Valley Vista Care Center of Sandpoint
220 South Division Ave, Sandpoint, ID 83864 · Non profit - Corporation · 73 certified beds · (208) 265-4514 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $40,918 in federal fines (most recent 2024-05-06)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (64%) 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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own 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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 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 | 23.0% | 15.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.8% | 5.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 1.2% | 1.2% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 6.0% | 2.0% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.2% | 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 | 6.4% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.3% | 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 | 100.0% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.9% | 3.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.7% | 22.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 34.3% | 20.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.3% | 1.8% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 87.5% | 86.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.8% | 17.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.5% | 12.3% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.24 | 1.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.39 | 1.66 | 1.80 | 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.
54.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 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 0.09 therapist hours per resident per day in 2026Q1 — more than 5% 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 | 54.4%CMS range 43.5–66.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 6.5–16.9 | 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 | 48.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 36.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 56.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 2.9% | 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 | 5.9% | 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 2.8–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.89 | 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 73 beds and averages 67.3 residents a day — about 92% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.47 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.13 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.18 hrs/resident/day on weekends vs 4.59 on weekdays — 9% thinner on weekends. RN hours go from 0.61 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% 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 unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · J2024-05-06 · 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, policy review, review of the State Agency's Long-Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to protect the residents' right to be free from physical and verbal abuse by staff. This was true for 2 of 3 residents (#3 and #37) who were reviewed for abuse. These deficient practices placed the safety of Resident #3 and Resident #37 and all other residents residing in the facility at risk for immediate jeopardy of serious harm, impairment or death. Findings include: The faclity's Abuse policy, dated December 2023, defined verbal abuse as the use of oral, written, or gestured language that willfully included disparaging derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy stated when an incident of resident abuse was suspected staff were to ensure the resident was safe by stopping the abuse and/or removing the resident from 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.
- Actual harm · G2024-05-06 · 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 record review, review of the State Survey Agency's Long-Term Care Reporting Portal, I&A reports, and staff interview, it was determined the facility failed to ensure residents' care plans were followed to prevent falls. This was true for 1 of 5 residents (Resident #16) reviewed for falls. This resulted in harm to Resident #16 when he fell and sustained a calcaneal (heel) fracture while being assisted by one staff during his pericare. Findings include: Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including viral infection of the brain, dementia, epilepsy (seizure), and abnormal posture. An annual MDS assessment, dated 9/27/23, documented Resident #16 was rarely/never understood. A care plan, revised 2/18/21, documented Resident #16 had an ADL self-care performance deficit related to his alteration in cognition, behaviors, weakness, and decreased mobility secondary to Human Prion (group of disorders that damage brain and nervous system tissues 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 · E2025-06-27 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including intrahepatic (within the liver) bile duct (small tubes that transport bile to the small intestine) cancer. Resident #27's record documented a PASRR Level II was completed on 4/18/24. Resident #27's admission MDS assessment section A1500 dated 4/24/24, documented she did not have a PASRR Level II evaluation. 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) Assessments included correct assessment information. This was true for 6 of 6 residents (#27, #35, #37, #38, #47, and #57) whose MDS records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The RAI Manual, revised 10/1/2024, documented section A1500, PASRR (Preadmission Screening and Resident Review),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-27 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, it was determined the facility failed to ensure residents were routinely provided nourishing evening snacks. This was true for 5 of 7 resident's (#5, #26, #31, #56, and #115) who attended the resident council discussion with surveyors. This failure created the potential for residents to experience hunger between meals, increased fatigue, weight loss, and poor quality of sleep. Findings include: The CMS SOM, Appendix PP, updated 4/25/25, documented no more than 14 hours between a substantial evening meal and breakfast the following day should elapse, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. The SOM defines a nourishing snack as items from the basic food groups (protein, grain, dairy, fruit, and vegetables), either singly or in combination with each other. On 6/25/25 at 10:33 AM, Resident #5, #26, #31, and #115 stated they were provided snacks when asked, but