Terraces of Boise, The
5301 E Warm Springs Ave, Boise, ID 83716 · Non profit - Corporation · 48 certified beds · (208) 336-5550 Medicare only — no Medicaid
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Dec 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $20,501 in federal fines (most recent 2025-12-19)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 8.8% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 5.2% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 1.4% | 1.2% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.1% | 2.0% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.9% | 15.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.3% | 3.0% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 13.3% | 16.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.0% | 16.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.6% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.7% | 3.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.5% | 22.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 38.0% | 20.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.8% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 98.3% | 86.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 13.1% | 17.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.3% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.01 | 1.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.43 | 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.
48.2% 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 134 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.9% 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 91 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 0.59 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% 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 | 48.2%CMS range 39.4–55.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.1%CMS range 6.1–12.5 | 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 | 53.9% | 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 | 64.8% | 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 | 39.6% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 98.2% | 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 | 0.0% | 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 | 1.0% | 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 | 6.7%CMS range 3.9–10.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 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 48 beds and averages 39.0 residents a day — about 81% occupied, or roughly 9 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 5.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.10 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.72 is at or above 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 4.69 hrs/resident/day on weekends vs 5.25 on weekdays — 11% thinner on weekends. RN hours go from 1.33 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% 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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2025-12-19 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 Idaho State LTC Reporting Portal System, policy review, record review and staff interview, it was determined the facility failed to ensure resident's rights were protected to be free from misappropriation of residents' funds. This was true for 1 of 3 residents (Resident #39) whose record was reviewed for misappropriation. This deficient practice caused emotional and financial harm when Resident #39's personal finances were used by a facility staff member. Findings include: Resident #39 was admitted to the facility on [DATE] with multiple diagnoses including a left pubic fracture, dementia, and depression. Resident #39's admission MDS assessment dated [DATE], documented Resident #39 was cognitively intact. An I&A, dated 12/4/25, was submitted to the Idaho State LTC Reporting Portal System identifying a facility staff member had stolen $1900 from Resident #39.The report documented on 12/4/25 at 11:30 AM, the Executive Director (ED) was contacted by the Boise Police Department regarding the status of 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.
- Actual harm · G2023-12-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review I&A report review, record review and staff interview, it was determined the facility failed to ensure call lights were within residents' reach. This was true for 1 of 2 residents (Resident #49) reviewed for falls. This resulted in harm to Resident #49 when she fractured her left hip and left wrist. Findings include: The facility's Safety and Supervision of Residents policy, revised July 2017, documented the facility strived to make the environment as free from accidents and hazards as possible. It also stated the facility identified hazards and risks on an ongoing basis. This policy was not followed. 1. Resident #49 was initially admitted to the facility on [DATE], with multiple diagnosis including a tibia fracture. An MDS admission assessment, dated 11/28/23, documented Resident #49 required supervision or touching (cueing) assistance for upper body dressing and supervision or touching assistance when rolling left or right. Resident #49's care plan, dated 11/21/23, directed staff to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-12-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, the FDA Food Code, and staff interview, it was determined the facility failed to ensure food items were appropriately labeled, dated, and covered, dish racks and air condenser refrigerator fans were cleaned and sanitized. These deficiencies had the potential to affect the 36 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: Based on observation, the FDA Food Code, and staff interview, it was determined the facility failed to ensure food items were appropriately labeled, dated, and covered, and dish racks, air condenser refrigerator fans were cleaned and sanitized. These deficiencies had the potential to affect the 36 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The FDA Food Code Section…
