Meridian Meadows Transitional Care
2656 E Magic View Drive, Meridian, ID 83642 · For profit - Limited Liability company · 52 certified beds · (208) 996-2801 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
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 6.7% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.8% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.3% | 1.2% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.8% | 2.0% | 2.0% | better |
| Long-stay residents with depressive symptoms | 12.8% | 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 | 8.3% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 24.9% | 16.1% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 20.6% | 16.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 89.2% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 3.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.3% | 22.1% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.6% | 20.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 94.4% | 86.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 9.7% | 17.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.9% | 12.3% | 12.0% | worse |
‡ 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.
59.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 106 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 38.5% 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 52 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 0.50 therapist hours per resident per day in 2026Q1 — more than 81% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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 | 59.0%CMS range 50.8–66.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.7–14.6 | 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 | 38.5% | 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 | 61.5% | 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 | 23.1% | 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 | 97.2% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 0.0% | 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 | 6.2%CMS range 3.1–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 52 beds and averages 41.9 residents a day — about 81% occupied, or roughly 10 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 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 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 3.12 hrs/resident/day on weekends vs 3.97 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.46 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2025-09-04 · 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 record review, staff interviews, and review of the Long-Term Care Reporting Portal, it was determined that the facility failed to ensure residents were free from neglect. This was true for 3 of 6 residents ( #3, #10, and #20) whose records were reviewed for abuse and neglect. This failure resulted in harm when Resident #3 was injured during a transfer and created the potential for embarrassment and psychosocial harm when Resident #10 and Resident #20 were not provided timely incontinence care. Findings include:The facility's Abuse and Neglect policy, dated 12/2/24, documented that the facility will identify events, occurrences, patterns, and trends that may constitute neglect-defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.The facility's Safe Resident Handling/Transfer policy, dated 12/20/24, documented that two staff members must be utilized when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-03 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interviews, representative interviews, staff interviews, observations, review of grievances, and review of the three-week nursing schedule, it was determined the facility failed to ensure sufficient staffing was available to meet resident needs according to their plan of care. This failure had the potential to affect all residents residing in the facility if staff were not available to ensure resident needs and safety measures were provided. Findings include: The National Academies of Sciences, Engineering, and Medicine (NASEM) website accessed on 4/8/26, article titled The National Imperative to Improve Nursing Home Quality (2022) documented, inadequate staffing contributes to delayed care, missed care tasks, and reduced resident safety. Staffing must be aligned with resident acuity, not just minimum numbers.A review of facility grievances dated 10/1/25 through 3/31/26, documented the following:-A Grievance Form dated 1/12/26, documented a resident reported not receiving incontinence care from 6:00 PM to 6:00 AM and was found wet the following morning. 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 · D2026-04-03 · tag F0552 — isolatedEnsure 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 and staff interview, it was determined the facility failed to ensure residents were informed in advance of the care and treatment to be furnished, including the risks and benefits of that treatment. This was true for 1 of 6 residents (Resident #5) whose records were reviewed for informed consent. This failure created the potential for miscommunication and adverse effects when Resident #5 was not informed in advance of the risks and benefits of the ordered medication. Findings include:Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease.Resident #5's medical record included the following physician orders:-Lorazepam (a controlled substance anti-anxiety medication) Oral Concentrate 2 mg/mL: Give 0.5 mL by mouth every 8 hours as needed for anxiety.