the snacks were not very…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-27 · 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 and staff interview, it was determined the facility failed to ensure the resident's refrigerators were cleaned, and expired spices were discarded. These deficiencies had the potential to affect the 59 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, documented marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions, documented cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained when the facility failed to offer hand hygiene to residents before their meals were served. This was true for 7 of 9 residents (#6, #9, #36, #37, #46, #47, and #50) eating in the Lodge dining room and 3 of 6 resident's (#12, #38, and #39) observed eating in their rooms. This failed practice had the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination. Findings include: The CMS SOM, Appendix PP, revised 4/25/25, documented hand hygiene should be offered to residents before meals. The facility's Hand Hygiene Policy, revised October 2023, documented hand hygiene should be practiced helping to prevent the spread of infections, and offered to residents, family members, and/or visitors. On 6/23/25 at 12:04 PM, the following was observed in the Lodge dining room: 1. Residents #6, #9, #37, #46, #47, and #50 were not offered hand hygiene before being provided their beverages 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 · Dcited before2025-06-27 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents' right to be treated with respect and dignity was upheld for 1 of 4 resident (Resident #1) who required assistance with their meals. This deficient practice resulted in a resident not being fed in a dignified manner. Findings include: The facility's Assistance with Meals policy, revised July 2017, documented residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example not standing over residents while assisting them with meals. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including intracranial (brain) injury with loss of consciousness of unspecified duration. On 6/23/25 from 12:38 PM to 12:56 PM, LPN #4 was observed standing while feeding Resident #1 his meal. On 6/23/25 at 2:25 PM, LPN #4 stated he was standing when he assisted Resident #1 with his meal. LPN #4 stated he should have been sitting down while assisting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-27 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined the facility failed to ensure residents exercised their right to formulate an Advance Directive. This was true for 2 of 15 residents (#37 and #38) whose records were reviewed. This failed practice created the potential for an adverse outcome if the resident's wishes were not followed. Findings include: The State Operation Manual (SOM), Appendix PP, defined an Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient'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 · D2025-06-27 · 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, resident representative, and staff interview, it was determined the facility failed to ensure residents had a homelike environment. This was true for 1 of 1 resident's (Resident #16) whose room was observed to have a wall in disrepair. This deficient practice created the potential for psychosocial harm if Resident #16 was not provided a homelike environment. Findings include: The facility's Homelike Environment policy, revised February 2020, documented the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized and homelike setting. Resident #16 was admitted to the facility on [DATE] with multiple diagnoses including aphasia (inability to communicate verbally) after a stroke, right side weakness and paralysis, and dementia. On 6/24/25 at 9:39 AM, Resident #16's Representative stated she was concerned the baseboard area of his wall had exposed wood. On 6/25/25 at 3:19 PM, the base of the wall near the headboard of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-27 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined the facility failed to provide hospital transfer paperwork for 1 of 3 residents (Resident #18) when they were discharged to the hospital. This deficient practice created the potential for Resident #18 to experience harm if the receiving hospital was not provided current medical documentation when he was transferred for emergency medical care. Findings include: The CMS SOM Appendix PP, revised 4/25/25, documented when a facility transfers or discharges a resident the facility must ensure the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Additionally, the facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility in a form and manner the resident can understand. 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 · D2025-06-27 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — 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 provided notice of bed-hold and return policy and the Ombudsman advocate for residents was not informed of their transfer. This was true for 2 of 4 residents (#18, and #54) whose records were reviewed for discharge documentation. This failure placed the residents at risk for unnecessary psychosocial distress if they were unaware they could return to the facility following a hospitalization or therapeutic leave and the Ombudsman was not made aware a resident may require an advocate while out of the facility. Findings include: 1. Resident #54 was admitted to the facility on [DATE] with multiple diagnoses including a history of blood clots and kidney and bladder cancer. Resident #54's medical record documented he went to the hospital on 6/14/25 when his nephrostomy tube (a thin surgically placed tube from the kidney to a collection bag outside the body for urine) fell out. Resident #54's medical 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 · D2025-06-27 · 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 Based on policy review, record review, and resident and staff interviews, it was determined the facility failed to provide a copy or summary of the baseline care plan to residents and/or their representative. This was true for 1 of 1 residents (Resident #115) reviewed for baseline care plan. This failure placed Resident #115 and/or his representative at risk of not being informed and having input in his care plan. Findings include: The facility's Care Plans - Baseline policy, revised December 2016 stated the resident and/or their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and d. Any updated information based on the details of the comprehensive care plan, as necessary. Resident #115 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.
