Life Care Center of Treasure Valley
502 North Kimball Place, Boise, ID 83704 · For profit - Corporation · 120 certified beds · (208) 377-1900 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- 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
- its facility-reported quality-measure score sits well above its independent inspection score
- about 22% of its spending goes to commonly-owned related companies
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 held steady at 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.8% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.8% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 2.0% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.4% | 15.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 1.5% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 0.0% | 3.0% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 5.5% | 16.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.8% | 16.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.5% | 3.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.0% | 22.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 32.4% | 20.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.2% | 1.8% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 82.4% | 86.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 20.4% | 17.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 4.7% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.25 | 1.17 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.06 | 1.66 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
66.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.0% 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 50 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 0.32 therapist hours per resident per day in 2026Q1 — more than 52% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 66.1%CMS range 54.6–75.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 7.1–15.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 54.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 60.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 46.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.6%CMS range 3.1–10.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 120 beds and averages 91.3 residents a day — about 76% occupied, or roughly 29 beds typically open. It usually has some room. 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 3.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.95 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 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 3.46 hrs/resident/day on weekends vs 4.07 on weekdays — 15% thinner on weekends. RN hours go from 1.10 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.
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
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.
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 · G2022-03-04 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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, resident and staff interview, review of investigations and grievances, and policy review, it was determined the facility failed to ensure a resident's pain was effectively managed and treated in a respectful manner. This was true for 1 of 6 residents (Resident #40) reviewed for pain management. Resident #40 was harmed when she felt publicly degraded when denied narcotic pain medication necessary to effectively manage her pain. Findings include: The facility's Pain Assessment and Management Policy, revised on 7/17/21, stated the purpose of the pain policy was to help residents attain or maintain their highest practicable level of well-being by proactively identifying, care planning, monitoring, and managing the resident's pain indicators. Based on record review, resident and staff interview, review of investigations, and policy review, it was determined the facility failed ensure a resident's pain was effectively managed and treated in a respectful manner. This was true for 1 of 6…
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.
- Potential for harm · E2025-06-26 · tag F0641 — patternEnsure 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 the MDS assessment accurately reflected resident's status. This was true for 5 of 19 residents (#4, #30, #34, #45, and #52) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: 1. Resident #4 was admitted to the facility on [DATE], with a readmission on [DATE], with multiple diagnoses including congestive heart failure (heart does not pump blood as well as it should) and major depressive disorder. On 11/11/24, Resident #4's PASRR level I documented she had diagnoses of depressive disorders, bipolar disorder, and anxiety disorders. The PASRR level I was to be forwarded to BLTC for further screening. On 11/21/24, Resident #4's PASRR Level II, documented diagnoses of bipolar, anxiety, and depression. Resident #4's PASRR level II was to be sent for further evaluation by a mental…
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.
- Potential for harm · D2025-06-26 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on incident and accident log review, record review and interviews, it was determined the facility failed to ensure resident representatives were notified following resident fall with injury. This was true to 1 of 4 residents (Resident #211) whose records were reviewed. This deficient practice created the potential for harm or adverse outcomes if the residents' representatives were not notified of resident injuries. Findings include: Resident #211 was admitted to the facility on [DATE], with multiple diagnoses including dementia and history of falls. On 6/23/25, reviewed documentation in the facility incident and accident log of a resident who fell with resulting injury to her elbow on 4/1/23, and resident representative had not been notified of the fall or injury. On 6/26/25 at 11:45 AM, the DON stated the facility failed to notify the family/POA of the resident's fall with injury.
- Potential for harm · D2025-06-26 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on incident and accident log review, record review and interviews, it was determined the facility failed to ensure resident specific discharge paperwork was provided to the hospital during transfer to the hospital. This was true for 1 of 2 residents (Resident #211) whose records were reviewed. This deficient practice had the potential for harm if resident required health information was not provided to the hospital. Findings include: Resident #211 was admitted to the facility on [DATE], with multiple diagnoses including dementia and history of falls. On 6/23/25, reviewed documentation in the facility incident and accident log of resident who fell on 4/1/23, with resulting nasal fracture, two black eyes, and a facial laceration and no documentation the facility sent resident required information (hospice) to the hospital during transfer. On 6/26/25 at 11:45 AM, the DON stated the facility failed to send resident information to the hospital when she was transported to the hospital.
