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Shaw Mountain of Cascadia

909 Reserve Street, Boise, ID 83712 · For profit - Corporation · 108 certified beds · (208) 343-7717 Medicare & Medicaid certified

Call the home — (208) 343-7717 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0604) — most recent May 2026Resident-funds citation (F0565)1 actual-harm citation$10,839 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0604) — most recent May 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • 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 $10,839 in federal fines (most recent 2024-02-09)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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.

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

Worth a closer look. This home's quality-measure rating runs 3 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

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
300 E Jefferson St · (208) 381-4100 · Call to confirm hours
Pharmacy
190 E Bannock St · (208) 381-4353 · Call to confirm hours
Grocery
311 N Elm Ave · (208) 519-4856 · Call to confirm hours
Park
629 San Jose Way · Typically dawn to dusk
Place of worship
700 E Bannock St · (208) 342-7092

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 3 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 rating3★
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 increased6.6%15.6%15.4%better
Long-stay residents who lose too much weight2.8%5.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.2%0.9%better
Long-stay residents with a urinary tract infection0.3%2.0%2.0%better
Long-stay residents with depressive symptoms12.7%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 injury1.5%3.0%3.3%better
Long-stay residents whose ability to walk worsened11.6%16.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.4%16.3%18.9%typical
Long-stay residents given the seasonal flu vaccine97.8%96.2%95.3%typical
Long-stay residents with pressure ulcers0.3%3.2%4.7%better
Long-stay residents with worsening bladder/bowel control29.5%22.1%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table23.4%20.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.4%1.8%1.4%typical
Short-stay residents given the seasonal flu vaccine95.8%86.5%79.4%better
Short-stay residents rehospitalized after admission8.7%17.7%22.6%better
Short-stay residents with an outpatient ER visit7.8%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days0.811.171.67better
Long-stay outpatient ER visits per 1,000 resident days0.271.661.80better

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.

49.5% 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 118 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.5%U.S. median 51.5%
Got home and stayed home
10.8%U.S. median 10.7%
Went back to hospital
62.2%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 62.2% 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 82 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 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 SNF49.5%CMS range 41.8–56.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.8%CMS range 7.4–15.810.7%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 discharge62.2%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 discharge59.8%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 discharge48.8%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 identified100.0%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 setting100.0%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 stay0.0%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 worsened1.0%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 hospitalization5.8%CMS range 3.3–9.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.801.02Oct 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

0.57
RN hours/ resident / day
1.11
LPN hours/ resident / day
2.40
Aide hours/ resident / day
4.08
Total nurse hours/ resident / day
0.43
RN hoursweekends
51.3%
Total nursing turnover
36.4%
RN turnover

How full it usually is: this home is certified for 108 beds and averages 90.9 residents a day — about 84% occupied, or roughly 17 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 4.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.40 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 3.61 hrs/resident/day on weekends vs 4.27 on weekdays — 15% thinner on weekends. RN hours go from 0.62 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% 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

4
deficiencies at the latest standard inspection (2026-05-14)
10
at the previous standard inspection (2025-03-07)