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 · Fcited before2025-12-19 · tag F0880 — failed to prevent and control infections — widespreadProvide 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, and staff interview it was determined the facility failed to ensure sanitary laundry services were provided to the residents, hand hygiene was performed by facility staff, and medication was stored appropriately. This deficient practice had the potential for harm if facility residents were provided laundry, staff cares, and medications which were not handled with appropriate sanitation practices. Findings include: 1. On 12/17/25 at 2:35 PM, it was observed in Redwood House's laundry room, Resident #18's laundry was left wet in the washing machine. On 12/17/25 at 2:37 PM, RN #1 stated Resident #18's laundry would not have been washed earlier than 10:00 AM as CNAs will sometimes do laundry during the day if a resident requires it. She stated, the facility has a shift change at 2:00 PM in the afternoon, so the laundry would not have been waiting wet more than 4 hours. RN #1 could not provide an exact time the laundry had been started as the day shift CNAs were no longer…
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 before2025-12-19 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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, policy review, and staff interview it was determined the facility failed to ensure residents were treated with dignity when referring to resident's as feeders who require assistance when eating, as well as serving meals at the same time to residents sitting at the same table. This was true for 4 of 4 residents (#3, #13, #17, and #22) who were observed during dining. This deficient practice had the potential to create psychosocial harm to residents if resident's felt inferior by being referred to as feeders or not being served meals at the same time. Findings include:The Facility's Dignity Policy, revised February 2021, documented residents are to be cared for in a manner which promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff are expected to provide a dignified dining experience, and to always speak respectfully to residents.1. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses…
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 · E2025-12-19 · tag F0802 — failed to prepare enough nourishing food — patternProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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, SOM Appendix PP, and staff interviews it was determined the facility failed to provide timely meals to residents when they had to wait more than 45 minutes to receive breakfast from the posted time. This was true for 7 of 15 residents (#3, #13, #14, #17, #22, #33 and #50) observed during dining service. This deficient practice created the potential for harm if residents did not receive their meal to avoid potential food-medication interactions, and psychosocial harm if not provided meals in a timely manner. Findings include:A review of the MDS Assessment, section GG, self care, documented Resident #33 required substantial/maximal assistance with eating, Resident's #3 and #13 were dependent for eating, Resident #17 required partial/moderate assistance, and Resident #14 required supervision or touching assistance. On 2/9/26 at 7:15 AM, a dining meal schedule was observed posted in the [NAME] dining room which documented a hot breakfast serviced started at 8:00 AM.Four staff members (1 LPN 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 · D2025-12-19 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure 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, staff interview, and record review, it was determined the facility failed to ensure position change alarms were assessed as potential restraints and a consent from the residents' representative and physician's order were obtained prior to installation of the alarms. This was true for 2 of 3 residents (#14 and #22) reviewed for potential restraints. This deficient practice had the potential for harm if the position change alarms were improperly used and if resident's experienced physical deterioration due to lack of movement. Findings include:The State Manual Appendix PP issued 7/23/25, documented if the facility staff choose to implement alarms, they should document their use aimed at assisting the staff to assess patterns and routines of the resident. Use of these devices, like any care planning intervention, must be based on assessment of the resident and monitored for efficacy on an on-going basis.The facility's Falls and Fall Risk, Managing policy revised March 2018, documented:If…
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 before2025-12-19 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 and resident interview, it was determined the facility failed to ensure resident's missing personal item was investigated as potential misappropriation of resident's property. This was true for 1 of 1 resident (Resident #34) reviewed for misappropriation of personal property. This failure created the potential for Resident #34 to experience emotional distress due to the loss of a personal item with inherent value. Findings include:Resident #34 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including Parkinson's disease (a movement disorder that affects the nervous system), diabetes and hypertension.A Quarterly MDS assessment dated [DATE], documented Resident #34 was cognitively intact.On 12/16/25 at 9:36 AM, Resident #34 stated a ring which was given to her by her grandmother went missing. Resident #34 stated she reported it to the facility and was told they will look for it. Resident #34 stated she was told the ring had not been found yet,…