- Potential for harm · D2025-06-26 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
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 incorporate PASRR recommendations in MDS assessment and care planning. This was true for 1 of 19 residents (Resident #32) reviewed for Level I and II PASRR evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not incorporated in their care. Findings include: The facility's Pre-admission Screening and Resident Review (PASRR) policy dated 10/6/22, documented recommendations from PASRR Level II determination and PASRR evaluation report are to be incorporated into the person-centered care plan as well as in transitions of care. As part of the PASRR process, the facility is required to notify the appropriate state mental health authority or state intellectual disability authority when a resident with a mental disorder (MD) or intellectual disability (ID) has a significant change in their physical or mental condition. This will ensure that…
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.
- Potential for harm · Dcited before2025-06-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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, and staff interview, it was determined the facility failed to follow current physician oxygen orders. This was true for 1 of 19 residents (Resident #26) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services had been provided that were not ordered by the physician. Findings include: Resident #26 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (refers to the lungs' inability to adequately oxygenate the blood (hypoxia) over an extended period, typically due to underlying chronic lung conditions) and diabetes. Resident #26's physician's order dated 9/11/24, documented oxygen at 2 liters/minutes continuously via nasal cannula and obtain oxygen sats every shift. Resident #26's care plan documented oxygen settings via nasal prongs, liters per current MD/NP orders. Resident #26's TAR for the month of June 2025, documented oxygen…
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.
- Potential for harm · D2025-06-26 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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, and staff interviews, it was determined the facility failed to ensure licensed nurses performed tasks which they had the knowledge, skills, and competencies. This was true for 7 of 28 licensed nurses. This had the potential for adverse effects to all residents when skin related issues were missed during assessments. Findings include: The facility's Skin Integrity and Pressure Ulcer/Injury Prevention policy dated 7/9/24, documented a skin assessment/inspection should be performed weekly by a nurse. Skin observations also occur throughout points of care provided by CNAs during ADL care (bathing, dressing, incontinent care, etc). Any changes or open areas are reported to the Nurse. CNAs will also report to the nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including chronic heart failure and…
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.
- Potential for harm · D2025-06-26 · tag F0728 — failed to protect against nurse-aide misconduct — isolatedEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of the staffing schedules, personnel files, and staff interviews, it was determined the facility failed to ensure full-time employees working as an NA were either in a State approved training and competency evaluation program or had recently and successfully completed such a program. This was true for 3 of 12 NAs (NA #1, #2, and #3) whose personnel files were reviewed. This failure had the potential to result in negative outcomes for all residents living in the facility. Findings include: NA #1 was hired on 1/2/25 and had not obtained their CNA certification and was not enrolled in a CNA program as of 6/23/25. NA #2 was hired on 8/28/24 and had not obtained their CNA certification as of 6/23/25. NA #3 was hired on 4/3/24 and had not obtained their CNA certification as of 6/23/25. On 6/25/25 at 2:35 PM, the DON stated NA #1, #2, and #3 had not yet obtained their CNA certification and should have.
- Potential for harm · D2025-06-26 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts audited. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: On 6/24/25 at 9:08 AM, during 300-Wing medication cart audit, observed the narcotic accountability record dated 6/1/25 to 6/24/25, with 6 licensed nurse signatures not documented. On 6/24/25 at 11:12 AM, the DON stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 6/25/25 at 2:04 PM, during A-Wing medication cart audit, observed the narcotic accountability record dated 6/1/25 to 6/25/25, with 5 licensed nurse signatures not documented. On 6/25/25 at 2:05 PM, RN #1 stated two nurses should have signed the narcotic accountability record when they…
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.
- Potential for harm · Dcited before2025-06-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 Based on observations, review of the State Operations Manual, and staff interviews it was determined the facility failed to ensure medications were stored and kept secure, and biologicals were labeled when opened. This was true for the facility. These deficient practices created the potential for theft and/or diversion and use of expired biologicals. Findings include: The State Operations Manual, Appendix PP, updated [DATE], Schedule II-V medications must be maintained in separately locked, permanently affixed compartments. 1. The following was observed for unlocked medication cart. On [DATE] at 9:17 AM, observed 300-Wing medication cart had been left unlocked and unattended by the medication nurse. On [DATE] at 9:20 AM, LPN #1 stated the medication cart should have been locked and had not been. On [DATE] at 3:10 PM, the DON stated the medication cart should have been locked when the medication nurse walks away from the cart. 2. The following was observed for controlled medications. On [DATE] at 2:10 PM,…
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.
