the partial or total paralysis of all four limbs, both arms and both legs, and the torso), epilepsy, and retention of urine.A physician's order initiated 4/24/25 and revised on 1/20/26, documented to measure and record output for Resident #4's indwelling urinary catheter every shift for hydration management.A review of Resident #4's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the months of October 2025 through April 2026 showed the physician ordered monitoring of urinary output was not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-11-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, the Food Drug Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure ice machines were cleaned, and resident freezers were not contaminated by non-food items, or undated, opened food. These deficiencies had the potential to affect the 70 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.On 9/26/25 at 12:08 PM, it was observed in the Alpine Resident freezer, undated lemon ices, a frozen yogurt, and a frozen entree meal were not labeled with the resident's name or dated. A therapy ice pack was wrapped in a pillowcase and stored on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS a standardized assessment tool that measures health status in nursing home residents) Assessments were accurate. This was true for 3 of 6 residents (#5, #16, and #59) whose MDS assessment records were reviewed for accuracy. This deficient practice created the potential for negative outcomes if residents were not assessed and/or monitored due to assessment inaccuracies'. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory failure, anxiety disorder, panic disorder, and depression. Resident #5's PASRR Level I, dated 6/26/23, documented, in Section I at #1, diagnoses of depressive disorders and anxiety disorders, and at #3, panic disorder. Resident #5's PASRR Level II, dated 7/20/26, documented, in Section IX at #33, Individual has a current diagnosis of sever mental illness per PASRR criteria: Depression, Anxiety, Panic…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined the facility failed to ensure residents' care plans were revised according to their post fall needs. This was true for 1 of 22 residents (Resident #33) whose records were reviewed for care plan timing and revision. This deficient practice created the potential for harm when residents' needs were not identified and or met. Findings include:Resident #33 was admitted to the facility on [DATE] with multiple diagnoses including a broken right leg, difficulty walking, muscle weakness, Alzheimer's disease, and dementia.On 9/22/25 at 5:28 PM, Resident #33's representative stated her mom had fallen out of bed a few times as she is a restless sleeper and was on a new mattress. Resident #33's representative stated fall precautions had been put into place. There was a floor pad placed, and Resident #33's bed was in the lowest position while she was in bed.An Incident & Accident (I&A) fall report, dated 8/21/25, documented an unwitnessed fall with Resident #33. She…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and Insulin Lispro website, it was determined the facility failed to ensure residents' medications were administered according to professional standards of practice. This was true for 1 of 2 residents (Resident #36) whose insulin administration was observed. This failed practice created the potential for Resident #36 experience low or high blood sugar if she receives an incorrect amount of insulin. Findings include:Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including diabetes.A physician's order, dated 9/2/25 documented Resident #36 was to receive Insulin Lispro 100 unit/ml, inject two units subcutaneously (under the skin) before meals for diabetes management.On 9/24/25 at 11:58 AM, RN #3 took the Insulin Lispro pen, removed the needle, sanitized the tip of the insulin pen, placed a new needle and dialed the pen to two units. RN #1 stated she did not prime the needle because it was an old pen, if it was a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined the facility failed to ensure professional standards of practiced were followed. This was true for 3 of 22 residents (#6, #7, and #58) reviewed for following physician's orders. This deficient practice created the potential for harm if the facility failed to follow physician's orders and if resident's experienced complications related to catheter placement and care, and hypoglycemia (a condition in which blood glucose (BG, sugar) falls below normal.) Findings include: 1.Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including diabetes. A physician's order, dated 8/22/25, directed staff to check blood glucose for hypoglycemic (low blood sugar) and/or hyperglycemic (high blood sugar) symptoms. If blood sugar (BG) is less than 70 initiate hypoglycemic protocol and notify MD as indicated. If BG is greater than 400 notify MD and follow directives. A physician's order, dated 8/20/2025, documented staff provide: Gvoke HypoPen…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, it was determined the facility failed to ensure medication orders were clarified. This was true for 1 of 6 residents (Resident #87) whose records were reviewed for unnecessary medications. This failure placed Resident #87 at risk for over medication when her rescue seizure medication orders did not clearly direct their use. Findings include: Resident #87 was admitted the facility on 4/5/23 with multiple diagnoses including spastic quadriplegic cerebral palsy (characterized by stiff muscles and movement difficulties in all four limbs, the trunk, and the face due to early-life brain damage), a seizure disorder, and congenital hydrocephalus (a condition present at birth where excess cerebrospinal fluid (CSF) builds up in the brain, increasing pressure and potentially causing brain injury and developmental problems). Resident #87's medical record contained the following physician orders:Nayzilam Nasal Solution 5 MG/ 0.1 ML, Midazolam (benzodiazepine anticonvulsant), give 1 spray in 1 nostril as needed for seizure that lasts for more than 5…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined the facility failed to ensure resident's records contained accurate documentation related to their vital signs. This was true for 1of 22 residents (Resident #7) whose record was reviewed for accurate documentation. This deficient practice had the potential for adverse outcomes and harm if Resident #7's blood pressure was taken in an unsafe