Deficiencies are fewer than at the previous inspection — improving. 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 · G2024-02-09 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 ensure a lap tray was used to treat a medical symptom and not used as a physical restraint for 1 of 1 resident (Resident #78) who was observed for use of restraints. This resulted in harm to Resident #78 was left in a wheelchair with a lap tray for long periods which resulted in skin impairment and psychosocial distress. Findings include: Resident #78 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), anxiety disorder, and malnutrition. Resident #78's admission MDS assessment, dated 12/9/23, documented she was severely cognitively impaired with unclear speech and rarely/never understood others. The assessment documented Resident #78 was dependent on eating and personal hygiene assistance and required maximal assistance for upper body dressing, sitting to standing, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 interview, record review, and review of the facility policy, the facility failed to protect the residents' right to be free from sexual abuse by a resident for two residents (Resident (R) 70) and R110) of three residents reviewed for abuse out of a total sample of 26. R10 touched R70's breast and R10 touched R110's breast. This failure had the potential to negatively affect R70 and R110's overall physical and mental health. Findings include: 1. Review of R70's admission Record, located in the Profile tab of the electronic medical record (EMR) indicated that resident (R) 70 was re-admitted to the facility on [DATE] with severe dementia and schizophrenia. Review of R70's admission Minimum Data Set (MDS), located under the MDS tab, with an Assessment Reference Date (ARD) of 03/09/26, revealed R70 has a Brief Interview for Mental Status (BIMS) of two out of 15, indicating severe cognitive impairment. During an attempted interview 05/10/26 at 11:50 AM, R70 was alert yet confused, mumbling as she colored 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 interview, record review, and review of the facility policy, the facility failed to ensure two abuse allegations were reported within two hours to the State Agency for two of three residents (Resident (R) 70 and R110) reviewed for abuse out of a total sample of 26 residents. This failure had the potential to negatively affect the facility by not making the State Agency aware of the situation timely.Findings include: 1. Review of R70's admission Record, located in the Profile tab of the electronic medical record (EMR), indicated that resident (R) 70 was re-admitted to the facility on [DATE] with diagnoses including severe dementia and schizophrenia. Review of R70's admission Minimum Data Set (MDS), located under the MDS tab, with an Assessment Reference Date (ARD) of 03/09/26, revealed R70 had a Brief Interview for Mental Status (BIMS) of two out of 15, indicating severe cognitive impairment. Attempted to interview R70 on 05/10/26 at 11:50 AM; however, R70 was alert yet confused, mumbling as she colored…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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, interview, and policy review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) level one screen was updated with a new major mental illness diagnosis for one of two residents (Resident (R) 19) reviewed for PASARR out of a total of 26 sample residents. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate. Findings include: Review of R19's admission Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 03/30/26, revealed R19 was admitted to the facility on [DATE]. R19 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R19 had sever cognitive deficits. Per the MDS, R19 had a diagnosis of Post Traumatic Stress Disorder (PTSD). Review of R19's Idaho Preadmission Screening and Review (PASRR) Level 1 HW00087, dated 03/19/26 and located in the EMR under 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 · D2026-05-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 record review, observation, and interview, the facility failed to ensure respiratory equipment was stored in a sanitary manner for one resident of two residents (Resident (R) 67) reviewed for respiratory care out of a total sample of 26. This failure had the potential to expose the resident to infections. Findings include:Review of R67's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R67 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) and unspecified dementia. Review of R67's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 02/20/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated R61 had intact cognition. Review of R67's Care Plan Report, located in the EMR under Care Plans tab, revealed a focus dated 12/27/24 which indicated R67 had terminal prognosis due to COPD. An…

    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 before2026-05-14 · 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 record review, observation, interview, and facility policy review, the facility failed to adhere to infection control practices and policies during wound care when staff failed to wear a gown for one resident (Resident (R) 36) on Enhanced Barrier Precautions (EBP) and failed to implement EBP for one resident (R92) with open wounds requiring dressing changes of three residents observed for wound care in a total sample of 26 residents. The deficient practice increased the risk for cross contamination and infections. Findings include:1. Review of R36's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R36 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebrovascular disease, neuromuscular dysfunction of bladder, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 03/16/26 revealed R36 had a Brief Interview…

    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 · D2026-05-14 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, interview, and facility policy review, the facility failed to offer pneumococcal vaccines based on Centers for Disease Control and Prevention (CDC) guidelines for one of five residents (Resident (R) 51) reviewed for immunizations out of a total of 26 sample residents. The deficient practice had the potential to increase the risk for this resident to contract pneumonia. Findings include:Review of R51's admission Record, located under the Profile tab in the electronic medical record (EMR), indicated R51 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, chronic kidney disease, and history of malignant neoplasm of breast. R51 was over [AGE] years of age. Review of R51's Immunizations, located under the Immunizations tab, and Immunization Record, located under the Documents tab, in the EMR revealed R51 had received PPSV23 (pneumococcal polysaccharide vaccine) on 06/07/04 and Prevnar 13 (also known as PCV13, a pneumococcal conjugate vaccine) on 11/04/14. R51 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-30 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan, and the residents' choices. This was true for 3 of 8 residents (Resident #1, #2, and #4,) whose records were reviewed for quality of care. This failure created the potential for harm when residents were not reassessed to ensure the plan of care was effective, when physician orders were conflicting, and physician orders were not implemented or followed when ordered. Findings include:1.The American Heart Association website accessed 12/30/25, documented the following blood pressure categories: Normal: less than 120/ less than 80 Elevated: 120-129/ less than 80 Stage 1 hypertension: 130-139/ 80-89 Stage 2 hypertension: 140 or higher / 90 or higher Severe hypertension: Higher than 180 / higher than 120 Hypertensive emergency Higher than 180/ higher than 120 a) Resident #1 was admitted on [DATE] with multiple…