Show the remaining 17 citations
- Potential for harm · D2025-06-27 · 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 observation, record review, and staff interviews, it was determined the facility failed to ensure medications were administered according to physician's order and professional standards of practice. This was true for 2 of 5 residents (#23 and #41) whose medications administration were observed. This deficient practice created the potential for Resident #41 to develop a yeast infection when he did not rinse his mouth after using his inhaler. Resident #23 had the potential of not receiving the full benefit of his medication from incorrect dosage administration. Findings include: 1. The Wixela Inhub website: www.wixelahcp.com, accessed on 7/1/25, documented Candida albicans [a fungus] has occurred in patients treated with fluticasone propionate and salmeterol inhalation powder. Advise patients to rinse the mouth with water without swallowing following inhalations to help reduce the risk of oropharyngeal candidiasis [mouth and throat yeast infection]. Resident #41 was admitted to the facility on [DATE],…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-27 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to ensure physician's order to provide non-pharmacological intervention were offered to residents prior to administration of their as needed narcotic pain medications. This was true for 3 of 3 residents ( #22, #54 and #115) reviewed for pain medications. This deficient practice created the potential for harm if the residents were overmedicated when their pain may have responded to nonpharmacological interventions. Findings include: The CDC website, www.cdc.gov, article titled, Overdose Prevention: Guideline Recommendations and Guiding Principles, accessed on 7/2/25, recommended clinicians should maximize use of nonpharmacological and nonopioid pharmacological therapies as appropriate for the specific condition and patient, and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. 1. Resident #22 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 · D2025-06-27 · 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 a resident was free from unnecessary medications. This was true for 1 of 5 residents (Resident #22) reviewed for unnecessary medications. Resident #22 was continually prescribed of cough medication without clear indication and in excessive duration. This deficient practice had the potential for harm if Resident #22 received medications that may result in negative outcomes without clear indication of need. Findings include: 1. Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including chronic bronchitis, low back pain, and dementia. A physician's order, dated 1/30/25, documented Resident #22 was to receive guaifenesin ER (an expectorant-extended release) oral tablet 600 mg every 12 hours for congestion. Resident #22's March 2025, April 2025, May 2025, and June 1-26, 2025, documented Resident #22 was administered guaifenesin ER oral tablet 600 mg every 12 hours for congestion. A Nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-27 · tag F0839 — isolatedEmploy staff that are licensed, certified, or registered in accordance with state laws.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on license and certification review and staff interview, it was determined the facility failed to ensure nursing staff were licensed/certified within the state where they provided care. This was true for 1 of 3 nursing staff (Staff #1) whose licenses/certification were reviewed and had the potential to affect all 61 residents in the facility. This failure created the potential for harm if residents received inappropriate care due to a nursing staff lacking the credentials to provide nursing care. Findings include: On 6/25/25 at 3:18 PM, licenses and certification of three nursing staff were reviewed with the HR personnel. Staff #1 who was hired as a CNA on 3/26/25 did not have a certification to work as a CNA in this state. The HR personnel stated she was recently hired in the facility as the HR when Staff #1 was hired, and would look further for the certification of the Staff #1. On 6/26/25 at 2:01 PM, the HR personnel stated she reached out with the previous HR personnel and was told Staff #1 had certification as a nursing assistant when she was hired in the facility. The HR…
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 · E2024-05-06 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it was determined the facility failed to meet the regulation requirements for frequency of QA meetings. This has the potential to negatively affect all residents in the facility if quality deficiencies throughout the facility were not identified and responded timely and appropriately. Findings include: The facility's Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, stated the committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. On 5/3/24 at 1:02 PM, the Administrator stated the facility held their QAPI meetings monthly. The surveyor then asked for the attendance sheet of QAPI meetings from April 2023 to April 2024. The QAPI attendance sheet was reviewed with the Administrator. Upon review of the sign-in sheets, it was determined there was no QAPI meetings held between April 2023 and June 2023. When asked why there was no meetings held between April 2023 and June 2023, the Administrator stated he could not find the sign-in sheets…