manner. Findings include:Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including high blood pressure, end stage renal disease (ESRD), and dependence on renal dialysis.A physician's order, dated 8/20/25 and 8/26/25, documented, Check fistula sight to the Left arm for signs and symptoms of infection and if bruit or thrill present, enter = if present and - if not present. Enter NA if not applicable. Every shift for dialysis monitoring. A physician's order, dated 8/20/25, documented, Do NOT take blood pressure on Left arm.A review of blood pressure (BP) measurements documented BP was taken on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Dcited before2025-11-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and review of Centers for Disease Control and Prevention (CDC) guidance, it was determined the facility failed to implement infection prevention and control practices to prevent cross-contamination for 2 of 2 Residents (Resident #85 and Resident #59) reviewed for infection control. This failure created the potential for adverse health outcomes, including infection. Findings include:The Centers for Disease Control and Prevention (CDC) web page titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 2/27/24, documented hand hygiene should be performed:Immediately before touching a patient.Before performing aseptic task such a placing an indwelling catheter device or handling invasive medical device.Before moving from a soiled body site to a clean body site on the same patient.After touching a patient or patients' surroundings.After contact with blood, body fluids, or contaminated surfaces.Immediately after glove removal.1.Resident #85 was admitted to the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-08 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed develop a comprehensive resident-centered care plan. This was true for 1 of 21 residents (Resident #18) whose care plans were reviewed. This failure placed Resident #18 at risk of unmet care needs when he did not have a care plan for pneumonitis. Findings include: Review of the facility's Care Plans policy, dated 10/15/22 revealed, A comprehensive care plan is developed consistent with the residents' specific conditions, risks, needs, behaviors, cultural expectations, preferences and with standards of practice including measurable objectives, interventions/services, and timetables to meet the resident's needs as identified in the resident's assessment or as identified in relation to the resident's response to the interventions or changes in the resident's condition . Resident #18 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia (paralysis of the legs and lower body) and diabetes…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-08 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interview, it was determined the facility failed to ensure medication orders were written accurately per current standards of practice. This was true for 2 of 21 residents (#52 and #710) whose physician's orders were reviewed. This failure created the potential for residents to receive the wrong dosage or receive the medication via the wrong route. Findings include: The facility's Eight Rights of Medication Administration policy, undated documented the following: right resident, right medication, right dose (confirm the appropriateness of the dose using a current drug reference), right route (confirm that the resident can take or receive the medication by the ordered route), right time, right documentation, right reason and right response. 1. Resident #71 was admitted to the facility on [DATE] with multiple diagnoses including tracheostomy (a surgically created hole in the windpipe for breathing), dementia, and gastrostomy (presence of surgical opening into the stomach…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, it was determined the facility failed to ensure physician's order was followed regarding dressing changes for 1 of 2 residents (Resident #84). This failure created the potential for infection to spread to Resident #84's open areas to his left arm if it was not covered as ordered by the physician. Findings include: Resident #84 was admitted to the facility on [DATE] with multiple diagnoses including stroke, acute respiratory failure with hypoxia (low level of oxygen in the body tissues), and left hemiparesis (weakness) and hemiplegia (paralysis). An admission MDS assessment dated [DATE], documented Resident #84 was severely cognitively impaired. A Physician Order dated 8/6/24, directed staff to cleanse Resident #84's open rash to his left arm with wound cleanser, cover with boarder gauze and change two times a week and as needed. Resident #84's care plan dated 8/7/24, documented Resident #84 had a rash on his left arm. Interventions included: avoid…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-08 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and record review, it was determined the facility failed to obtain physician ordered laboratory testing. This was true for 1 of 21 residents (Resident #18) whose records were reviewed. This failure created the potential for a physician to inaccurately diagnose and/or treat a resident appropriately due to lack of information. Findings include: Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including paraplegia (paralysis of the lower limbs below the navel) and cerebral palsy (CP is caused by abnormal brain development or damage to the developing brain that affects a person's ability to control their muscles). Resident #18 did not have any cognitive deficiencies and could make his own medical decisions. Resident #18's record contained physician orders, dated 5/23/24, for 3 laboratory tests: 1. Complete Blood Count (a CBC examines the number and types of cells in a person's blood); 2. Comprehensive Metabolic Panel (a CMP measures 14 substances in a person's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-08 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility's policy titled, Documentation of Resident Health Status Needs and Services, dated 10/14/22, documented directions to document services provided after the encounter has concluded and do not document in advance or prior to providing treatments. Resident #84 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (lack of oxygen in the blood and body tissues), hypertension, heart disease, and stroke. Resident #84 was severely cognitively impaired. Resident #84's record contained a physician order, dated 8/6/24, that directed staff to