- Potential for harm · D2025-06-26 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, policy review, and staff interview, it was determined the facility failed to appropriately store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to put residents who consume thickened liquids at risk for potential contamination and adverse health outcomes including contracting food-borne illnesses. Findings include: Facility policy, Resident Dining Services revised 4/29/25, documented the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety. On 6/23/25 at 11:40 AM, during the initial tour of the kitchen, the following was observed with the Food Service Manager present: - In the dry storage room, were 8 cartons of Lemon-flavored thickened water with expiration dates of April 2025. On 6/23/25 at 11:42 AM, the Food Service Manager stated the Lemon-flavored thicken water was expired and should have been discarded.
Show the remaining 19 citations
- Potential for harm · D2025-06-26 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and users manual review, the facility failed to ensure patient care equipment was monitored to ensure it was in a safe operating condition. This was true for 1 of 3 warming cabinets. This failed practice: 1) placed residents residing in the facility, at risk for adverse outcomes including skin burns 2) placed facility at risk for adverse outcomes in the event of malfunctioning equipment. Findings include: The Accucold PureTherm Warming Cabinet user manual listed a warning, to reduce the risk of fire, electric shock, or injury when using this appliance, follow these basic precautions . appliance is not meant to exceed a temperature of 140 degrees. On 6/24/25 at 2:52 PM, observed the 100-Hall towel warming cabinet with temperature reading of 148 degrees. On 6/24/25 at 4:05 PM, the DON stated warming cabinet should not exceed temperature of 140 degrees as per manufacturer's recommendation and the cabinet should not have been used.
- Potential for harm · E2022-03-04 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
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, resident and staff interview, policy review, and record review, it was determined the facility failed to ensure a) residents' personal information was communicated in a way that protected the confidentiality of the information and the dignity of the residents, and b) residents' physical privacy was maintained during care and services. This was true for 3 of 28 residents (#7, #27, and #52) reviewed for privacy and confidentiality. These deficient practices placed residents at risk psychosocial harm due to embarrassment and loss of control over their personal information and physical privacy. Findings include: 1. The facility's Perineal Care of the Female Patient policy, revised on 11/19/21, documented the staff were to provide privacy during perineal care to minimize the resident's exposure and embarrassment, drape the resident with a bath blanket, sheet, or towel, exposing only the perineum (area between the genitals and the anus). This policy was not followed. a. Resident #52 was admitted…
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.
- Potential for harm · Ecited before2022-03-04 · tag F0880 — failed to prevent and control infections — patternProvide 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, record review, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices related to hand hygiene, PPE, and ensuring urinary catheter bags were not placed on the floor were followed. This was true for 4 of 28 staff (CNAs #1, #2, #3, and #4) observed during resident care, and 1 of 6 residents (Resident #56) reviewed for urinary catheter use. These deficient practices placed residents at risk of infection and cross-contamination. Findings include 1. The facility's policy and procedure for Hand Hygiene, revised 12/4/20, stated it was important to ensure hand hygiene was performed at the appropriate times before and after touching a resident, between residents, and frequently during resident care. The policy documented hand hygiene was to be performed at the following times: * Before and after all resident contact; * After contact with potentially infectious material; * After contact with blood, body fluids, or visibly…
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.
- Potential for harm · Dcited before2022-03-04 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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, resident and staff interview, policy review, and record review, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 2 of 28 residents (#7 and #56), reviewed for respect and dignity. This deficient practice placed residents at risk of skin breakdown, diminished sense of self-worth, and lack of sleep. Findings include: The facility's policy titled Dignity, revised 8/30/21, documented each resident must be treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. 1. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure (weakness of the heart leading to a buildup of fluid in the lungs and body tissue). Resident #7's annual MDS assessment, dated 12/6/21, documented she was cognitively intact, required one person's extensive assistance for bed mobility, toileting, and personal hygiene,…
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.