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 · D2025-12-19 · tag F0641 — isolatedEnsure 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 observation, record review, and staff interview, it was determined the facility failed to ensure resident's MDS assessments accurately reflected their status. This was true for 1 of 1 resident (Resident #6) whose MDS assessment was reviewed. This deficient practice had the potential for negative outcomes if Resident #6 was not assessed and/or monitored due to inaccurate assessments. Findings include:Resident #6 was admitted to the facility on [DATE] and readmitted [DATE] with multiple diagnoses, including heart disease, anemia, and hypertension.Resident #6's MDS assessments documented the following: admission assessment dated [DATE], he had no impairment on his upper and lower extremities Quarterly assessment dated [DATE], he had impairments on both sides of his upper and lower extremities.Resident #6 was observed on the following days as follows: 12/16/25 at 3:05 PM, able to move his both [NAME] while his wheelchair was being push by the staff. 12/17/25 at 10:52 AM, sitting in his wheelchair in 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 · D2025-12-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record, policy review, and staff interviews, it was determined the facility failed to follow residents comprehensive centered care plans. This was true for 1 of 6 residents (Resident #22) reviewed for care plan implementation. This deficient practice had the potential for physical harm related to Resident #22's receiving beverages that did not meet her ordered dietary needs. Findings include:The facility's Care Plan policy, revised March 2022, documented care interventions are chosen after data gathering, considering the residents problem areas and their causes, and relevant clinical decisions. Resident #22 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease, muscle weakness, dementia, depression, and anxiety.Resident #22's care plan, initiated 4/3/25, documented a diet order to include offering unsweetened or sugar-free beverages.On 2/9/26 the following observations were made:At 7:37 AM, CNA #2 provided Resident #22 with orange juice.At 8:33 AM,…
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 · D2025-12-19 · 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, and staff interview it was determined the facility failed to ensure care plans were revised as needed. This was true for 1 of 13 residents (Resident #8) whose record was reviewed for care plan revision. This deficient practice created the potential for harm if the Resident #8 did not receive oxygen treatment as ordered. Findings include:Resident #8 was admitted to the facility on [DATE], and re-admitted on [DATE], with multiple diagnoses including sleep apnea and chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs).A physician's order, dated 11/12/25, directed staff to provide oxygen at 2 LPM via nasal cannula, at all times for every shift.Resident #8's care plan, dated 11/12/25, directed staff to provide oxygen continuously at 2 LPM via nasal cannula and to provide oxygen monitoring and management.On 12/16/25 at 9:19 AM, Resident #8 was observed lying in bed without an oxygen nasal cannula.On 12/18/25 at 11:36 AM, Resident #8 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 · D2025-12-19 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, it was determined the facility failed to ensure medications were administered according to professional standards of practice. This was true for 1 of 7 residents (Resident #42) observed during medication administrations. This failed practice created the potential for Resident #42 to experienced adverse effects when her medications were not administered according to physician's order. Findings include: The facility's Administering Medications policy revised April 2019 documented the individual administering the medication checks the label three times to verify the right resident, right medications, right dosage, right time, and right method (route) of administration before giving the medication.Resident 342 was admitted to the facility on [DATE], with multiple diagnose including inflammatory neuropathy (condition that affects the peripheral nerves, leading to symptoms such as weakness, numbness, and pain), anemia and hypertension.A physician's order documented…
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.
Show the remaining 17 citations
- Potential for harm · D2025-12-19 · 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 provide respiratory services. This was true for 1 of 1 resident's (Resident #8) who was reviewed for oxygen and respiratory services. This deficient practice had the potential for Resident #8 to experience shortness of breath when her physician's order was not followed. Findings include:Resident #8 was admitted to the facility on [DATE], and re-admitted on [DATE], with multiple diagnoses including sleep apnea and chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs).A physician's order, dated 11/12/25, directed staff to provide Oxygen at 2 LPM via nasal cannula, at all times for every shift. On 12/16/25 at 9:19 AM, and on 12/18/25 at 11:36 AM, Resident #8 was observed lying in bed without oxygen via nasal cannula. Resident #8 stated she had not been using her oxygen for some time and did not know the exact date it stopped. On 12/19/25 at 10:14 AM, the ADON confirmed the facility 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 · Dcited before2025-12-19 · 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 observation, record review, staff interview, and policy review, it was determined the facility failed to ensure medications were secured when they were unattended by staff and to ensure pharmacy labels matched the physician's order. This was true for 1 of 1 resident (Resident #30) whose medication administration was observed. This failed practice created the potential for harm if medications were taken by another resident and should Resident #30's Oxycodone (opioid pain medication) be administered at the wrong dose. Findings include: Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including stage 4 pressure ulcers of left and right heels, and hypertension (high blood pressure).1.On 12/18/25 at 12:05PM, LPN #2 entered Resident #30's room with her medications on hand. Upon entering Resident #30's room, she stated she needed to use the restroom, LPN #2 requested help from CNA to assist Resident #30 to the restroom. LPN #2 exited room with medications in hand along with dirty…