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 · E2024-05-06 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, policy review, and staff interview, the facility failed to provide a minimum of 12 hours of in-service education per year for 3 of 25 CNAs (CNA #7, CNA #8, and CNA #9) reviewed for sufficient and competent CNA staffing. This failure placed residents at risk of receiving care from staff who are not adequately trained in competencies to meet residents' needs. Findings include: The facility's policy, In-Service Training Program, dated 12/1/23, stated, .All nursing home direct care personnel (CNAs) are required to complete twenty-four (24) hours of in-service per year .Attendance at all mandatory in-service is incorporated as a part of the annual performance evaluation. Lack of completion of mandatory in-service hours or required in-services may impact any pay raise normally given at the time of the annual evaluation and will result in termination if the training is required for the position . An untitled document provided by the Human Resources Coordinator (HRC) documented CNA #7 was hired as a CNA in 2/2022. Review of CNA #7's training log documented 2.75 hours…
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 before2024-05-06 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interview, it was determined the facility failed to ensure to respect and maintain a residents' dignity. This was true for 1 of 1 resident (Resident #12) reviewed for respect and dignity. This deficient practice created the potential for psychosocial harm if Resident #12 experienced embarrassment or lack of self-esteem. Findings include: The facility's Resident Rights policy, dated 12/26/22, stated residents are to be treated with respect, kindness, and dignity. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including intracranial (brain) injury with loss of consciousness and epilepsy (seizure disorder), and aphasia (an impairment of language due to brain injury, affecting the production or comprehension of speech and the ability to read or write). An annual MDS assessment, dated 9/20/23, documented Resident #12 was rarely/never understood. On 4/29/24 at 1:11 PM and 5/2/24 at 7:36 AM, Resident #12 could be seen from outside his room…
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 · D2024-05-06 · 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 record review, policy review, observation, and resident and staff interview, the facility failed to ensure the interdisciplinary team had determined it was appropriate for a resident to self-administer medications for 2 of 6 residents (#39 and #52) reviewed for self-administration of medications. Findings include: The facility's policy Self-Administration of Medications dated December 2016, documented Residents had the right to self-administer medications if the interdisciplinary team clinically determined it was appropriate and safe for the resident to do so. 1. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - group of diseases that cause airflow blockage and breathing-related problems). A quarterly MDS assessment, dated 3/25/24, documented Resident #39 was cognitively intact. A physician order, dated 4/4/24, documented Resident #39 was to start a Ventolin inhaler, two puffs every 4 hours as needed for bronchospasms 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 · D2024-05-06 · 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 record review and staff interview, it was determined the facility failed to ensure the physician was notified of a resident's decision to leave the facility against medical advice. This was true for 1 of 1 resident (Resident #62) reviewed for discharge. This deficient practice placed Resident #62 at risk of harm due to lack of physician input or involvement. Findings include: Resident #62 was admitted to the facility on [DATE], with multiple diagnoses including dementia, weakness, and anxiety. A nurse's progress note, dated 1/31/24 at 1:46 PM, documented Resident #62's representative told the nurse he was taking Resident #62 home. The nurse documented, I attempted to explain that unless we have a discharge order, he would have to take her home AMA [against medical advice]. A Social Services progress note, dated 1/31/24 at 3:37 PM, documented Resident #62's representative stated Resident #62 was unhappy with the placement and he was taking her home. The RSC informed Resident #62 that the facility would…