    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 · D2025-12-30 · tag F0725 — failed to have enough nursing staff — isolated
    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 record review and staff interview, it was determined the facility failed to ensure sufficient staff were on-site to provide nursing services. This failure had the potential to affect all residents living in the facility and placed them at risk for harm if their call lights were not able to be answered in a timely manner or care was not provided due to not having adequate numbers of staff. Findings include:The facility Grievance Log was reviewed for July-December 2025, and documented the following:On 8/8/25, a resident reported long call light wait times. The facility completed call light audits and staff were provided education to answer call lights in a timely manner. On 8/15/25, a resident reported they were left soiled for 2 hours while their call light was on, once staff responded they seemed hurried. The facility provided one to one training to the CNA for answering call lights.On 8/22/25, a resident reported they used their call light for incontinence care, a CNA responded and turned off the call light, then said they would come help them with a shower, then did 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-30 · 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, the facility failed to ensure resident records were accurately documented in accordance with professional standards of practice. This was true for 1 of 8 residents (Resident #4) whose records were reviewed for accuracy of resident records. This failure resulted in inaccurate clinical documentation. Findings include:Resident #4 was admitted to the facility on [DATE], for care following sepsis (a life-threatening, extreme response to an infection that causes the immune system to damage the body's own organs and tissues) and multiple abscesses (pus-filled infected pockets of fluid) of his liver. Upon his admission, Resident #4 had 3 drain tubes surgically placed in his abdomen to drain waste from the liver abscesses into collection bags outside his body. On 3/14/25, a drain check note from Interventional Radiology documented: Drain #1 was removed, drain #2 and #3 remain in place, re-check tubes in 7 to 10 days On 3/21/25, a drain check note from Interventional Radiology…

    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 · Fcited before2025-03-07 · tag F0880 — failed to prevent and control infections — widespread
    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, review of the State Operations Manual, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained when 1) staff was assisting residents with meals and 2) medication administration, and 3) unsanitary conditions in the laundry room. This failure had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The State Operations Manual, Appendix PP, updated 8/8/24, documented failure to change gloves and wash hands between tasks, such as medical treatments or contact with residents .can contribute to cross-contamination. The facility policy, Dining Standards, updated 9/10/20, documented staff was to complete hand hygiene using soap and water at the beginning of meal service and are to sanitize hands when changing tasks or assisting different residents. The following issue were observed in the dining room; On 3/3/25 at 8:37 AM, CNA #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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · D2025-03-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, review of the State Operations Manual, policy review, and staff interviews, the facility failed to treat residents with respect and dignity during dining operations. This failed practice had the potential to negatively affect resident's self-esteem, decreased enjoyment of meals and mealtime, and may negatively impact resident's food and fluid intake. Findings include: State Operations Manual, Appendix PP, updated 8/8/24, documented to promote independence and dignity while dining, avoid standing over residents while assisting them to eat. The facility policy, Dining Standards, updated 9/10/20, documented staff are to sit down next to the resident while feeding and/or assisting with feeding. On 3/3/25 at 8:37 AM, CNA #5 was observed standing next to the dining room table, spoon feeding 2 of 5 residents seated at the table eating their breakfast. On 3/3/25 at 8:45 AM, LPN #2 stated staff should not be standing over the residents when assisting with feeding. 03/06/25 at 10:00 AM, the DON stated staff should not be standing while feeding residents.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-07 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 Based on record review and staff interview, it was determined the facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an Advance Directive. This was true for 2 of 24 Residents (#18 and #30) whose records were reviewed for Advance Directives. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning. Findings include: 1) Resident #18 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Parkinson's disease with dyskinesia (a condition where someone with Parkinson's disease experiences involuntary, uncontrolled movements) and dementia. Resident #18's medical record had not contained a copy of his Advance Directives. Resident #18's admission agreement document which contains the following wording By signing below, I acknowledge that I am legally bound by this Agreement and I indicate…

