Mini-Cassia Care Center
1729 Miller Street East, Burley, ID 83318 · For profit - Corporation · 68 certified beds · (208) 678-9474 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2022
- it has 3 actual-harm citations
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its 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)
- nursing-staff turnover (57%) runs well above the national median (45%)
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 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 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 | 12.6% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.5% | 5.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.8% | 2.0% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 58.7% | 15.1% | 6.5% | worse 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 | 0.0% | 3.0% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 13.1% | 16.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 41.4% | 16.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.0% | 3.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.6% | 22.1% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 61.9% | 20.1% | 17.1% | check this† — see note marked dagger below the table |
* 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.
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.
Therapy staffing: this home’s payroll records show 0.07 therapist hours per resident per day in 2026Q1 — more than 3% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 68 beds and averages 55.6 residents a day — about 82% occupied, or roughly 12 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.05 hrs/resident/day on weekends vs 3.56 on weekdays — 14% thinner on weekends. RN hours go from 0.83 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above 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 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.
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 13 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2022-05-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 7 of 13 residents (#6, #13, #26, #35, #44, #48, and #51) whose records were reviewed for quality of care. Specifically: - Resident #35 suffered harm when she sustained a hip fracture with pain after a fall and the fracture was not diagnosed until 10 days after the fall. - Resident #48 and #51 were at risk for undetected injury and neurological changes when fall assessments and neurological assessments were not completed after falls. - Resident #44 was at risk for undetected injury when fall assessments were not completed after falls. - Resident #13 was at risk for increased psychiatric symptoms related to missed doses of her antipsychotic medication. - Resident #51 was at risk for abnormally high or low blood sugar when his insulin was administered per physician order. - Resident #26 was at risk for abnormally low blood pressure when his blood pressure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2022-05-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure a resident received appropriate care to prevent and treat a pressure ulcer. This was true for 1 of 2 residents (Resident #22) reviewed for wound care. This failure resulted in harm when Resident #22 developed an abrasion on his right trochanter (upper end of the thigh bone that is connected to the hip bone) which became an unstageable pressure ulcer. Findings include: The National Pressure Injury Advisory Panel website, accessed on 6/2/22, defined pressure injury as a localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (friction to the skin causing it to separate from the bottom layer of skin). Stages of pressure injury are as follows: Stage 1- Intact skin with localized area of non-blanchable erythema, which may appear differently in darkly…
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 · G2022-05-27 · 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, record review, review of I&A reports, and staff interview, it was determined the facility failed to ensure adequate supervision was provided to residents to prevent falls. This was true for 1 of 5 residents (Resident #47) reviewed for falls. This resulted in harm to Resident #47 when he sustained bruises and a fracture to his finger. Findings include: The facility's policy Fall and Fall Risk Managing, revised 3/2018, documented staff completed a fall risk assessment and enter it into the resident's medical record. Staff would identify the cause of the resident's fall and document interventions related to a resident's specific risks and causes, try to prevent the resident from falling, and try to minimize complications from falling. Staff were to implement a resident-centered fall prevention plan to reduce specific factors of falls for each resident at risk and would monitor and document each resident's response to interventions. If a resident continued to fall, staff would re-evaluate 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 · Fcited before2025-05-30 · 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
Based on observation, FDA Food Code, and staff interview, it was determined the facility failed to ensure kitchen equipment was cleaned. These deficiencies had the potential to affect the 56 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes. Findings include: The FDA Food Code Section 4-602.12 Cooking and Baking Equipment documented food-contact surfaces of cooking equipment must be cleaned to prevent encrustation's that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. On 5/30/25 at 10:40 AM, it was observed the baking sheet used to make honey buns had a black residue along the edge of the pan, which flaked off with minimal abrasion. Two skillets had a ring of dark, encrusted residue around the majority of the pan's interior and exterior surfaces. The dark, encrusted residue did not scrape off. On 5/30/25 at 10:55 AM, the Food Services Manager stated the pans should not have the black, encrusted…