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 · Fcited before2024-12-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined the facility failed to ensure kitchen equipment was clean and food was stored in a safe and sanitary manner. This deficency had the potential to affect the 36 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils: (E) Surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned: (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation…
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 · F2024-12-19 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and FDA Food Code review, it was determined the facility failed to ensure garbage was properly disposed of to minimize attracting insect and rodents. This deficient practice had the potential to affect all residents, staff, and visitors in the facility. Findings include: FDA Food Code Section 5-501.15 Outside Receptacles: (B) Receptacles and waste handling units for refuse and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit. On 12/19/24 it was observed in the facility garbage compactor area, various items of edible and non-edible refuse were spread around the ground near the garbage compactor. On 12/19/24 at 10:15 AM, the Dietitian stated she was unsure when the area around the garbage compactor had last been cleaned. On 12/19/24 at 11:48 AM, the Maintenance Technician and Administrator confirmed the garbage compactor area 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 · Dcited before2024-12-19 · 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, and staff interview, it was determined the facility failed to ensure infection prevention measures were taken when reusable medical equipment was not disinfected between residents. These failures had the potential to impact residents in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised 9/22, documented, resident care equipment, including reusable medical equipment will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommedations. The CDC Website for Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, accessed on 12/23/24 stated: Clean and reprocess (disinfect or sterilize) reusable medical equipment (e.g., blood glucose meters and other point-of-care devices, blood pressure cuffs, oximeter probes, surgical instruments, endoscopes) prior to use on another patient or when soiled. On 12/19/24, at 8:45 AM, 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.
- Potential for harm · E2023-12-15 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview, it was determined the facility failed to ensure residents were monitored for side effects and offered non-pharmacological interventions prior to administering an opioid pain medication. This was true for 3 of 7 residents (#34, #49, and #102) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to a lack of appropriate monitoring or increased pain due to not offering non-pharmacological interventions. Findings include: 1. Resident #102 was admitted on [DATE], with multiple diagnoses including a fracture of his right femur. Resident #102 was prescribed Oxycodone Hcl 5mg (opioid medication), take 1 oral tablet by mouth every 6 hours as needed for moderate pain. Resident #102's MAR, dated 12/8/23 through 12/12/23, did not include documentation nonpharmacological pain interventions were attempted prior to the administration for Oxycodone for 8 of 8 administrations on the following dates and times: -…
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 before2023-12-15 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled and dated; this was true for 2 of 3 medication storage rooms inspected. This failure created the potential for residents to receive medication used for another resident presenting a risk for cross-contamination or to receive expired medications with decreased efficacy. Findings include: The facility's Medication Storage policy, dated January 2023, documented the provider pharmacy dispenses medications in containers that meet the state and federal labeling requirements. Medications are to remain in these containers. Outdated or discontinued medications are immediately removed from stock. This policy was not followed. 1. On 12/11/23 at 3:23 PM, a blister pack of Lyrica (schedule 3 narcotic used to treat neuropathic pain) was observed in the Maple medication cart, narcotic box. The label on the Lyrica was handwritten, in red marker, with no expiration date. LPN…
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 before2023-12-15 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
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 food items were dated and labeled and hygiene practices followed. This failure had the potential to affect 43 of 43 residents residing in the facility who consumed food prepared by the facility at risk of adverse health outcomes, including food-born illnesses. Findings include: The facility's Food Storage policy, undated, documented food should include a date to indicate by which a ready-to-eat food should be consumed. It also stated left over food was to be stored in a covered container or wrapped carefully and securely. Each item was to be clearly labeled and dated before refrigerated and leftover food should be used within 3 days or discarded. This policy was not followed. 1. On 12/11/23 at 7:26 AM, during a main kitchen inspection, 7 of 32 opened seasoning containers did not have a use by date on the container. On 12/11/23 at 7:29 AM, the Chef stated he did not know if the seasonings were good. He stated…
