Bridgeview Estates
1828 Bridgeview Blvd Suite 2, Twin Falls, ID 83301 · For profit - Limited Liability company · 116 certified beds · (208) 735-5730 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has 1 actual-harm citation
- 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 (2/5)
- about 18% of its spending goes to commonly-owned related companies
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 5 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 11.5% | 15.6% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.5% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.3% | 2.0% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.9% | 15.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.6% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 30.9% | 16.1% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.9% | 16.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.4% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.9% | 3.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.0% | 22.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.9% | 20.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.0% | 86.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.5% | 17.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.0% | 12.3% | 12.0% | better |
‡ 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.
68.1% 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 99 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 91.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 62 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 68.1%CMS range 58.5–75.9 | 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 | 10.2%CMS range 7.3–15.2 | 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 | 91.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 82.3% | 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 | 77.4% | 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 | 97.6% | 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 | 97.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 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 | 7.7%CMS range 4.4–13.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 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 116 beds and averages 47.7 residents a day — about 41% occupied, or roughly 68 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 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 3.44 hrs/resident/day on weekends vs 4.20 on weekdays — 18% thinner on weekends. RN hours go from 0.69 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2018-12-03 · 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 record review and staff interview, it was determined the facility failed to coordinate care to prevent the development of an avoidable pressure ulcer. This was true for 1 of 2 residents (Resident #29) who were reviewed for pressure ulcers. Staff failed to follow physician orders to remove a leg brace and to conduct skin assessments. This resulted in harm for Resident #29 when they developed a pressure ulcer which required skin grafting and a lengthy healing period. Findings include: Resident #29 was admitted to the facility on [DATE], with diagnoses which included a right femur (thighbone) fracture. Resident #29's hospital Discharge summary, dated [DATE], documented Upon arrival at new facility: Encourage up in Chair every 4-6 hrs [hours] or 3 times daily. Non-weight bearing right lower extremity. Work on bed to chair transfers. Remove brace for physical therapy. Resident #29's July 2018 MAR documented FYI: NWB (non-weight bearing) RLE [right lower extremity]. Encourage up in chair every 4-6 hours or 3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-07-09 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 2022 FDA Food Code, resident and staff interviews, it was determined the facility failed to ensure resident meals were palatable and maintained their correct temperature. This deficient practice had the potential to affect all residents who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The 2022 FDA Food Code states hot food will be maintained at 135 degrees F (Fahrenheit) or above and cold food will be maintained at 41 degrees F or below. The following comments were obtained during resident interviews. On 7/6/25 at 2:45 PM, Resident #46 stated meals are cold, with over or undercooked vegs that are often tasteless and mushy. On 7/6/25 at 2:52 PM, Resident #34 stated food is always cold and horrible, poorly fixed. Turkey and rice in last night’s dinner was horrible and tasted old. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including Multiple…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-07-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include: The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 7/6/25 at 10:11 AM, observed the following issues in the Walk-in Refrigerator. - a large container of cooked turkey in liquid, partially covered with plastic…
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 · D2025-07-09 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 interviews, it was determined the facility failed to ensure residents were initially assessed to determine if they were safe to self-administer medications for 1 of 1 resident (Resident #10). This failure created the potential for adverse effects if residents self-administered medications inappropriately. Findings include:Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including emphysema and anxiety. On 7/6/25 at 1:51 PM, observed in Resident #10's room [ROOM NUMBER] tubes of Cortisone-10 cream on her overbed table. Resident #10 stated she self-administers the medication when she needs it. Resident #10's medical record had not contained a self-administration assessment for the Cortisone-10 cream.On 7/8/25 at 2:15 PM, the DON stated Resident #10 should have been assessed for the Cortizone-10 cream to allow her to have it in her room to self-administer and was not.
- Potential for harm · D2025-07-09 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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, interview, and record review, it was determined the facility failed to ensure the MDS assessment accurately reflected the resident's status. This was true for 1 of 1 resident (Resident #10) whose MDS, care plan, and nursing assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed and cared for or monitored due to inaccurate assessments. Findings include:Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including emphysema and anxiety. Review of Resident #10's Level I PASRR dated 10/6/23, and Level II PASRR dated 10/10/23, and noted PTSD was listed as a diagnosis. Review of Resident #10's MDS dated [DATE], 1/18/25, 10/18/24, 7/20/24, 4/19/24, 1/18/24, and 10/18/23 which documented under I6100 Post Traumatic Stress Disorder (PTSD) was marked NO.On 7/7/25 at 1:20 PM, the DON stated once PTSD is listed on the PASSR's it should have been documented in each MDS and was not.