cleanse the open rash on his left arm with wound cleanser, cover with bordered gauze, and change two times per week and as needed. On 8/7/24 at 11:30 AM, Resident #84 was observed in his room, he did not have a dressing on his left arm. On 8/7/24 at 1:28 PM, LPN #2 documented in a progress note, [Rash on left arm] was cleaned, and foam dressings applied. No other new skin issues noted at this time. On 8/7/24 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and nursing competency review, it was determined the facility failed to observe infection control guidelines during a wound care dressing change for 1 of 2 residents, (Resident #71) whose wound care was observed. This failure placed the resident at increased risk of contracting an infection in their wound. Findings include: Resident #71 was admitted to the facility on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia (lack of oxygen in the blood and body tissues), dementia, and a stage 4 pressure ulcer (localized damage to the skin and underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure, a stage 4 pressure ulcer has full thickness tissue loss exposing bone, tendon, or muscle) on his sacral region (the area located between the lower back and the tailbone). Resident #71 was dependent on a gastric tube (g-tube) for all of his nutrition, hydration, and medications, and he…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-22 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, observation, and resident and staff interview, it was determined the facility failed to ensure residents were assessed for safety and care-planned to self-administer medication. This was true for 2 of 3 residents (#4 and #7) reviewed for self-administration of medication. This failure created the potential for adverse outcomes if residents self-administered medications inaccurately and received too much or too little of the medication. Findings include: Findings include: The facility's policy, Self-Administration of Medications, dated 11/28/17, states residents may self-administer drugs if the interdisciplinary team has determined that it is safe. The policy states the interdisciplinary team periodically reviews residents' self-administrations of drugs according to the resident's status. lf the medication is to be stored in the resident's room, a method of storing and securing the medication is prearranged and approved for storing medications, such as a locked cabinet.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-22 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, observation, and staff interview, it was determined the facility failed to ensure a resident's MDS assessment documented his nephrostomy tube (a thin flexible tube surgically placed into a kidney to drain urine). This was true for 1 of 19 residents (Resident #17) reviewed for accuracy of MDS assessments. This failure had the potential for Resident #17 to not receive care and services necessary to prevent infection and damage to her kidney. Findings include Findings include: The facility's policy, Resident Assessment and RAI, revised 10/15/22, documented a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, needs, strengths, goals, life history and preferences using the Resident Assessment Instrument (RAI), was used which directed the care of the resident based on his or her individual needs. Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Hydronephrosis (when…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, observation, and staff interview, it was determined the facility failed to ensure interventions were in place on a resident's care plan for the care of her nephrostomy tube (a thin flexible tube surgically placed into a kidney to drain urine) and biliary tube (a thin flexible tube surgically placed into the bile duct of the liver to drain bile). This was true for 1 of 19 residents (Resident #17) whose care plans were reviewed. This failure had the potential for Resident #17 to not receive care and services necessary to prevent infection and damage to her kidney and liver. Findings include: The facility's policy for Care Plans, dated 10/15/22, documented A comprehensive care plan is developed consistent with the residents' specific conditions, risks, needs, behaviors, cultural expectations, preferences and with standards of practice including measurable objectives, interventions/services, and timetables to meet the resident's needs as identified in the resident's assessment…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-22 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and family and staff interview, it was determined the facility failed to provide communication assistance as needed to 1 of 2 residents (Resident #54) reviewed for activities of daily living. This failure placed Resident #54 at risk for decreased quality of life and psychosocial distress related to inability to communicate effectively. Findings include: The facility's Communication policy, revised 10/15/22, documented information about the facility was communicated to the residents by using materials printed in the primary language of the resident and using an interpreter or interpreter services. Resident #54 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues). A quarterly MDS assessment, dated 1/2/24, documented Resident #54 was cognitively intact and his primary language was Nepali. Resident #54's care plan, revised 4/24/23, documented Resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, observation, and resident and staff interview, it was determined the facility failed to ensure residents received treatment and services to prevent skin injuries. This was true for 1 of 5 residents (Resident #308) who were reviewed for pressure injuries. This placed residents at risk of adverse outcomes if care and services were not provided due to skin assessments not being completed as ordered. Findings include: Resident #308 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease and a non-pressure chronic ulcer of lower leg. On 3/19/24 at 3:12 PM, Resident #308 was observed during peri care. A large dark purple/dark red area was observed on the inner side of his right buttock, by the scrotum. A physician's order, dated 3/14/24, documented staff were to update, evaluate, and document all ongoing and new skin alterations for Resident #308 with scheduled skin checks weekly. Resident #308's care plan, revised 3/14/24, directed staff…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-22 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #53 was admitted on [DATE], with multiple diagnoses including paraplegia (paralysis of the lower legs and body) and altered mental status. On 3/18/24 at 3:25 PM, a can of Biofreeze (a medication used topically to relieve pain) was observed on Resident #53's bedside table. On 3/18/24 at 3:28 PM, LPN #4 stated medication should not be left at the bedside unless the resident had an order for it to be left at bedside. 