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 before2025-05-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of the Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM), Appendix PP, and resident and staff interviews, it was determined the facility failed to ensure the residents had an environment where housekeeping and maintenance services provided a sanitary shower room in good repair. This was true for 1 of 4 showers used in the facility. This deficient practice created the potential for psychosocial harm if residents felt they were not provided the same homelike environment as other residents. Findings include: On 5/27/25 at 5:10 PM, it was observed the main shower in the south wing had brown and black spots resembling mold on the floor of the shower and near the drain. The shower chairs had a ring of red built up residue on the underside portion of the seat. The edge of the shower wall bar did not have an end cap cover, and a sharp metal ridge was observed. On 5/30/25 at 10:33 AM, the CRN and DON stated the shower was in disrepair and should have been closed. The DON stated there would not be a build-up of mold/dirt if the showers…
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 · D2025-05-30 · 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 2. Resident #20 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder. An Annual MDS Assessment, dated 3/23/25, documented no at A1500, a PASRR level II was not completed. Resident #20's medical record included documentation of a PASRR level I screening, dated 8/20/21, which identified she had a serious mental illness diagnosis of bipolar disorder. Resident #20's medical record included documentation of an abbreviated PASRR level II screening, dated 8/23/21, which identified she had a diagnosis of serious mental illness per PASRR criteria. On 5/29/25 at 3:28 PM the Regional MDS Nurse stated in 2021, Resident #20's MDS documented yes at A1500, a PASRR level II had been completed, but beginning in 2022, it was marked no in error and it should have been corrected. Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) assessment included correct…
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 · D2025-05-30 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the CMS SOM, Appendix PP, record review, and staff interview, it was determined the facility failed to ensure 1 of 14 residents (Resident #21), mental health needs were evaluated through the State's level II PASRR process. This deficient practice had the potential to cause harm if the resident's mental health needs were not adequately met. Findings include: Resident #21 was admitted to the facility 8/16/23, with multiple diagnoses including major depressive disorder and post-traumatic stress disorder (PTSD). A PASRR level II, dated 8/16/23, documented, A 30-day exemption rehabilitation - if [Resident #21] stays (30 days) past admission, please submit most current MDS, physician's order, social notes and psych[iatric] information to [agency name]. If discharged , please notify [agency name] per information below. A PASRR level II, dated 5/13/25, documented Resident #21 had serious mental health diagnoses including depression, anxiety, PTSD, and the PASRR level II was forwarded to [agency name] for further review. On 5/29/25 at 10:42 AM the Administrator 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 · D2025-05-30 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, it was determined the facility failed to ensure PASRR's were completed for 1 of 14 residents (Resident #40) reviewed for PASRR's. This deficient practice had the potential for more than minimal harm when if residents required, but did not receive, specialized services for mental health while residing in the facility. Findings include: Resident #40 was admitted to the facility 5/6/22, with multiple diagnoses including Alzheimer's disease, depression, and anxiety. A Psychiatric Progress Note, dated 6/24/22, documented Resident #40 had mental health diagnoses of anxiety, insomnia, and dementia with behavioral disturbances and was taking Trazodone (antidepressant medication) 25 mg at bedtime and Seroquel (antipsychotic medication) 50 mg at bedtime. Resident #40's PASRR level I from Nevada documented No MI [mental illnesses], MR [intellectual disability], RC [related conditions] or Dementia, and was not referred for further evaluation. Resident #40's care plan, initiated on 5/19/22, documented she had Alzheimer's and dementia with behavior…
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 · D2025-05-30 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including low back pain, fracture of the right leg, altered mental status, diabetes, and opioid dependence. Resident #27's medical record did not document a baseline care plan was completed. On 5/29/25 at 1:28 PM, the DON stated a baseline care plan was not completed for Resident #27. Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of residents' admission. This was true for 2 of 14 residents (#1 and #27) reviewed for baseline care plans. This failure created the potential for harm if the care plan failed to provide direction for care. Findings include: The facility's Baseline Care Plans policy (undated) documented a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. 1. Resident #1 was admitted to the facility 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.