- Potential for harm · Dcited before2025-07-09 · 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, interview, and record review, the facility failed to develop and implement resident's comprehensive person-centered care plan. This was true for 1 of 1 resident (Resident #10) whose care plan was reviewed. This deficient practice of not developing and implementing care plans placed residents at risk to their health and wellbeing with negative outcomes if services were not provided or provided incorrectly. Findings include: Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including emphysema and anxiety. Resident #10's comprehensive person-centered care plan had not documented PTSD diagnosis with goals and interventions.On 7/8/25 at 2:19 PM, the DON stated Resident #10's PTSD diagnosis should have been care planned and was not.
- Potential for harm · Dcited before2025-07-09 · 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 policy review, record review, and staff interview, it was determined the facility failed to update care plans when changes occur to resident's care. This was true for 2 of 14 residents (#12 and #34) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided as resident's needs changed. Findings include:The facility's policy, Comprehensive Care Plans and Conferences dated 9/5/24, documented resident’s care plans must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including COPD (a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe), congestive heart failure, and repeated falls. On 3/3/25, Resident #12 had a fall when his quad-cane bent during a transfer, resulting in a laceration and skin…
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 before2025-07-09 · 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 facility standing orders, record review and staff interview, it was determined the facility failed to follow facility bowel care standing order of delivering specific medications when residents do not have BM within 72 hours for 3 of 4 Residents (#34, #41, and #43) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include: The facility standing orders and protocols documented BM (Bowel Movement) Step 1: Lactulose 10GM/15ML: 30 ml PO daily PRN for no bowel movement X 72 hrs +. If no results within 8 hrs proceed to step 2: BM Step 2: Dulcolax Suppository 10mg: give one Suppos rectally PRN daily for NO BM X 72 Hrs +. If no results within 8hrs proceed to step 3. BM Step 3: Fleet Enema 7-19 GM/118 ml: Give one Enema rectally PRN daily for NO BM X 72 Hrs+. If no results within 8 hours Notify MD for further instructions. a. Resident #34 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-09 · 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, policy review, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 2 of 5 residents (#34 and #43) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include: a. Resident #34 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including acute respiratory failure with hypoxia (a condition where the lungs cannot adequately oxygenate the blood, leading to dangerously low levels of oxygen in the body) and cellulitis of right lower limb (a bacterial infection affecting the skin and underlying tissues of the right leg, causing redness, swelling, pain, and warmth).On 7/6/25 at 2:52 PM, observed Resident #34 was not using his oxygen concentrator located in his room. Resident #34 stated he uses it when he feels he needs it.Resident #34'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 · D2025-07-09 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include:On 7/8/25 at 8:57 AM, during Sawtooth Hall medication cart audit, observed the narcotic accountability record, dated 5/3/25 to 7/8/25, with 3 licensed nurse signatures not documented. On 7/8/25 at 9:01 AM, LPN #1 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 7/8/25 at 9:10 AM, during Sun Valley Hall medication cart audit, observed the narcotic accountability record, dated 5/28/25 to 7/8/25, with 5 licensed nurse signatures not documented. On 7/8/25 at 9:36 AM, RN #1 stated two nurses should have signed the narcotic accountability record 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 · Dcited before2025-07-09 · 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 secure and inaccessible to unauthorized staff and residents. This was true for 1 of 19 Residents (Resident #28). This failure created the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include:The facility’s Storage and Expiration Dating of Medications and Biologicals policy revision date 8/1/24, documented the following: - the facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is not accessible by residents and visitors. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis, lumbar region (condition where spaces narrow, putting pressure on the spinal cord and nerves) and diabetes. On 7/8/25 at 8:47 AM, the following was observed in Resident #28’s room; LPN…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · D2025-07-09 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, Department of Health and Welfare - Idaho Administrative rules, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include: Department of Health and Welfare - Idaho Administrative Rules 16.03.02. Environmental Sanitation 108. Garbage and Refuse 03a. All containers used for storage of garbage and refuse shall be constructed of durable, nonabsorbent material and shall not leak or absorb liquids. Containers shall be provided with tight-fitting lids unless stored in vermin-proof rooms or enclosures, or in a waste refrigerator.U.S. Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in…
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 · D2025-07-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure accurate and complete clinical records were maintained for each resident. This was true for 1 of 1 resident (Resident #12) whose records were reviewed. This deficient practice resulted in incomplete documentation and created the potential for harm if inappropriate care and/or treatments were provided to the resident. Findings include:Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including COPD (a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe), congestive heart failure, and repeated falls.A physician's order dated 1/30/25, documented Resident #12's inappropriate sexual comments towards staff were to be documented on the TAR and include number of episodes, intervention, and outcome.A care plan dated 2/21/25, documented Resident #12 makes sexually inappropriate comments to staff and a behavior tracking document is in…