    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 · D2025-03-07 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 provide the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123 at least 2 days prior to discharge for 1 of 3 residents (Resident #302) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended. Findings include: Resident #302 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event) and cirrhosis (a condition in which your liver is scarred and permanently damaged). Resident #302 was discharged from Medicare Part A 12/16/24, and the NOMNC was signed on 12/16/24. On 3/7/25 at 9:45 AM, the Administrator stated Resident #302's NOMNC had not been completed 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-07 · 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 staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 24 residents (Resident #52) whose care plans were reviewed. This placed residents at risk for adverse outcomes if care and services were not provided due to care plans not being revised as resident's needs changed. Findings include: The facility's Comprehensive Care Plans policy, revision date 10/15/22, documented the team of qualified persons monitors the resident's condition and effectiveness of the care plan interventions and revises the care plan annually, with a significant change assessment, or more frequently as needed. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses which include dementia and weakness. Resident #52's medical recorded documented that she fell out of bed on 12/7/24. Resident 52's care plan was not updated with new fall interventions. 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
  • Potential for harm · D2025-03-07 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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, record review, policy review, and staff interview, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 1 resident (Resident #21) reviewed for feeding tube use. This created the potential for harm if complications developed from improper tube feeding practice. Finding include: The facility's Enteral Nutrition policy, revised 10/30/18, directed staff to verify tube placement by gently tugging on the tube and taking note of the marking on the tube. The policy also directed staff to properly label and date the enteral formula bottle. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including Spastic Diplegic Cerebral Palsy (a neurological disorder that affects movement and causes overly toned muscles) and anxiety. Resident #21's Physician's order dated 11/15/24, documented enteral feed every shift. For enteral nutrition precautions check feeding tube placement by observing change in the external length 4cm's marked 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-07 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure 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 personnel record review, resident record review, and staff interview it was determined the facility failed to ensure employees had completed the required annual trainings and competencies necessary to care for resident's needs. This was true for 1 of 5 employees whose training information was reviewed and 1 of 1 resident (Resident #32) medical records reviewed. This failure had the potential to affect all residents in the facility and increased the risk of harm to residents if staff were not trained on how to provide care and services to residents. Findings include: 1) RN #2's hire date was 5/29/21. Review of his personnel file did not document he had completed his dementia and communication training. RN #2's personnel file documented a Statement of Discussion dated 1/2/25, regarding the need to complete assigned training. On 3/7/25 at 10:00 AM, the DON stated RN #2 had not completed his training. 2) Resident #32 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple…

    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 · D2025-03-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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, policy 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 1 of 3 medication carts reviewed. 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: The facility's Controlled Substance Administration & Accountability policy dated 12/16/24, documented it is the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion, or accidental exposure. On 3/5/25 at 12:41 PM, during hall 300's medication cart audit, observed the narcotic accountability record, dated 11/22/24 to 12/3/24, with 16 licensed nurse signatures for each shift not documented. Review of the narcotic accountability record, dated…

    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 · D2025-03-07 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 the medication error rate was less than 5%. This was true for 3 medications (8.82%) which affected 1 of 6 residents (Resident #58) whose medication administration were observed. This failed practice placed residents at risk of not receiving their prescribed medication or dosage of their medication. Findings include: The facility's Oral Medication Administration policy dated 1/1/18, documented oral medications are to be administered per physician orders. The facility's Eye Drop Administration policy dated 2/28/18, documented wait a sufficient contact time of approximately 3-5 minutes before applying additional medication to the eye. The facility's Insulin Pen Use policy undated, documented before administering insulin, a 2-unit air shot must be performed to remove air bubbles and ensure accurate dosing. The following was observed during the medication pass: 1. Resident #58 was admitted [DATE], with multiple…

    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 before2025-03-07 · 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, CDC guidelines review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately. This was true for 1 of 1 medication storage rooms inspected and 3 of 5 medication carts audited for labeling and storage of medication. This failure created the potential for residents to have missed doses of medication and to receive expired medications with decreased efficacy. Findings include: The CDC guidelines for Preventing Unsafe Injection Practices dated 3/26/24, documented once a multi-dose vial is opened (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial. The beyond-use-date should never exceed the manufacturer's original expiration date. On 3/5/25 at 10:45 AM, the Hall 100 medication cart was audited with RN #4 present. In the top drawer of the medication cart a dairy digestive tablet was observed with an expiration date of July 2024. On 3/5/25 at 10:47 AM, RN #4 stated the dairy…