- Potential for harm · D2025-05-30 · 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 review, the CMS SOM review, and staff interview, it was determined the facility failed to ensure resident centered care plans were comprehensively written. This was true for 1 of 14 residents(Resident #34) whose care plans were reviewed. This deficient practice placed the resident at risk for harm when their care plan did not reflect the care necessary. Findings include: Resident #34 was admitted to the facility on [DATE], for care following a stroke affecting her right side, with multiple diagnoses including diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing irreversible lung and airway damage making it hard to breathe). On 5/28/25 at 8:34 AM, Resident #34 stated the swelling in her right leg had increased over the past few weeks, and elevating her legs in bed helped a little bit, but not enough. Physician's orders, dated 8/27/22, documented give Lasix 40 mg (a diuretic) by mouth in the morning for edema. Physician's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-30 · 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 record review and staff interview, it was determined the facility failed to ensure services provided met professional standards. This was true for 1 of 14 residents (Resident #43) whose physician orders were reviewed. This failure placed Resident #43 at risk for harm from overmedication when his seizure medication orders were not clarified. Findings include: Resident #43 was admitted to the facility on [DATE], with multiple diagnoses including a seizure disorder, dementia with agitation, and right sided hemiplegia (a form of paralysis to one side of the body). Resident #43's record documented the following physicians' orders for controlled substance emergency seizure medications, dated 11/22/24: - lorazepam oral concentrate 2 mg/ml, give 1 ml by mouth as needed for seizures, may repeat 1 time in 15 minutes if seizure activity continues, - midazolam nasal solution 5 mg/0.1 ml, give 1 spray in 1 nostril every 10 minutes as needed for non-intractable epilepsy (seizures that can be managed medically, either…
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 · D2025-05-30 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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, medication error reports, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 5 of 5 residents (#10, #23, #31, #34, and #44) reviewed for medication errors. This deficient practice created the potential for harm if residents received medications not as prescribed. Findings include: 1. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses including, Alzheimer's disease, schizophrenia, and muscle spasms. Resident #10's record documented a physician's order for lorazepam 2 mg/ml, give 0.5 ml twice a day for anxiety. A Medication Error and Analysis report, dated 12/23/24, documented Resident #10 received 1 ml of lorazepam in error on the following dates and times: -On 12/21/24 at 5:00 AM -On 12/21/24 at 12:00 PM -On 12/21/24 at 7:00 PM -On 12/22/24 at 12:00 PM On 5/30/25 at 9:30 AM, the DON confirmed Resident #10 was administered the wrong dose of lorazepam on 12/21/24 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 · E2022-05-27 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of medications for 5 of 15 residents (#6, #12, #17, #37, and #47) reviewed for unnecessary medications. This deficient practice placed residents at risk for receiving medications without knowledge of why the medication was prescribed, the expected benefits, and the risks associated with the medications. Findings include: The facility's policy Psychotropic Medication Informed Consent, Dose Reduction and Behavior Monitoring, undated, documented the following: - An informed consent was obtained for all facility residents using psychotropic medication for each medication class, including antipsychotic, anxiolytic, mood stabilizer, sedative/hypnotic, and antidepressant, used for the treatment of residents. - The facility informed the resident and/or responsible party of the psychotropic medication ordered by the physician and explained the rationale for its use.…
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 · E2022-05-27 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure residents were provided with baths/showers and personal hygiene consistent with their needs. This was true for 9 of 13 residents (#4, #6, #13, #16, #26, #35, #44, #48 and #51) reviewed for ADLs. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, and/or skin impairment due to lack of personal hygiene. Findings include: The facility's policy, Activities of Daily Living, revised 3/2018, stated residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who were unable to carry out activities of daily living independently received the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Hygiene was defined as including bathing, dressing, grooming, and oral care. This policy was not followed.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-05-27 · 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
Based on observation, policy review, and staff interview, it was determined the facility failed to ensure measures were in place to prevent possible cross-contamination from dirty to clean areas in the kitchen. This had the potential to affect 51 residents residing in the facility 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: The facility's Infection Prevention and Control policy on personal hygiene, adopted 10/2017, documented all staff were to practice frequent and appropriate handwashing and hand hygiene, and should be aware of contact with contaminated articles and equipment. The policy was not followed. On 5/26/22 at 12:00 PM, [NAME] #1 was observed washing pots and pans in the 3-compartment sink. [NAME] #1 rinsed food off the dishes and carried them to the dish machine. [NAME] #1 placed the dishes in the dish machine, then returned to the sink and continued to rinse dirty dishes. When the dish machine had finished, [NAME] #1 removed 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 · E2022-05-27 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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 staff interview, record review, and policy review, it was determined the facility failed to develop and implement processes to minimize the risk of residents acquiring, transmitting or experiencing complications from Pneumococcal pneumonia. The facility failed to implement an immunization program that tracked residents' Pneumococcal vaccine status, so immunization could be offered or provided as indicated. This was true for 1of 7 residents (Resident #26) reviewed for Pneumococcal vaccination and had the potential to affect all residents residing in the facility. Findings include: The Centers for Disease Control and Prevention (CDC) website, last reviewed 1/24/22, and accessed on 6/8/22, documented two types of pneumococcal vaccines available as follows: - Pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20) - Pneumococcal polysaccharide vaccine (PPSV23) The CDC recommended the Pneumococcal vaccination for all adults [AGE] years old or older as follows: - For adults 65 years or older who have 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.