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 · D2024-05-06 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure residents were provided with an Advance Beneficiary Notice (ABN) when their Medicare Part A benefits ended. This was true for 1 of 3 residents (Resident #19) reviewed for an ABN. This failure created the potential for Resident #19 and his representative to experience financial and psychological distress when they were not informed of their potential financial liability to continue services. Findings include: Resident #19 was admitted to the facility on [DATE] for care related to his dementia diagnosis. Resident #19 had a representative who made healthcare and financial decisions on his behalf. On 4/3/24 Resident #19's Representative was given the Notice of Medicare Non-Coverage CMS 10123 Form (NOMNC). The form documented his Skilled Nursing Service Coverage would end on 4/5/24 as his health had improved and he no longer qualified for coverage. On 5/2/24 at 11:48 AM, the RSC stated Resident #19 continued to stay at 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 · D2024-05-06 · 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, policy review, and resident and staff interview, it was determined the facility failed to report allegations of potential abuse to the State Survey Agency within 2 hours. This affected 1 of 3 residents (Resident #37) who were reviewed for abuse/neglect. This failure resulted in Resident #37's allegation of verbal abuse not being acted on in a timely manner, investigated, and measures implemented to protect residents during the investigation, which placed all residents in the facility at risk of abuse. Findings include: The facility's Abuse policy, dated December 2023, stated each resident had the right to be free from abuse. Residents must not be subjected to abuse by anyone. The policy defined verbal abuse as the use of oral, written, or gestured language that willfully included disparaging derogatory terms to residents or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy stated the Initial Report of allegations of abuse, or…
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 · D2024-05-06 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and resident and staff interview, it was determined the facility failed to ensure an allegation of verbal abuse was thoroughly investigated for 1 of 3 residents (Resident #37) reviewed for abuse. This failure subjected Resident #37 and other residents in the facility to ongoing abuse without detection. Findings include: The facility's Abuse policy, dated December 2023, stated Each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone. The policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging derogatory terms to residents regardless of their age, ability to comprehend, or disability. The policy stated that when an incident of resident abuse is suspected staff members are to ensure the resident is safe by stopping the abuse and/or removing the resident from the situation. If the accused individual is an employee, the alleged perpetrator will be removed from resident care…
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 · D2024-05-06 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff and resident interview, it was determined the facility failed to implement a restorative nursing program for 1 of 1 resident (Resident #13) reviewed for restorative nursing services. This deficient practice created the potential for Resident #13 to experience a decline in range of motion (ROM). Findings include: The facility's policy, Restorative Nursing Services, undated, documented residents would receive restorative nursing services care as needed to help promote optimal safety and independence. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following stroke. Resident #13's care plan, revised 5/19/22, documented Resident #13 was to receive LUE/PROM (left upper extremity/Passive Range of Motion) 1 set/3 reps-Left shoulder flex/ext (extension) adb (abduction)/add (adduction) (up to 90 degrees). L (left) elbow flex/ext, L…
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 · D2024-05-06 · 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 and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 1 resident (Resident # 12) reviewed for standards of practice. This deficient practice placed Resident #12 at risk of neck and back discomfort when his head was not supported. Findings include: Resident #12 was admitted to the facility on [DATE] with multiple diagnoses including intracranial (brain) injury with loss of consciousness and epilepsy (seizure disorder) and aphasia (loss of ability to understand or express speech). On 4/29/24 at 1:11 PM, Resident #12 was observed in his bed with his eyes closed. Resident #12's head was tilted to his left side almost touching his shoulder. On 4/30/24 at 10:40 AM and 5/2/24 at 2:47 PM, Resident #12 was observed sitting in his wheelchair in the Lodge Unit TV room. Resident #12's head was tilted to his left side and almost touching his shoulder. There was no supporting device for his head or to support his posture. On 5/2/24…