    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 · F2024-02-09 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility record review, review of the Payroll-Based Journal Staffing Data Report, and staff interview, it was determined that the facility failed to have an RN on duty for at least eight consecutive hours daily. This was true for 4 of the 31 days reviewed for RN coverage. This created the potential for harm if routine and/or emergency nursing services went unmet and had the potential to affect all residents residing at the facility. Findings include: The Payroll-Based Journal Staffing Data Report for Quarter 1, 2023, documented the facility had no RN coverage on Sunday 12/4/22, Saturday 12/17/22, Sunday 12/18/22, and Monday 12/26/22. The Centers for Disease Control and Prevention website for Covid 19 Nursing Home Data, accessed on 2/18/24, documented the facility's census the week of 12/4/22 was 80 and the census was 78 the week of 12/25/22. On 2/9/24 at 8:32 AM, the Clinical Resource Nurse said there was no RN coverage on 12/17/22 and 12/18/22. She said the DON was working on 12/4/22, and the ADON was working on 12/26/22. She stated they were salaried employees, and there…

    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 · F2024-02-09 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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, policy review, and staff interview, it was determined the facility failed to ensure food items were dated, labeled, and stored in a sanitary manner in accordance with professional standards for food service safety. This failure had the potential to affect the 87 residents who consumed food prepared by the facility and were at risk for adverse outcomes including foodborne illness. Findings include: The facility's Refrigerated-Storage Policy, undated, stated all foods were stored to prevent contamination and foodborne illness. A use-by date, (UBD - expiration date) system was utilized for foods once opened. The policy also stated dry goods would be stored 1 year and spices once opened would be marked with a UBD of 1 year. The facility's Food Safety Dating and Storage Guidelines, undated, stated All foods will be labeled with the name of the product and dated with the expiration date. The guidelines further stated, All received foods will be dated with the date of receipt and expiration date (if known), before placing on shelves in the storeroom. On 2/5/24 at 7:40…

    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 · F2024-02-09 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility record review, staff interview, and Centers for Medicare and Medicaid (CMS) policy manual review, it was determined the facility failed to accurately submit direct care staffing information to CMS. Findings include: The CMS Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual, dated June 2022, documented nursing home facilities were required to submit Payroll-Based Journal (PBJ) information of the facility's daily actual work hours by staff. The manual documented if a nurse spent the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse the facility can change the designated job title and report four hours as a nurse with administrative duties, and four hours as a direct care nurse (without administrative duties). The facility's Certification and Survey Provider Enhanced Reporting System (CASPER) report, included the PBJ report, dated October 1 to December 31, 2022. The report documented the facility did not meet the required minimum RN hours of 8 hours a day on Sunday…

    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 · E2024-02-09 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on Resident Group interview, policy review, Resident Council Meeting minutes review, and staff interview, it was determined the facility failed to ensure resident concerns were addressed. These negative practices placed residents at risk of ongoing frustration and decreased sense of self-worth, as well as, unmet care needs, when issues of concern to them were not promptly addressed by the facility. Findings include: The facility's Resident Council policy, revised 5/24/19, documented residents' recommendations and/or concerns would be addressed and communicated back to the council and/or Council President. A Resident Group interview was attended by 14 Residents on 2/6/24 at 10:39 AM. All the residents voiced concerns related to long call light response times. The residents stated it was an ongoing problem in the facility. The Resident Council minutes from July 2023 through December 2023 documented residents' concerns. Examples include: a. Resident Council Meeting minutes, dated 9/6/23, documented Evening staff is not getting to call lights for over an hour. Residents believe…

    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 · E2024-02-09 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for 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 staff interview, it was determined the facility failed to ensure residents were given the appropriate treatment and services to maintain or improve ability to carry out activities of daily living. This was true for 4 of 4 residents (#18, #28, #31, and #51) reviewed for restorative nursing services. This failure placed residents at risk for decreased range of motion, functional ability, and decreased quality of life. Findings include: The facility's Restorative Nursing policy, revised 1/20/20, documented a restorative nursing program was implemented to promote residents' abilities to adapt and adjust to living as independently as possible and as safely as possible. The policy stated restorative services focused on achieving and maintaining optimal physical, mental, and psychosocial functioning. a. Resident #31 was re-admitted to the facility on [DATE], with multiple diagnoses including muscle weakness. Resident #31's care plan, revised on 5/9/23, documented he required…