- Potential for harm · D2022-05-27 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — 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, representative interview, and staff interview, it was determined the facility failed to ensure residents' representatives were immediately notified when residents fell or had a change in condition. This was true for 2 of 2 residents (#35 and #48) whose records were reviewed for changes in condition. This deficient practice placed residents at risk of harm due to lack of advocacy and support from their representatives when they were unable to make decisions for themselves due to decreased health status and level of consciousness. Findings include: The facility's policy for Change in a Resident's Condition or Status, revised May 2017, documented the facility would notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition or status. The policy stated the nurse should notify the resident's representative when the resident was involved in any accident or incident resulting in an injury, or if there 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 before2022-05-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 residents were provided with a sanitary environment free of unpleasant odors. This was true for 1 of 14 residents (Resident #37) whose environment was observed. This deficient practice created the potential for diminished quality of life and psychosocial distress for Resident #37 when she was placed in a room with a strong odor of urine due to her roommate's lack of compliance with personal hygiene. Findings include: Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including dementia with behavioral disturbance and catatonic (a psychomotor disorder that affects both speech and behavior functions) schizophrenia (characterized by significant impairments in the way reality is perceived and changes in behavior). A quarterly MDS assessment, dated 4/4/22, documented Resident #37 was severely cognitively impaired. Resident #37 and Resident #39 were roommates. On 5/23/22 at 12:14 PM, a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-27 · 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 Survey Agency's Long Term Care Reporting Portal, review of I&A reports, and staff interview, it was determined the facility failed to ensure 3 of 14 residents (#26, #52, and #53) reviewed for abuse, neglect, and misappropriation. The facility failed to ensure residents were not abused by a staff member. This failure resulted in the potential for residents to be subjected to ongoing abuse and potential harm. Findings include: The facility's Abuse Prevention Program policy, dated 12/2016, stated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility's policy, Recognizing Signs and Symptoms of Abuse/Neglect, dated 1/2011, stated the facility's administration protected residents from abuse by anyone, including facility staff and other residents. The policy defined abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-27 · 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, review of I&A reports, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as residents' needs changed. This was true for 4 of 16 residents (#12, #20, #22, and #44) whose care plans were reviewed. This deficient practice placed residents at risk for adverse outcomes if care and services were not provided appropriately due to a lack of information in the care plan. Findings include: 2. Resident #44 was admitted to the facility on [DATE], with multiple diagnoses including right thigh muscle atrophy (a condition in which muscles shrink and cause weakness) and dementia. An MDS assessment, dated 7/21/21, documented Resident #44 was moderately cognitively impaired, he did not walk, and his ADLs had declined from his prior function of independent to extensive two-person assistance for bed mobility, transfer, toilet use, and one-person setup assistance for moving between locations in his room. Resident #44 had impaired…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-27 · 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 in policy review, observation, record review, and staff interview, it was determined the facility failed to ensure residents received respiratory care for a resident receiving oxygen by nasal cannula. This was true for 1 of 2 residents (Resident #26) reviewed for respiratory care. This deficient practice had the potential for harm if the residents experienced discomfort from non-humidified oxygen. Findings include: The Infection Prevention and Control Regarding Oxygen Use policy and procedure, revised October 2010, directed staff to check and make sure the water level in the humidifying jar was high enough that the water bubbles as oxygen flows through, and to periodically re-check the water level in the humidifying jar. This policy was not followed. Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including emphysema (a lung condition wherein the air sacs in the lungs are damaged causing shortness of breath), heart failure, and anxiety disorder. A significant change MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 receiving PRN lorazepam (anti-anxiety) had clinical rationale supporting the continued use of the medication beyond 14 days. This was true for 1 of 9 residents (Resident #39) reviewed for unnecessary medications. This deficient practice had the potential for Resident #39 to experience adverse effects from unnecessary psychotropic medications. Findings include: Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including anxiety disorder. An annual MDS assessment, dated 4/14/22, documented Resident #39 had severe cognitive impairment and received anti-anxiety medication on 7 of the previous 7 days. A physician order dated 5/3/22, documented Resident #39 was to receive lorazepam 1 mg, one tablet orally every 12 hours as needed for agitation and psychosis. There was no documentation in Resident #39's record to support the continuation of lorazepam beyond 14 days. On 5/27/22 at 11:46 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 · Dcited before2022-05-27 · 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 control measures were consistently implemented and maintained to provide a safe and sanitary environment during perineal care. This was true for 1 of 1 resident (Resident #55) whose perineal care was observed. This failure created the potential for negative outcomes by exposing a resident to the risk of infection and cross-contamination. Findings include: The facility's Handwashing/Hand Hygiene policy, revised August 2019, stated the use of gloves did not replace hand washing/hand hygiene and directed staff to perform hand hygiene before moving from a contaminated body site to a clean body site during resident care. This policy was not followed. Infection control measures were not consistently implemented and maintained to provide a safe and sanitary environment during perineal care, as follows: On 8/23/22 at 2:15 PM, Resident #55 was observed during perineal care. CNA #1 had gloves on and unfastened Resident #55's brief which was soiled with feces. CNA #1 wiped her…
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 before2019-04-11 · 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
Based on observation, review of facility policy, [NAME] Cleaning list, temperature logs, sanitation logs, and the 2017 FDA Food Code, and staff interview, it was determined the facility failed to ensure food was handled properly and maintained according to safe practices. This was true when Potentially Hazardous Food (PHF) cold food temperatures were not maintained at safe temperatures. In addition, the facility failed to ensure measures were in place to prevent possible cross-contamination of dirty to clean areas in the kitchen and the kitchen was routinely cleaned. These failed practices placed 11 of 11 sample residents (#16, #18, #27, #28, #29, #32, #36, #37, #40, #41, and #47) who dined in the facility and the other 36 residents who dined in the facility, at risk of adverse health outcomes. Findings include: 1. The facility's Environment and Equipment policies, both dated May 2014, documented the equipment and the physical kitchen were cleaned after each use. The policies documented the kitchen staff were responsible for notifying maintenance when repairs were needed. Kitchen…
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 · E2019-04-11 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the 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, review of recipes, and staff interviews, the facility failed to ensure menus were updated to reflect the residents' dietary needs. This affected 7 of 7 (#7, #13, #16, #32, #34, #42, and #50) residents who required fortified foods. This failed practice had the potential for harm if residents were dissatisfied with their meals or experienced weight loss. Findings include: a. Resident #7 was admitted to the facility on [DATE], with diagnoses that included nausea, heart failure, and chronic obstructive pulmonary disease. A physician's order, dated 1/4/19, documented Resident #7 required fortified foods with her meals for a consistent carbohydrate diet. b. Resident #13 was admitted to the facility on [DATE], with diagnoses that included heart disease and dementia. A physician's order, dated 12/28/18, documented Resident #13 required fortified foods with her meals with a regular mechanical soft meats diet, due to her teeth. c. Resident #16 was admitted to the facility on [DATE], with 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 · E2019-04-11 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, temperature log review, resident interview, Resident Group interview, and staff interview, it was determined the facility failed to ensure palatable food was served. This directly impacted 3 of 3 (#40, #41, and #44) residents in Resident Group interview and had the potential to affect the other 45 residents who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: a. Review of the Resident Council Meeting Minutes documented the following concerns with the food. - 11/5/18: Six residents were in attendance and concerns with the food included a lack of flavor and appearance, not happy with the temperatures, and the meat tough. - 12/3/18: Six residents were in attendance and concerns with the food included sandwiches with dry and hard bread, grilled cheese sandwiches offered without cheese, meet is too tough, and meals were unappealing, and the residents would not feed the food to their dogs. The meeting minutes documented the concerns from last month still…
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 · D2019-04-11 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, policy review, and record review, it was determined the facility failed to ensure information was provided to the receiving hospital for emergent situations of 1 of 1 resident (#4) reviewed for transfers. This deficient practice had the potential to cause harm if the resident was not treated in a timely manner due to lack of information. Findings include: The facility's Transfer and Discharge policy, revised 9/1/14, documented when it was necessary to transfer or discharge a resident to a hospital, staff were to: *notify the resident's attending physician *notify the receiving facility that the transfer was being made *prepare a transfer form to send with the resident Resident #4 was readmitted to the facility on [DATE], with multiple diagnoses including urinary tract infection and stroke with hemiplegia (paralysis) on the left side. A Nursing Progress Note, dated 4/7/19 at 3:00 AM, documented Resident #4 had an elevated temperature, complained of abdominal pain, and not feeling well.…