-Lorazepam Oral Concentrate 2 mg/mL: Give 0.5 mL by mouth every 8 hours as needed for terminal agitation for 180 days.A review of 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 · D2026-04-03 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, resident interview, and staff interviews, it was determined the facility failed to ensure an interdisciplinary team assessment, physician orders, or care plan documentation were in place for self administration of glucose tablets. This was true for 1 of 3 residents (Resident #15), whose record was reviewed for medication administration. This failure created the potential for harm when unsafe medication practices and unmonitored treatment of hypoglycemia were identified. Findings include:The facility's Resident Self-Administration of Medication policy reviewed 12/30/25, documented residents may only self-administer medications after the facility's interdisciplinary team (IDT) has determined which medications may be self-administered safely. The results of the IDT assessment are recorded on the Medication Self-Administration Safety Screen. The care plan must reflect resident self-administration and storage arrangements for such medications. A re-assessment of safety at minimum…
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 before2026-04-03 · 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, policy review, and staff interview it was determined the facility failed to assess a resident for safety related to bed rail use or informed consent was obtained prior to use of the bed rail. This was true for 1 of 1 resident (Resident #18) reviewed for restraint assessment. This deficient practice had the potential for physical and psychosocial harm if Resident #18 were injured, trapped, or felt she was being restrained unnecessarily. Findings include:The facility's Use of Assistive Devices policy, dated 12/29/25, documented the facility's process for the proper and consistent use of assistive devices for residents requiring equipment to maintain or improve function and/or dignity is based on the residents' comprehensive assessment, in accordance with the residents' plan of care. The facility's Restraint Free Environment policy, reviewed 12/31/25, defined the use of bed rails as one type of physical restraint.Resident #18 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 · Dcited before2026-04-03 · 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 — the official record, unedited, 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 care plans accurately reflected the use of assistive devices. This was true for 1 of 16 residents (Resident #18) reviewed for comprehensive person-centered care plans. This failure had the potential to result in unmet care needs and increased risk to resident safety. Findings include:Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including leukemia, dementia, anxiety, and depression.On 3/30/26 at 10:52 AM, Resident #18 was observed in her bed with a transfer pole on the left side of her bed, and a 1/4 bed rail on the right side of her bed.A review of Resident #18's care plan did not document the use of a transfer pole or 1/4 bed rail on her bed.On 4/3/26 at 10:28 AM, the CRN stated Resident #18 did not have a care plan implemented related to the 1/4 bed rail and transfer pole, and there should have been.
- Potential for harm · D2026-04-03 · 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 physician orders were clarified to verify the correct route of medication administration. This was true for 1 of 16 residents (Resident #4) reviewed for professional standards of practice. This failure created the potential for harm if Resident #4 were to receive oral medications despite having difficulty swallowing. Findings include:According to the National Council of State Boards of Nursing (NCSBN) website, accessed 4/6/26, nurses are professionally obligated to clarify and verify any order that is incomplete, inaccurate, unclear, or contraindicated before implementing it.Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses including dysphagia, disease of the esophagus, and gastrostomy.Resident #4's nutritional care plan, revised 4/3/26, documented the resident was NPO (nothing by mouth).A review of Resident #4's physician orders showed the following medications were ordered to be administered…
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 · D2026-04-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, record review, policy review, and staff interview, it was determined the facility failed to ensure residents who were dependent on staff for activities of daily living assistance received services for their fingernails. This was true for 1 of 1 residents (Resident #50) reviewed for nail care. This placed Resident #50 at risk of embarrassment which could affect him socially due to the appearance of his fingernails. Findings include: The facility's Nail Care policy, implemented 12/20/24 and revised 12/31/25 documented:The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health.Policy Explanation and Compliance Guidelines:Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care, if possible.Report unusual or abnormal conditions of the nails to the physician and the responsible party (e.g., curling, color changes, separation…
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 · D2026-04-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, and staff interview, it was determined the facility failed to ensure residents had an active physician's order. This was true for 1 of 16 residents (Resident #15) whose record was reviewed for quality of care. This deficient practice created the potential for adverse outcomes when Resident #15 self-administered a medication not ordered by a physician. Findings include: Resident #15 was readmitted to the facility on [DATE] with multiple diagnoses including type 1 diabetes, partial paralysis of left side, and ataxia after a stroke.On 3/30/26 at 1:07 PM, it was observed Resident #15 had a bottle of glucose tablets on his desk. When asked why there were glucose tablets on his desk, Resident #15 stated he took glucose tablets whenever he felt his blood sugar going low.A physician's note dated 2/13/26, documented the physician had seen Resident #15 for low blood sugars, and referenced Resident #15 was taking glucose tablets whenever his blood sugar was 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 · D2026-04-03 · 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 observation, record review, and staff interview, it was determined the facility failed to ensure wound care was provided according to physician orders and acceptable standards of practice. This was true for 1 of 1 residents (Resident #5) observed for wound treatment. This failure created the potential for delayed healing and wound deterioration. Findings include:a.Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease.A physician order directed staff to cleanse Resident #5's left heel with wound cleanser, apply normal saline-moistened gauze, and cover with a dry dressing every shift.On 4/3/26 at 10:01 AM, RN #1 was observed performing wound care for Resident #5. RN #1 removed the soiled dressing, cleansed the wound with wound cleanser and gauze, patted the wound dry, applied skin prep, and applied a clean dry dressing.The treatment provided did not include the ordered normal saline-moistened…
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 before2026-04-03 · 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, policy review, and staff interview, it was determined the facility failed to ensure residents received oxygen therapy per physician orders. This was true for 1 of 1 residents (Resident #1) reviewed for oxygen therapy. This deficient practice created the potential for adverse outcomes if residents' did not receive the proper amount of oxygen. Findings include:The facility's Oxygen Administration policy, implemented 12/30/25 documented, Oxygen is administered under orders of a physician, except in the case of an emergency.Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory failure with hypoxia and congestive heart failure.Resident #1's care plan revised on 3/7/26, documented Resident #1 used oxygen per physician order.A physician order dated 3/26/26, documented oxygen at 0-2 LPM via nasal cannula as needed to keep oxygen saturations equal to or greater than 88% and to check oxygen saturation every shift.Resident #1's March…
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 20 citations
- Potential for harm · D2026-04-03 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview, the facility failed to ensure the presence of a registered professional nurse for at least 8 consecutive hours per day, as required. This failure had the potential to affect all residents in the facility who may require a higher level of nursing assessment or intervention. Findings include:Review of the facility's three-week nursing schedule, dated 3/8/26 through 3/28/26, documented the facility did not provide 8 consecutive hours of registered professional nursing coverage on the following dates:-3/14/26 - No consecutive 8 hours-3/15/26 - No consecutive 8 hours-3/28/26 - No consecutive 8 hoursOn 4/2/26 at 9:47 AM, the Staffing Coordinator stated she was unaware the registered professional nursing hours must be consecutive.
- Potential for harm · D2026-04-03 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 free from duplicate medication orders and side effect monitors were in place. This was true for 2 of 6 residents (#2 and #5) whose records were reviewed for unnecessary medications. This failure placed Resident #2 at risk for overmedication and Resident #5 at risk for their needs to go unmet when they were not monitored for side effects of their medications. Findings include: 1. According to the Food and Drug Administration (FDA) Ativan (lorazepam) prescribing information, accessed 4/7/26, patients receiving lorazepam must be monitored for the following potential adverse effects: -Sedation -Respiratory depression -Cognitive impairment -Paradoxical reactions (such as agitation or hyperactivity) -Dependence and withdrawal symptoms Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease. Resident #5'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 · Dcited before2026-04-03 · 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, policy review, and staff interview, it was determined the facility failed to ensure expired medications were not available for administration to residents and failed to securely store medications. This was true for 1 of 3 medication carts (West Wing Cart) inspected for expired medications and true for 1 of 1 residents (Resident #4) reviewed for storage of self-administered medications. These failures created the potential for residents to receive expired medications with decreased efficacy and created the potential for harm to residents if they were to obtain medications which were left unsecured. Findings include:The facility's Medication Storage policy, implemented 12/29/25 documented all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.1. Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses including dysphagia, disease of the esophagus, 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 · D2026-04-03 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, SOM Appendix PP, and staff interview, it was determined the facility failed to keep complete hospice records on file at the facility for residents receiving hospice services. This was true for 1 of 3 residents (Resident #18) whose record was reviewed for accuracy and completeness. This deficient practice created the potential for harm if hospice paperwork did not confirm Resident #18 agreed to receive hospice services. Findings include:SOM Appendix PP: Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess 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 · D2026-04-03 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record and policy review, and staff interview, it was determined the facility failed to implement a performance improvement plan (PIP) for a systemic concern related to staffing. This deficient practice created the potential for harm if residents received substandard quality of care if staffing concerns were not identified and responded to accordingly. Findings include:The facility's QAPI Facility Plan, dated January 2026, documented the QAPI plan for the facility was to establish and maintain an organized facility-wide program that is data-driven and utilizes a proactive approach to improving quality of care and services throughout the facility. Objectives of the QAPI plan include:-Establish a facility-wide process to identify opportunities for improvement through continuous attention to quality of care, quality of life and resident safety.