    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 · Ecited before2024-02-09 · 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 and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained when hand hygiene was not performed, equipment was not cleaned, and urinary catheters were not kept . This was true for 2 of 12 residents (Resident #62 and #191) who were observed in their rooms and at meals. This failure had the potential for adverse outcomes due to the risk of cross-contamination and infection. Findings include: 1. The Centers for Disease Control and Prevention (CDC) website included Catheter-Associated Urinary Tract Infection guidelines, accessed on 1/12/24, documented the Proper Techniques for Urinary Catheter Maintenance, including keeping the tubing and collecting bag below the level of the bladder at all times and not resting the tubing and collecting bag on the floor. Resident #62 was admitted to the facility on [DATE], with multiple diagnoses including dementia and urinary retention. Resident #62 was observed sleeping with his bed 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 before2024-02-09 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 identify a positive Level I Preadmission Screening and Resident Review (PASARR) and refer the resident to the appropriate state-designated authority for further review. This was true for 1 of 2 residents (Resident #78) reviewed for PASARR. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not provided due to a lack of updated PASARR screening. Findings include: The CMS State Operation Manual, Appendix PP, revised 2/3/23, defines the PASARR process as follows: The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is PASARR Level I, completed before admission to a nursing facility. A negative Level I screen allows admission to proceed and ends the PASARR process unless a possible…

    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 before2024-02-09 · 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, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated. This was true for 1 of 18 residents (Resident #57) whose care plans were reviewed. This created the potential for harm if cares and/or services were not provided appropriately due to inaccurate information on the care plan. Findings include: The facility's Care Plans policy, revised 10/15/22, documented residents' care plans were reviewed after each assessment except discharge assessments, and revised based on changing goals, preferences and needs of the residents, and in response to current interventions. Resident #57 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke. a. Resident #57's care plan, revised 2/21/22, documented she used a CPAP machine with a setting of 17/12 cm H20 on room air at night. On 2/7/24, CNA #3…

    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 before2024-02-09 · 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 — the official record, unedited, may be distressing

    Based on observation and staff interview, it was determined the facility failed to ensure medications available to residents were dated after opened. This was true for 1 of 2 medication carts reviewed for storage and labeling. This failure created the potential for residents to receive expired medications with decreased efficiency. Findings include: On 2/7/24, at 9:36 AM, during inspection of a medication cart 3 different vials of insulin were in the top drawer of Medication Cart #1. The insulin vials were Humalog, Novolog, and Humulin. There was no opened date documented on the labels. On 2/7/24 at 9:37 AM, RN #1 stated the vials should have been dated. She stated they were only good for 28 days after opening, but she did not know when the vials were opened.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-09 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for 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, record review, and resident and staff interview, it was determined the facility failed to ensure oral hygiene and dental services were provided for 1 of 2 residents (Resident #28) reviewed for dental services. This deficient practice had the potential to result in Resident #28 experiencing severe tooth decay and gum disease. Findings include: Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including cerebral palsy (a condition marked by impaired muscle coordination and/or other disabilities), contracture of the right knee, contracture of the neck, difficulty swallowing, anxiety, and difficulty speaking. Resident #28's record included a dental exam, dated 12/3/21, documented she required full assistance with oral care twice daily to decrease oral bacteria due to high risk for abscess (infection) and poor condition of her teeth. The dental examination documented Resident #28 had bleeding and inflammation of her gums, and poor dental…

    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

“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

$10,839 in federal fines across 1 penalty.

  • $10,839 — penalty dated 2024-02-09

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 3 of 53.0≈ chain avg
Health inspection 2 of 52.8-0.8 vs chain
Staffing 3 of 52.7+0.3 vs chain
Quality measures 5 of 53.9+1.1 vs chain
The other 45 homes this chain runs (chain average 3.0★, per CMS)
1 of 5Caldwell Care of CascadiaCaldwell, ID 1 of 5Cascadia of BoiseBoise, 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 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
CASCADIA IDAHO OPERATIONS LLCOrganizationDIRECT OWNERSHIP INTERESTsince 05/01/2016
CASCADIA HC GROUP LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/05/2025
CASCADIA HEALTHCARE LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 05/01/2016
CASCADIA HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/05/2025
HAMMOND, OWENIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 05/01/2016
LAFORTE, STEPHENIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 06/05/2025
NELSON, TIMOTHYIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 06/05/2025
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 SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/12/2025
BAIR, BRADENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2025
WILLIAMS, RYANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/12/2025

CMS files one row per role, so the 19 rows in the source record cover these 12 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.

7 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.

$12.1M
Net patient revenuemost recent cost report
+5.0%
Operating marginrevenue minus expenses
$603K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 6%Other / private 26%

This home reported $603K 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

$362per resident / day
operating cost
$11,003per month
≈ monthly operating cost
$381per 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 135090. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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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