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 · D2019-04-11 · 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 staff interview, policy review, and record review, it was determined the facility failed to ensure a bed-hold policy was provided to a resident or their representative upon transfer to the hospital. This was true for 1 of 1 resident (#4) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time and may cause psychosocial distress if not informed they may be charged to reserve their bed/room. Findings include: The facility's Bed-Hold readmission policy, revised on 12/19/16, documented the facility will reserve the bed of a resident who has been transferred to a hospital or left the facility with expectation of returning in the near future, as long as payment was made in advance to reserve the bed. Resident #4 was readmitted to the facility on [DATE], with multiple diagnoses including urinary tract infection and stroke with hemiplegia (paralysis) on the left side. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-04-11 · 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 staff interview and record review, it was determined the facility failed to ensure residents' care plans were updated to include resident-specific behaviors and interventions related to the use of antipsychotic medication. This was true for 1 of 12 residents (Resident #13) whose care plans were reviewed. This failure created the potential for residents to receive unnecessary antipsychotic medication. Findings include: Resident #13 was admitted to the facility on [DATE], with multiple diagnosis including dementia with behavioral disturbances, and weakness. Resident #13's Quarterly MDS assessment, dated 1/15/19, documented Resident #13 experienced severe cognitive impairment with depressed mood. A physician's order, dated 10/30/18, documented Resident #13 was to receive Seroquel 100 mg every morning, and Seroquel XR (extended release), 50 mg every night for treatment of depression. Resident #13's care plan, revised on 1/24/19, did not include resident-specific depressive mood/behavior symptoms staff were…
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 before2019-04-11 · 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, staff interview, record review, and policy review, it was determined the facility failed to ensure infection control measures were consistently implemented for hand hygiene during perineal care (peri-care), and care of urinary tubing and the urine collection bag. This was true for 1 of 12 residents (Resident #9) reviewed for infection control. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include: 1. The facility's Infection Control Hand Hygiene policy, dated 6/2015, documented all staff members were to follow handwashing and/or hand hygiene procedures to prevent the spread of infection. Hand hygiene or hand washing were to be completed after contact of body fluids or secretions, and the removal of gloves. On 4/9/19 at 10:55 AM, CNA #1 and CNA #2 were observed performing peri-care for Resident #9. After completing the peri-care, CNA #1 placed a new brief on Resident #9. CNA #1 did not remove her gloves or perform hand hygiene after completing the peri-care and before she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CASCADES HEALTHCARE — 19 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 | 1.9 | +0.1 vs chain |
| Health inspection | 1 of 5 | 1.7 | -0.7 vs chain |
| Staffing | 3 of 5 | 2.1 | +0.9 vs chain |
| Quality measures | 5 of 5 | 4.1 | +0.9 vs chain |
The other 18 homes this chain runs (chain average 1.9★, 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 |
|---|---|---|---|---|
| BRP HEALTH MANAGEMENT SYSTEMS INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 06/12/2025 |
| EELIR FLP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2018 |
| QUEST FLP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| RONNMARK FLP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2018 |
| SNAKE RIVER HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 06/12/2025 |
| TAKAYAMA FLP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2018 |
| TOWER BRIDGE FLP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2018 |
| CRUMP, JASON | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| FULLMER, CHAD | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| MCSPADDEN, DARIN | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| MOORE, THOMAS | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| WHITE, DEREK | Individual | CORPORATE DIRECTOR | — | since 11/01/2018 |
| CHAROLAIS CARE I, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/27/2025 |
| GIES, FLORIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2018 |
| MEYER, DAWN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2018 |
| BURLEY SKILLED NURSING FACILITY, LLC | Organization | ADP OF THE SNF | — | since 06/01/2008 |
CMS files one row per role, so the 23 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $820K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in ID
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Idaho Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 135081. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-30, 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.