-Address gaps in the systems or processes.-Ensure adequate provision of staffing time, equipment and technical training resources.-Establish clear expectations around safety, quality, rights, choices and respect.-Continually improve the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not perform proper hand hygiene during medication administration or wound care, did not follow proper wound care protocol, and did not sanitize reusable medical equipment. This was true for 2 of 5 residents (#10 and #27) observed for medication administration and for 1 of 1 residents (Resident #5) observed for wound care. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: 1. On 4/1/26 at 7:38 AM: LPN #2 was observed for morning medication pass. LPN #2 prepared medications for Resident #27, poured water into a clear plastic cup, locked the medication cart and went to Resident #27's room. LPN #2 knocked and entered Resident #27's room and handed resident #27 a medication cup and a cup of water. No hand…
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 · D2026-04-03 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record and policy review, SOM Appendix PP, and staff interview, it was determined the facility failed to educate residents on the risks and benefits of pneumococcal and influenza immunizations. This was true for 3 of 5 residents (#4, #8, and #36) whose records were reviewed for current immunizations. This deficient practice created the potential for harm if residents were not educated about the risk and benefits of receiving or declining the pneumococcal and influenza immunizations. Findings include:The facility's Pneumococcal Vaccine and Influenza Immunization policies, reviewed 12/22/25 documented:-Prior to administration of the influenza or pneumococcal vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of the CDC's current vaccine information statement relative to the vaccinations.-The vaccine information statements will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits…
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 · D2026-04-03 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 and policy review, and staff interview, it was determined the facility failed to document if the COVID-19 vaccine was offered to residents. This was true for 2 of 5 residents (#4 and #8) reviewed for COVID-19 vaccination. This deficient practice created the potential for harm when residents were not offered education related to the risks and benefits of receiving the COVID-19 vaccination. Findings include:The facility's COVID-19 Vaccination policy dated 12/11/25, documented the resident's medical record will include documentation of the following:-Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine.-Each dose of the vaccine administered to the resident, or,-If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal.1. Resident #4 was readmitted to the facility on [DATE] with multiple diagnoses including muscle wasting and osteonecrosis.A review of Resident #4's record did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · 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 record review and staff interview, it was determined the facility failed to ensure allegations of neglect were reported to the State Agency within the regulated time period. This was true for 2 of 6 residents, (#3, and #10) who were reviewed for abuse and neglect. This failure had the potential to affect all residents in the facility and placed them at risk for harm related to neglect. 1. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (a condition that occurs when the blood flow to part of the brain is obstructed), hemiplegia (paralysis or weakness on one side of the body), and major depressive disorder. A review of the facility's Incidents and Accidents (I&A) record dated 3/31/25 documented that Resident #3 was being transferred in a full mechanical lift when the sling detached, and she fell, landing on her left arm. The I&A documented that X-ray services were provided on 4/1/25, revealing that Resident #3 sustained a comminuted fracture (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 · Fcited before2025-01-10 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on policy review, observation, and staff interview, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. This was true for 1 of 3 medication carts observed in the facility. This failed practice created the potential for harm if an unauthorized person obtained medications left unattended and unsecured by staff. Findings include: CMS SOM-Appendix PP, accessed on 1/10/25, documents, in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments. On 1/6/25 at 10:25 AM, the medication cart on the 200 hall was observed to be unlocked and unmonitored by staff. On 1/6/25 at 10:33 AM, RN #1 returned to the cart and stated she should have locked the cart when she was away, and she had been trying to remember to do so. On 1/10/25 at 10:40 AM, the Director of Nursing (DON) stated RN #1 did not follow the facility's process for locking the cart before stepping away from it.