- Potential for harm · Dcited before2022-03-04 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 ensure a bed-hold notice was provided to a resident or their representative when they were transferred to the hospital. This was true for 1 of 2 residents (Resident #34) reviewed for transfers. This deficient practice created the potential for harm if the resident or his representative was not informed of the right to return to his former bed/room at the facility within a specified time. Findings include: The facility's policy for Bed-Hold/Reservation of Room, revised 8/7/21, documented at the time of admission, transfer or therapeutic leave, the facility would provide written information to the resident or resident representative that specified: * The duration of the State bed-hold policy, if any, during which a resident was permitted to return and resume residence. * The reserve bed payment policy in the State plan. * The facility's policies regarding bed-hold periods permitting a resident to return. This…
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.
- Potential for harm · D2022-03-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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, I&A reports, and staff interview, it was determined the facility failed to ensure a resident's care plan was reviewed and revised to reflect the use of a regular pressure-reducing mattress. This was true for 1 of 26 residents (Resident #26) reviewed for care plan revisions. This created the potential for harm if care was not provided or decisions were made based on inaccurate care plan information. Findings include: The facility's Comprehensive Care Plan Revisions policy, revised 5/10/21, stated when changes occurred, the facility reviewed and updated the care plan to reflect the changes to care delivery. This policy was not followed: Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis (a nervous system disease that affects the brain and spinal cord). An I&A report, dated 2/2/22 at 9:00 PM, documented Resident #26 fell out of bed. The report documented the immediate action taken by the care staff was 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.
- Potential for harm · Dcited before2022-03-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observation, record review, policy review, and staff interview, it was determined the facility failed to follow physician orders for 1 of 1 resident (Resident #168) reviewed for topical medication administration. This resulted in the potential for harm if residents did not receive medications as ordered. Findings include: The facility's Incident and Reportable Events Management policy, dated 7/19/21, described an event as a medication discrepancy and directed staff to assess the resident, create an event note, and notify the physician, the resident/resident representative, and a supervisor. This policy was not followed. Resident #168 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, pain, and left lower leg amputation. Resident #168's MAR documented a physician order for a Lidocaine patch (a topical pain medication) to be placed on Resident #168 in the morning and to remove it in the evening. The MAR documented the nurse removed the patch on the evening of 2/28/22 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.
- Potential for harm · Dcited before2022-03-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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, and staff interview, it was determined the facility failed to follow physician orders for the maintenance of supplemental oxygen for 1 of 1 resident (Resident #2) reviewed for supplemental oxygen use. This placed Resident #2 at risk for respiratory infections when the supplemental oxygen tubing and humidifier bottle were not changed. Findings include: Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including dementia and a cerebral vascular accident (a stroke). Resident #2's annual MDS assessment, dated 11/30/21, stated Resident #2 was unable to make wants and needs known and depended on one to two staff for all activities of daily living. On 3/3/22 at 8:47 AM, Resident #2 was observed using supplemental oxygen. The humidifier bottle, which was attached to the oxygen concentrator with supplemental oxygen flowing through it, had black writing on the humidifier bottle with the date of 2/15/22. The concentrator's filter was covered with gray debris…
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.
- Potential for harm · E2018-11-09 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (low oxygen levels). Resident #56's quarterly MDS assessment, dated 10/4/18, documented severe cognitive impairment. Resident #56's November 2018 physician orders documented a POST with a code status of DNR was ordered on 6/14/18. Resident #56's current care plan documented she had an Advance Directive with a code status of DNR and directed staff to honor her wishes per her POST. On 11/6/18 at 8:37 AM, Resident #56's clinical record documented a letter of guardianship/ conservatorship. There was no documentation of an Advance Directive, Living Will, or Power of Attorney. A Care Plan Conference Record, dated 9/27/18, did not document the Advance Directive status was addressed with Resident #56 or her representative. On 11/8/18 at 8:32 AM, the Licensed Social Worker (LSW) said Resident #56 had a guardian and was not able to complete an Advance Directive. The LSW said residents were asked…
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.