3/21/24 at 11:21 AM, the CNO stated medications were allowed at a resident's beside if the resident was approved to self-administer the medication. She stated the can of Biofreeze should have been stored on the medication cart and not left at Resident #53's bedside. Based on policy review, observation, and staff interview, it was determined the facility failed to ensure medications were secured when they were unattended by staff. This was true for 1 of 7 residents (Resident #20) observed during medication passes and for 1 of 19 residents (Resident #53) observed in their room. This failure…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-22 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents were monitored appropriately and offered non-pharmacological interventions while receiving opioid pain medications. This was true for 4 of 5 residents (#29, #44, #91, and #350) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to a lack of appropriate monitoring or increased pain due to not offering non-pharmacological interventions. Findings include: The facility's policy for Pain Management, revised 10/15/22, directed staff to provide non-pharmacological interventions for breakthrough pain management and to monitor for any adverse effects of opioid medication use. a. Resident #44 was admitted to the facility on [DATE], with diagnoses including traumatic brain injury, quadriplegia, chronic pain, chronic respiratory failure, and had a tracheostomy. A physician order, dated 2/3/23, directed staff to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-09-22 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not perform hand hygiene. This was true for 4 of 27 residents (#21, #29, #67, and #83) observed during resident care. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's policy for Hand Hygiene, revised 2/11/22, stated opportunities for hand hygiene were before moving to a clean body site after caring for a soiled body site. This policy was not followed. 1. Resident #21 was readmitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, cognitive communication deficit, need for assistance with personal care, and generalized muscle weakness. On 9/22/23 at 5:18 AM, NA #2 and CNA #3 were observed providing peri-care for Resident #21. Both CNA #3 and NA…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-22 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure a resident was provided an appropriate adaptive call light due to physical limitations or ensure the call light was within reach. This was true for 1 of 27 residents (Resident #21) reviewed for resident rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include: The facility's expectations were documented in their Quality of Life policy, revised 10/15/22, which included call lights were adapted to accommodate the individual needs of the resident. It also documented staff ensured the call light was available and staff were responsive to residents' needs. The facility did not accommodate Resident #21's needs based on assessment and plan of care as follows. Resident #21 was readmitted to the facility on [DATE], with multiple diagnoses including…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-22 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to develop and implement a comprehensive resident-centered care plan when a resident expressed suicidal thoughts. This was true for 1 of 27 residents (Resident #78) whose care plans were reviewed. This deficient practice placed Resident #78 at risk for a negative outcome if his emotional needs were not identified and interventions documented in his care plan. Findings include: The facility's policy for Care Plans, revised 10/15/22, documented a comprehensive care plan was developed consistent with residents' specific conditions, risks, needs, behaviors, cultural expectations, preferences and with standards of practice .to meet the resident's needs as identified in the resident's assessment or as identified in relation to the resident's response to the interventions or changes in the resident's condition. The policy documented the care plan collaborated for interventions to address mental and psychosocial needs, to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-22 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans were revised to reflect current needs and interventions. This was true for 2 of 27 residents (#1 and #21) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's Care Plan policy, revised 10/15/22, documented when developing the care plan, the facility staff used MDS assessments to assess the resident's clinical condition, cognitive, functional status, and use of services. The care plans were to be monitored and revised quarterly, annually, with a significant change or as more frequently as needed with the input of the resident and the representative. 1. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including non-pressure chronic ulcer to the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-22 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled and dated. This was true for 2 of 3 medication carts inspected. This failure created the potential for residents to receive medication used for another resident presenting a risk for cross-contamination or to receive expired medications with decreased efficacy. Findings include: The facility's House Supply Medications policy, dated 11/28/17, stated medications should be initialed and dated when opening. This policy was not followed. On 9/19/23 at 2:49 PM, 1 Advair inhaler and 1 bottle of carbamide 6.5% ear drops were in the top drawer of the medication cart located on the rehabilitation wing. They were not labeled with an opened date. LPN #2 stated she did not know when the inhaler was opened, and she was not able to determine if it was expired. She also stated the carbamide was no longer an active order, and the bottle should have been dated when it was opened, and the medication discarded when the order was discontinued. On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$13,049 in federal fines across 1 penalty.