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 · E2023-12-15 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 the facility's binding Arbitration Agreement was explained and understood by the resident and/or their representatives and to inform the resident and/or their representative of the 30 days to rescind the agreement if they so wished to do so. This was true for 39 of 43 residents in the facility. This had the potential for residents to make a misinformed decision when the agreement was not explained. Findings include: The facility's admission Arbitration Agreement Policy, dated 9/1/23, documented during the admission process, the facility's team member shall provide a clear explanation of the arbitration process to the resident and their legal representative. The team member shall address any questions or concerns regarding the arbitration. This policy was not followed. On 12/11/23 at 8:40 AM, a review of the facility's census documented 39 residents signed and agreed to the Arbitration Agreement. Three residents were pending the admission and signing process and 1 declined to sign 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 · E2023-12-15 · tag F0848 — patternProvide a neutral and fair arbitration process and agree to arbitrator and venue.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, and staff interview, it was determined the facility failed to ensure the facility's binding Arbitration Agreement provided a neutral arbitrator agreed upon both parties and a venue that was convenient to both parties. This was true for 39 of 43 residents in the facility who signed the Arbitration Agreement. This failure created the potential for an unfair Arbitration process in a venue convinent to both parties. Findings include: On 12/11/23, a review of the facility's Arbitration Agreement was conducted. The Agreement did not include the use of a neutral arbitrator and or the use of a convenient venue for both parties. On 12/11/23 at 2:52 PM, the Administrator stated the facility followed the Federal Arbitration Act, but the Arbitration Agreement did not clearly state the facility would use a convenient venue or a neutral arbitrator.
- Potential for harm · Dcited before2023-12-15 · 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, policy review, record review, and resident and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 2 of 2 residents (#5 and #35) reviewed for respect and dignity. This deficient practice placed Resident #5 and #35 at risk of embarrassment and diminished sense of self-worth. Findings include: The facility's admissions agreement, undated, documented the resident has the right to be treated with respect and recognition of their dignity in care of their personal needs. 1. Resident #35 was admitted on [DATE], with multiple diagnoses, including Alzheimer's disease and muscle weakness and atrophy. Resident #35's care plan, revised on 8/7/23, documented he required assistance to feed himself food and fluids. The care plan directed staff to adjust provision of ADLs to compensate for his changing abilities and to encourage participation to the extent he wished to participate. On 12/12/23, at 8:42 AM, Resident #35 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 · D2023-12-15 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure abuse and neglect were thoroughly investigated. This was true for 1 of 4 residents (Resident #39) reviewed for abuse and neglect. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease and dementia. Resident #39's care plan, dated 8/18/23, documented Resident #39 had impaired communication due to her dementia and impaired memory. The care plan directed staff to ask simple yes/no questions. The care plan also stated Resident #39 required extensive assistance from 1 person for transfers and peri-care. An I&A report, dated 11/24/23, documented a CNA reported Resident #39 was observed with blood in her brief. Upon closer…
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 before2023-12-15 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure potential abuse, neglect, and mistreatment was thoroughly investigated. This was true for 1 of 4 residents (Resident #39) reviewed for investigations. This failure reacted the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: The facility's Elder Abuse Prevention, Identification, Response and Reporting policy, revised 8/15/18, documented allegations of abuse, exploitation, neglect, or misappropriation of resident property shall be promptly investigated by: - Assessment of the immediate environment - Collection of physical evidence - Review of the resident assessment - Review of the resident record - Interviews of appropriate parties by the investigator who can be either the Director of Nursing, the Executive Director, or the Corporate Risk…
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 · D2023-12-15 · 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 and staff interview, it was determined the facility failed to ensure a bed hold was provided for residents leaving the facility for a hospital stay or therapeutic leave. This was true for 1 of 1 resident (Resident #49) whose record was reviewed for hospitalization. This deficient practice created the potential for psychosocial distress 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 bed hold consent form, stated residents may hold a specific bed for the entire length of hospital stay or therapeutic leave providing the resident or their responsible party has indicated in writing the desire to hold the bed. The consent form also stated the bed hold will be provided at the time of transfer for hospitalization or therapeutic leave. Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including a tibia fracture. A progress note, dated 12/5/23, documented Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-15 · 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 observation, policy review, and staff interview, it was determined the facility failed to ensure a controlled substance was tracked and disposed of in a timely manner. This was true for 1 of 3 medication carts observed. This failure created the potential for undetected misuse and/or diversion of a controlled medication. Findings include: The State Operations Manual, Appendix PP, dated February 2023, defines controlled medications as substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The facility's Discarding and Destroying Medications policy, revised November 2022, documented the disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use. This policy was not followed. On 12/11/23 at 3:23 PM, a blister pack (plastic packaging for individual medication doses) of Lyrica (schedule 3 narcotic used to treat neuropathic pain) was observed…