- Potential for harm · Dcited before2018-11-09 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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, facility policy review, and resident and staff interviews, it was determined the facility failed to ensure an environment was maintained that enhanced a resident's dignity and respect when staff placed a clothing protector on a resident without the resident's permission. This was true for 1 of 8 residents (#21) observed in the Ponderosa dining room. This failed practice created the potential for psychosocial harm if a resident experienced embarrassment or a lack of self-esteem due to being observed wearing a clothing protector. Findings include: The facility's policy and procedure for dignity, last revised 6/17/08, documented the following: * All residents are treated in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality. * Social Services staff promote staff interactions with residents to maintain their dignity, including promoting resident's independence and dignity in dining. Resident #21 was…
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.
- Potential for harm · D2018-11-09 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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, facility policy review, and record review, it was determined the facility failed to ensure completed transfer information was provided to the receiving hospital for emergent transfers. This was true for 1 of 2 residents (Resident #17) reviewed for transfers. This deficient practice had the potential to cause harm if the resident was not treated appropriately or in a timely manner due to a lack of information. Findings include: The facility's policy and procedure for Transfers and Discharges, last revised 9/1/17, directed staff to complete the Resident Transfer Form, copy any part of the clinical record necessary to care for the resident, and send the original Resident Transfer Form and the parts of the clinical record that were copied. The minimum information sent with the resident should include the following: * Face sheet * Medication List * Contact information of the healthcare provider responsible for the resident's care. * Resident representative information including contact…
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.
- Potential for harm · D2018-11-09 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 a resident's family member interview and staff interview, facility policy review, and record review, it was determined the facility failed to ensure transfer notices were provided in writing to a resident and the local ombudsman. This was true for 2 of 2 residents (#11 and #17) reviewed for transfers and had the potential for harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include: The facility's policy and procedure for Transfers and Discharges, last revised 9/1/17, documented the following: * Transfers and discharges will be handled appropriately to ensure proper notification and assistance to residents and families in accordance with federal and state-specific regulations. * The facility makes certain systems are carried out to provide written notification to residents and resident representatives prior to transfer. The written notification would be provided on the Notice of Discharge or Transfer form. * The written notification would include…
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.
- Potential for harm · Dcited before2018-11-09 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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, staff interview, and policy review, it was determined the facility failed to ensure written notification of the facility's bed-hold agreements were provided to residents. This was true for 2 of 2 residents (#11 and #17) reviewed for transfers. The deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: The facility's policy for bed hold/reservation of room, revised on 1/28/16, documented: * The facility will provide written information to the patient or patient representative regarding bed holds before the patient transfers to a hospital or the patient goes on therapeutic leave. * Bed hold policies will be provided and explained to the patient upon admission and explained to the patient before each temporary absence. * Before the patient transfers to a hospital or the patient goes on therapeutic leave, the facility will provide: - Written information 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.
- Potential for harm · Dcited before2018-11-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observation, record review, policy review, and staff and resident interviews, it was determined the facility failed to: a) provide supervision of medication administration to ensure a resident's medications were taken as ordered by the physician, b) ensure Prevalon boots (boots to protect skin) were in place as ordered by the physician, and c) ensure a dressing was in place as ordered by the physician. This was true for 2 of 19 residents (Residents #11 and #53) reviewed. This deficient practice had the potential for harm if residents did not receive medications ordered by the physician and if residents experienced a decline in skin condition due to lack of wearing Prevalon boots (a boot to protect skin) and protective dressings. Findings include: 1. Resident #53 was admitted to the facility on [DATE] with multiple diagnoses including Stage IV pressure ulcer of the left heel and Alzheimer's disease. The National Pressure Ulcer Advisory Panel website, accessed on 12/4/18 describes a Stage IV pressure…
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.
- Potential for harm · D2018-11-09 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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, facility policy review, and record review, it was determined the facility failed to ensure residents received proper treatment and care to maintain good foot health. This was true for 1 of 7 residents (#53) reviewed for foot care. This failed practice created the potential for harm should residents experience complications from their medical condition related to the lack of proper foot care. Findings include: The facility's policy and procedure for Foot Care, dated 8/28/18, documented the following: * The facility would make sure foot care was provided consistent with professional standards of practice and foot care would include treatment to prevent complications from conditions such as diabetes, peripheral vascular disease, and immobility. * The facility would make sure foot care included assisting residents to make needed appointments with healthcare providers such as podiatrists and arranging transportation to and from the appointments. Resident #53 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.