  • $13,049 — penalty dated 2023-09-22

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CASCADIA HEALTHCARE — 46 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 53.0-2.0 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 1 of 52.7-1.7 vs chain
Quality measures 3 of 53.9-0.9 vs chain
The other 45 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Caldwell Care of CascadiaCaldwell, ID 1 of 5Cherry Ridge of CascadiaEmmett, ID 1 of 5Coeur d Alene Health of CascadiaCoeur d'Alene, ID 1 of 5Colfax Health and Rehabilitation of CascadiaColfax, WA 1 of 5Colville Health and Rehabilitation of CascadiaColville, WA 1 of 5Curry Village Health And Rehab Of CascadiaBrookings, OR 1 of 5Eagle Rock Health and Rehabilitation of CascadiaIdaho Falls, ID 1 of 5Mount Ascension Transitional Care Of CascadiaHelena, MT 1 of 5Orchards of Cascadia, TheNampa, ID 1 of 5Spokane Valley Health And Rehabilitation Of CascadSpokane Valley, WA 1 of 5Teton Healthcare of CascadiaIdaho Falls, ID 2 of 5Cascadia of NampaNampa, ID 2 of 5Royal Plaza Health and Rehabilitation of CascadiaLewiston, ID 2 of 5Salem Transitional CareSalem, OR 2 of 5Secora Rehabilitation Of CascadiaPortland, OR 2 of 5Snohomish Health and Rehabilitation of CascadiaSnohomish, WA 3 of 5Arbor Valley of CascadiaBoise, ID 3 of 5Brookfield Health And Rehab Of CascadiaBattle Ground, WA 3 of 5Clarkston Health And Rehab Of CascadiaClarkston, WA 3 of 5Clearwater Health & Rehabilitation of CascadiaOrofino, ID 3 of 5Highland Health And Rehabilitation Of CascadiaBellingham, WA 3 of 5Northpark Health And Rehabilitation Of CascadiaPhoenix, AZ 3 of 5Shaw Mountain of CascadiaBoise, ID 3 of 5Weiser Care of CascadiaWeiser, ID 4 of 5Canyon West of CascadiaCaldwell, ID 4 of 5Cascadia of LewistonLewiston, ID 4 of 5Cove of Cascadia, TheBellevue, ID 4 of 5Grangeville Health & Rehabilitation of CascadiaGrangeville, ID 4 of 5Lewiston Transitional Care of CascadiaLewiston, ID 4 of 5Mountain Valley of CascadiaKellogg, ID 4 of 5Paradise Creek Health and Rehab of CascadiaMoscow, ID 4 of 5Stafholt Health And Rehabilitation Of CascadiaBlaine, WA 4 of 5Wellspring Health & Rehabilitation of CascadiaNampa, ID 5 of 5Alderwood Park Health And Rehab Of CascadiaBellingham, WA 5 of 5Aspen Park of CascadiaMoscow, ID 5 of 5Bend Transitional CareBend, OR 5 of 5Boswell Transitional Care Of CascadiaSun City, AZ 5 of 5Creekside Health and Rehabilitation of CascadiaEugene, OR 5 of 5Fairlawn Health And Rehabilitation Of CascadiaGresham, OR 5 of 5Hudson Bay Health And RehabilitationVancouver, WA

Showing 40 of 45; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
TIMBERLINE CTRE TENANT LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 06/05/2025
WHITE OAK HEALTHCARE FINANCE LLCOrganization5% OR GREATER SECURITY INTERESTsince 08/11/2022
CASCADIA HC GROUP LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/05/2025
CASCADIA SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/09/2025
HAMMOND, OWENIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/20/2018
NASH, HADENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/15/2025
WILLIAMS, RYANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/14/2025

CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$16.3M
Net patient revenuemost recent cost report
+3.4%
Operating marginrevenue minus expenses
$816K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 10%Other / private 20%

This home reported $816K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$468per resident / day
operating cost
$14,213per month
≈ monthly operating cost
$484per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in ID

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Idaho Medicaid page.

Typical monthly cost in Idaho
$10,494/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,175/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 135146. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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