- Potential for harm · D2025-01-10 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of policy, and interviews, it was determined the facility failed to ensure Certified Medication Aides (CMAs) performed tasks which they had the knowledge, skills, and competencies. This was true for 4 of 4 CMAs reviewed for medication administration competencies. This failure increased the risk for harm to residents receiving insulin when the CMAs did not have the appropriate medication administration competencies and skill sets to assure resident safety during insulin administration. Findings include: The facility Licensed Nurse Delegation and Supervision policy, undated, documented the RN/LPN must ensure the CMA is competent and trained to administer the medication being delegated. The facility CMA Restrictions and Prohibitions policy, undated documented CMAs cannot administer medication via parenteral routes and CMAs cannot convert or calculate medication dosages. The National Institute of Health Library, accessed on 1/10/24, documented, there are four types of parenteral injections, including intradermal, subcutaneous, intramuscular, and intravenous.…
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 before2024-01-26 · 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 policy review, record review, and staff interview, the facility failed to ensure a resident was free from a physical restraint. This was true for 1 of 1 resident (Resident #42) reviewed for physical restraints. This deficient practice placed Resident #42 at risk of experiencing loss of dignity, sleep disturbances, fear, agitation, and anxiety. Findings include: The facility's policy, Abuse, Neglect and Exploitation, dated 8/26/22, stated the facility would provide protections for the health, welfare, and rights of each resident that would prohibit and prevent abuse, neglect, exploitation, and misappropriation. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including non-operative fractures of the tailbone and hip, and dementia. An MDS assessment, dated 8/15/23, documented Resident #42 was severely cognitively impaired and required assistance for mobility and transfers. An IDT progress note, dated 8/22/23, documented Resident #42 sustained a non-injury fall when he stood up…
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 before2024-01-26 · 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, policy review, record review, and staff interview, it was determined the facility failed to ensure a resident's comprehensive care plan was implemented. This was true for 1 of 12 residents (Resident #11) whose care plans were reviewed. This failure placed Resident #11 at risk of negative outcomes when his care plan was not implemented for mobility transfers. Findings include: The facility's Comprehensive Care Plan policy, revised 6/20/23, documented the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs. Resident #11 was re-admitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). An annual MDS assessment, dated 10/21/23, documented Resident #11 required…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-26 · 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 residents' care plans were reviewed and revised to reflect current needs and interventions. This was true for 1 of 12 residents (Resident #9) whose care plans were reviewed. This failure created the potential for harm if care and services were not provided due to inaccurate or incomplete information in the care plan. Findings include: The facility's Care Plan Revision policy, revised 12/22/23, stated the comprehensive care plan would be reviewed and revised as necessary. Resident #9 was admitted to the facility on [DATE], with multiple diagnosis including central sleep apnea (breathing stops and starts multiple times while sleeping). A physician order, dated 4/20/23, documented to provide Resident #9 with a continuous positive airway pressure (CPAP) machine at bedtime. On 1/22/24 at 10:55 AM, Resident #9 was observed with his CPAP on his night stand next to him. Resident #9's TAR, dated January 2024,…
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 · D2024-01-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure maintenance of a resident's urinary needs were met. This was true for 1 of 1 resident (Resident #11) reviewed for bowel and bladder care. This failed practiceplaced Resident #11 at risk for deterioration in bowel and bladder function. Findings include: The facility's Activities of Daily Living policy, revised November 2017, documented the facility would ensure a resident's abilities do not deteriorate unless the deterioration was unavoidable. Resident #11 was re-admitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Resident #11's care plan, dated 11/7/22, documented Resident #11 required 2-person extensive assistance for toileting. The care plan directed staff to use a gait belt during toileting transfers. An annual MDS assessment, dated 10/21/23,…
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 · D2024-01-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure nutritional assistance was provided to residents. This was true for 1 of 12 residents (Resident #11) reviewed for nutritional assistance. This deficiency placed Resident #11 at risk for undetected weight loss and nutritional deficits. Findings include: The facility's Nutrition Management policy, dated 12/18/23, documented the facility would provide care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status. Resident #11 was re-admitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), and severe protein-calorie malnutrition. 1. Resident #11's care plan, revised on 7/11/23, directed staff to provide her assistance with meals and to document refusals. - On 1/22/24 at 7:41 AM, Resident #11 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 · Dcited before2024-01-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, record review, and staff interview, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 1 resident (Resident #9) whose record was reviewed for respiratory services. This failure created the potential for Resident #9 to experience increased fatigue and low oxygen levels. Findings include: The facility's Noninvasive Ventilation policy, revised 12/26/23, documented [respiratory] equipment would be immediately replaced when broken or malfunctioned. Resident #9 was admitted to the facility on [DATE], with multiple diagnosis including central sleep apnea (breathing frequently stops while asleep). A physician order, dated 4/20/23, documented to provide Resident #9 with a continuous positive airway pressure (CPAP) machine at bedtime. On 1/22/24 at 10:55 AM, Resident #9 was observed with his CPAP machine next to him. When asked if had concerns with his CPAP machine, he stated it had not worked since 1/20/24.…