- Potential for harm · D2018-11-09 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, and review of clinical records and facility policy, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 2 residents (Resident #38) reviewed for feeding tubes. This failure created the potential for harm if complications developed from improper feeding tube practices. Findings include: The facility's policy and procedure for Administering PO (oral) Medications through an Enteral Feeding Tube, dated 6/26/06, directed staff to rinse the feeding tube with 20-30 ml (milliliters) of warm water before giving medications in the tube and after giving the last medication. Resident #38 was re-admitted to the facility on [DATE] with multiple diagnoses including gastrointestinal hemorrhage and dysphagia (a swallowing disorder). Resident #38's 9/3/18 quarterly MDS assessment documented the following: * Severe cognitive impairment. * Feeding tube while a resident. * 501 cc (cubic centimeters) per day or more average fluid intake per day by IV…
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.
- Potential for harm · Dcited before2018-11-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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, facility policy review, and staff interviews, it was determined the facility failed to ensure staff changed residents' oxygen cannulas (tubing that delivers oxygen) and humidifier per physician orders and facility policy. This was true for 3 of 6 sample residents (#14, #17, and #38) reviewed for oxygen therapy. This failure created the potential for harm from respiratory infections due to the growth of pathogens (organisms that cause illness) in oxygen cannulas and humidifiers. Findings include: The facility's policy and procedure for Oxygen Administration/Safety/Storage/Maintenance, last revised 11/29/17, documented the following: * Change oxygen supplies every week and whenever visibly soiled. * Humidifier bottles should be dated and changed every 7 days, regardless of the water level. * Licensed healthcare providers and responsible to ensure that oxygen equipment/supplies are set up and cared for as documented in the policy. 1. Resident #14 was re-admitted to the facility…
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.
- Potential for harm · Dcited before2018-11-09 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, review of the facility's policy and staff interview, it was determined the facility failed to ensure expired medications were removed from medication storage room and medication carts and not available for administration to residents. This was true for 1 of 2 medication refrigerators and 1 of 3 medication carts checked for expired medications This failed practice created the potential for residents to receive expired medications with decreased efficacy. Findings include: The facility's policy for Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, undated, documented: * Once any medication or biological package is opened, facility should follow manufacture/supplier guidelines with respect to expiration dates for opened medications. On 11/6/18 at 12:55 PM, an open Tuberculin vial with an open date of 9/28/18 was found in the medication refrigerator located in the long-term care medication room. The medication box containing the Tuberculin vial documented, discard after once entered in 30 days. The UMD stated the medication was out…
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.
- Potential for harm · Dcited before2018-11-09 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, medical record review and staff interview, it was determined the facility failed to ensure the glucometer used to test capillary blood glucose levels was properly cleansed between testing. This was true for 2 of 5 residents (#8 and #16) observed for the testing of capillary glucose levels. This deficient practice created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include: The facility policy for Cleaning and Disinfection of the Glucometer, dated 3/2010, documented the following procedure: * Pick up the glucometer from the first barrier and disinfect it with a Super Sani-Cloth wipe or an equivalent product that kills hepatitis B and Blood borne pathogens. Follow the manufacturer's guidelines for wet time when applying disinfectant. Pay close attention to the strip holder area and be sure to not over-saturate the area. * Place the glucometer down on the second barrier. Allow enough time to dry per the manufacturer instructions, approximately 2 minutes. 1. On 11/07/18 at 4:55 PM, LPN#1 was…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LIFE CARE CENTERS OF AMERICA — 194 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; 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 / manager | Type | Role | Since |
|---|---|---|---|
| DEVELOPERS INVESTMENT COMPANY INC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2006 |
| PRESTON, FORREST | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/09/1994 |
| BANKS, STACY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 10/12/2019 |
| BUTNER, NANCY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 09/16/2018 |
| CATAMA, JERRY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/14/2025 |
| LAY, LISA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 02/09/2018 |
| SWANKER, RICHARD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2022 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 07/14/1995 |
| HENRY, TERRY | Individual | CORPORATE OFFICER | since 08/16/1999 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 09/22/2000 |
| EMERALD MEDICAL INVESTORS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/11/1996 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/14/2025 |
| FLETCHER, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| LUDWIG, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2019 |
| PRESTON, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| ZIEGLER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
CMS files one row per role, so the 27 rows in the source record cover these 16 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.
3 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.
About 79% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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
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
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.
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 135123. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-26, 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.