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 · D2023-12-15 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 record review and staff interview, it was determined the facility failed to ensure a resident was free from a medication error. This was true for 1 of 1 resident (Resident #102) whose medication record was reviewed for accuracy. This failure placed Resident #102 at risk of not receiving the correct ordered medication for constipation. Findings include: Resident #102 was admitted on [DATE], with multiple diagnoses including a fracture of his right femur. A nursing assessment was conducted upon Resident #102's admission. The space provided to document the resident's most recent bowel movement was blank. A nurse's progress note, dated 12/9/23 at 8:00 AM, documented Resident #102 had a distended abdomen and appeared to be uncomfortable and was requesting an enema. A physician order, dated 12/9/23, directed staff to administer 1 tablet of delayed release Bisacodyl (laxative) by mouth to Resident #102 as needed if he had no bowel movement for 96 hours. A nurse's progress note, dated 12/9/23 at 9:33 AM,…
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 · D2023-08-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 policy review, record review, review of the State Agency's Long-Term Care Reporting Portal, review of I&A and grievance reports, and staff interview, it was determined the facility failed to ensure a resident was free from abuse. This was true for 1 of 12 residents (Resident #1) reviewed for abuse. This failure resulted in Resident #1 not being free from abuse when her pain medication was withheld. Findings include: The facility's Resident Rights policy, revised February 2021, stated Employees shall treat all residents with kindness, respect, and dignity. The policy interpretation and implementation stated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation . This policy was not followed. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including high blood pressure, chronic kidney disease, history of left femur fracture,…
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
$20,501 in federal fines across 2 penalties.
- $11,190 — penalty dated 2025-12-19
- $9,311 — penalty dated 2023-12-15
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 HUMANGOOD — 17 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 | 2 of 5 | 4.5 | -2.5 vs chain |
| Health inspection | 1 of 5 | 3.6 | -2.6 vs chain |
| Staffing | 5 of 5 | 4.9 | ≈ chain avg |
| Quality measures | 4 of 5 | 4.2 | -0.2 vs chain |
The other 16 homes this chain runs (chain average 4.5★, per CMS)
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 | Share | Since |
|---|---|---|---|---|
| HUMANGOOD IDAHO | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 12/21/2015 |
| HUMANGOOD | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 05/01/2016 |
| HUMANGOOD CORNERSTONE | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 05/01/2016 |
| US BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER MORTGAGE INTEREST | — | since 01/14/2014 |
| UMB BANK NATIONAL ASSOCIATION | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 09/01/2021 |
| BAKER, JUDITH | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2016 |
| BROWN, HERMAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2016 |
| DAHAN, DAVID | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2016 |
| DECKER, DAVID | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2016 |
| FERRIS, RAND | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/25/2017 |
| KELLEY, ALBERT | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2016 |
| TINKER, BRET | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/18/2010 |
| COCHRANE, JOHN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/01/2016 |
| GHASSEMI, BETHANY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 05/28/2019 |
| MCDONALD, ANDREW | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2020 |
| OGUS, DANIEL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/21/2016 |
| HUMANGOOD NORCAL | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/21/2016 |
| ERICKSON, DEE ANNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/30/2020 |
| LOPEZ, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/20/2020 |
| SCHRADER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2022 |
| SEVERNS, JUDSON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2014 |
| SMITH, JOSHUA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/14/2022 |
| VANGELISTO, GWEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/30/2021 |
| BAKER TILLY ADVISORY GROUP LP | Organization | ADP OF THE SNF | — | since 03/21/2025 |
| BAKER TILLY US LLP | Organization | ADP OF THE SNF | — | since 10/15/2024 |
CMS files one row per role, so the 48 rows in the source record cover these 25 parties — each is shown once here with every role it holds. Nothing is omitted.
8 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.
This home reported $973K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Idaho Medicaid page for homes that do.
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 135141. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.