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 before2024-01-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications were dated when opened and not expired, and residents' medications were labeled with the resident's identifying information. This was true for 1 of 2 medication carts inspected. This failure created the potential for residents to receive the wrong medication or expired medications with decreased efficacy. Findings include: The facility's policy, Labeling of Medications and Biologicals revised on 12/27/23, states medications designed for multiple administrations (such as inhalers/eye drops), will identify the specific resident for whom it was prescribed. On 1/24/24 at 8:54 AM, the facility's medication carts in the 200 and the 400 halls were inspected with LPN #1 present. The following was found: - Lidocaine 5% patches: Not dated when opened, label torn and incomplete, and resident name not visible. - Antifungal powder in a shaker bottle: Not dated when opened, no label with resident identifying…
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 · D2024-01-26 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, and staff interview, it was determined the facility failed to ensure food items were dated and labeled and hygiene practices followed. This failure had the potential to affect 45 of 46 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 Date Marking for Food Safety policy, revised 12/18/23, stated the facility adhered to a date marking system to ensure safety of food. The policy also stated the food should be clearly marked to indicate the date by which the food shall be consumed or discarded. 1. On 1/22/24 at 7:31 AM, during a kitchen inspection the following seasoning containers were not marked with a date: - Spanish Paprika - Black pepper - Ground cinnamon - Whole rosemary - Parsley The following seasonings were not clearly marked if they were dated month and year or month and day: - Chopped chives: dated 12/14 - Lemon pepper: dated 12/28 - Garden seasoning: dated 3/16 - Taco seasoning: dated 12/18 - Dill weed: use by…
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 before2024-01-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment. This was true for 1 of 12 residents (Resident #11) observed during peri care. This failure had the potential for adverse outcome due to risk for cross contamination and infection. Findings include: The CDC's hand hygiene guidelines, accessed on 1/30/24 at 12:33 PM, stated hand hygiene should be performed when going from clean to dirty, after touching contaminated surfaces and immediately before and after touching a patient. On 1/23/24 at 11:30 AM, CNA #2 was observed providing peri care to Resident #11. During the cleaning process CNA #2 did not change her gloves or perform hand hygiene when going from dirty to clean. On 1/23/24 at 11:35 AM, CNA #2 stated she should have replaced her gloves when going from dirty to clean.
“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 TANABELL HEALTH SERVICES — 5 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 | 1 of 5 | 3.0 | -2.0 vs chain |
| Health inspection | 1 of 5 | 2.8 | -1.8 vs chain |
| Staffing | 1 of 5 | 2.2 | -1.2 vs chain |
| Quality measures | 4 of 5 | 4.2 | -0.2 vs chain |
The other 4 homes this chain runs (chain average 3.0★, 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 |
|---|---|---|---|---|
| BELL, JAMIE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 50% | since 01/01/2020 |
| AMERIPRISE TRUST C/O GERALD AGNEW | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| GDA GREEWOOD,LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| GIZA BUILD, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| JRSTOUTHEAD, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| RAMA GROUP, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| TAMBREE MANAGEMENT, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| AGNEW, GERALD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| AMAR, KEVIN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| ATKINSON, GREGORY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| STOUT, JAMES | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| WRIGHT, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 01/01/2020 |
| BELL, TROY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2020 |
| TANABELL HEALTH SERVICES, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2020 |
| TREASURE SENIOR PARTNERS | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2020 |
| BAILEY, GLEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/18/2022 |
| ANDERSON, CLAY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 05/02/2025 |
| BIG BOY PROPERTIES, LLC | Organization | ADP OF THE SNF | — | since 01/01/2020 |
| JMR GREENWOOD, LLC | Organization | ADP OF THE SNF | — | since 01/01/2020 |
| TRICON, LLC | Organization | ADP OF THE SNF | — | since 01/01/2020 |
CMS files one row per role, so the 40 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
11 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 $322K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 135147. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-03, 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.