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 · D2024-05-06 · 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 record review, policy review, observation, and staff interview, the facility failed to ensure the cleanliness of a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mouthpiece was maintained when not in use. This was true for 1 of 3 residents (Resident #42) reviewed for respiratory care. This created the potential for respiratory infections due to growth of pathogens (organisms that cause illness) in respiratory treatment equipment. Findings include: The facility's policy, Administering Medications through a Small Volume (Handheld) Nebulizer, dated October 2010, documented when the equipment was completely dry, to store it in a plastic bag with the resident's name and the date on it. 1. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including high blood pressure, dementia, malnutrition, and dementia. A quarterly MDS assessment, dated 3/26/24, documented Resident #42 was moderately cognitively impaired. On 4/30/24 at 9:34 AM 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 · D2024-05-06 · 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 failed to ensure professional standards of practice were met for monitoring the effectiveness of residents' medications. This was true for 1 of 17 residents (Resident #49) whose medications were reviewed. This deficient practice created the potential for Resident #49 to experience adverse reactions or side effects due to lack of appropriate monitoring of his medication. Finding include: The State Operation Manual, Appendix PP, documented an unnecessary drug is any drug when used: - in excessive dose, - for excessive duration or - without adequate monitoring or -without adequate indications for its use. Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including senile degeneration of the brain, chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness) and insomnia. Resident #49 physician's order, dated 6/6/22, included Trazodone (anti-depressant, also used to treat…
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 · E2019-01-31 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, it was determined the facility failed to ensure expired over the counter medications were removed from the medication carts. This failed practice created the potential for residents to receive expired medications with decreased efficacy. Findings include: On 1/30/19 at 10:00 AM, during the inspection of the 200 Hall medication cart with LPN #1, three bottles of expired over the counter medications were found. The medications included: * Docusate Sodium (stool softener) 250 mg with an expiration date of 10/2018 * Calcium 600 mg tabs with an expiration date of 8/2018 * Multi Pride Multi vitamin formula (250mcg Lutein and 300 mg Lycopene) with the expiration date of 6/2018 LPN #1 stated the medications were not being used by residents at this time and removed them from the cart. On 1/30/19 at 10:20 AM, during the inspection of the 100 Hall medication cart with LPN #2, one bottle of the over the counter medication Docusate Sodium, was found with an expiration date of 8/2018. LPN #2 stated she would discard the expired medication.
“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
$40,918 in federal fines across 1 penalty.
- $40,918 — penalty dated 2024-05-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| COWIN, WILLIAM | Individual | CORPORATE DIRECTOR | since 08/03/2016 |
| GOODALL, TOM | Individual | CORPORATE DIRECTOR | since 06/30/2021 |
| HAYES, DONNA | Individual | CORPORATE DIRECTOR | since 06/30/2021 |
| MCGREAL, HEIDI | Individual | CORPORATE DIRECTOR | since 10/26/1998 |
| POWELL, SABRINA | Individual | CORPORATE DIRECTOR | since 06/30/2024 |
| RYAN, DOUG | Individual | CORPORATE DIRECTOR | since 06/30/2020 |
| SPOONER, CLAUDIA | Individual | CORPORATE DIRECTOR | since 06/30/2013 |
| WILKS, KASEY | Individual | CORPORATE DIRECTOR | since 03/15/1999 |
| WOODIN, CHERI | Individual | CORPORATE DIRECTOR | since 06/30/2019 |
| LLOYD, CHARLES | Individual | CORPORATE OFFICER | since 06/17/2019 |
| VALLEY VISTA CARE CORPORATION | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 12/30/1999 |
| LAMBERT, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2022 |
| MEZA, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2018 |
CMS files one row per role, so the 15 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner 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 72% 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 $573K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in ID
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 135055. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-27, 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.