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 before2022-04-29 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, policy review, and staff interview, it was determined the facility failed to ensure measures were in place to prevent possible cross-contamination from dirty to clean areas in the kitchen. This had the potential to affect the 41 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The facility's Food and Nutrition policy, Prevention of Cross-Contamination, revised 12/17/21, documented all Food and Nutrition Services associates were trained in infection control techniques to prevent the contamination of food and the spread of infection to ensure food was stored, prepared, distributed and served in accordance with professional standards for food safety, and per federal, state and local requirements. The Idaho Food Safety and Sanitation Manual, Page 33, revised 2/2018, stated hands must be washed after handling garbage, dirty dishes or soiled equipment, and before handling food or clean…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-04-29 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 1. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder and dementia. A physician's order, dated 3/16/22, directed staff to monitor and document Resident #25's behavior for self-isolation/lack of interest. A care plan, initiated 4/3/22, documented Resident #25 was prescribed psychotropic medications related to depressive disorder and staff were directed to administer her medications as ordered by the physician and observe her for any side effects of the medications every shift. Resident #25's care plan did not include the physician's order to monitor her behavior for self-isolation and lack of interest. On 4/28/22 at 3:39 PM, the DON stated Resident #25 was being monitored for negative mood such as self-isolation. The DON stated she did not see documentation in Resident #25's care plan for behavior monitoring. 2. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder and anxiety disorder. 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 · D2022-04-29 · 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, policy review, and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of medications for 1 of 5 residents (Resident #25) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medication was prescribed, the expected benefits, and the risks associated with the medications. Findings include: The facility's policy, Psychotropic Medication Management, undated, documented the following: *Psychotropic drug is defined in the regulations at §483.45(c)(3), as any drug that affects brain activities associated with mental processes and behavior. *The resident's medical record must include documentation of adequate indications for a medication's use and the diagnosed condition for which a medication is prescribed. *Involvement of the resident, his or her family, and/or the resident representative in the medication management process. (A consent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-04-29 · 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 record review, policy review, and staff interview, it was determined the facility failed to ensure a resident's contact isolation was addressed on the baseline care plan. This was true for 1 of 5 residents (Resident #243) reviewed for baseline care plans. This failure created the potential for spread of infection if residents' contact isolation intervention was not initiated. Findings include: The facility's Baseline Care Plan policy, revised 5/19/21, directed staff to develop a baseline care plan within 48 hours of admission to provide an initial set of instructions needed to provide an effective and person-centered care of the resident that meets professional standards of care. This policy was not followed: Resident #243 was admitted to the facility on [DATE], with multiple diagnoses including Methicillin Resistant Staphylococcus Aureus Infection (MRSA - an infection caused by Staphylococcus bacteria that are resistant to commonly used antibiotics). A physician order, dated 4/20/22, directed staff to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-04-29 · 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, policy review, record review, and staff interview, it was determined the facility failed to ensure medications were administered in a manner that was consistent with physician's orders and professional standards of practice. This was true for 3 of 6 residents (#20, #31, and #38) reviewed for medication administration. This failure created the potential for adverse effects for Resident #20 and Resident #38 should they experience a life-threatening situation due to low or high blood sugar, and for Resident #31 when he received doses in excess of physician orders for nasal spray. Findings include: The Nursing 2019 Drug Handbook stated the eight rights of medication administration were right drug, right patient, right dose, right time, right route, right reason, right response, and right documentation. The facility's General Dose Preparation and Medication Administration policy, revised 1/1/22, documented the facility staff should verify the correct medication, dose, route, rate, time, 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 · D2022-04-29 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 40 medications (5%) which affected 2 of 7 residents (#31 and #38) whose medication administration was observed during the medication pass. This failed practice placed residents at risk of not receiving medications as ordered by their physician and the potential for harm when Resident #31 received doses in excess of physician orders for a nasal spray and potential to affect the therapeutic level and effectiveness of Resident #38's insulin when it was administered after meals instead of before meals as ordered by her physician. Findings include: The Nursing 2019 Drug Handbook stated the eight rights of medication administration were right drug, right patient, right dose, right time, right route, right reason, right response, and right documentation. 1. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including acute…
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 · D2018-12-03 · 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 record review, policy review, observation, resident interview, and staff interview, it was determined the facility failed to ensure the dignity of the residents was maintained. This was true for 2 of 3 residents (#16 and #50) who wore wrist bands and were reviewed for dignity. This failure created the potential for psychosocial harm and well-being should resident's self-worth and self-esteem be negatively affected. Findings include: The facility's policy Ready, Set, Go! Rehabilitation Program, undated, documented all residents on rehabilitation services will be given a colored wrist band when they are initially evaluated by therapy. These wrist bands will help all staff know what level of assistance to provide for residents during their stay at the facility. As residents progress in their therapy, their wrist bands will be changed by therapy staff. A red wrist band indicates residents are only walking with therapy staff and all transfers require assistance from a staff member. A yellow band indicates…
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 · D2018-12-03 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 resident interview, staff interview, and record review, it was determined the facility failed to ensure residents were provided the opportunity to participate in the care planning process for the development and implementation of their person-centered plan of care. This was true for 1 of 24 residents (Resident #49) who were reviewed for care planning. The failure created the potential for harm if residents' care was provided inconsistent with their needs and preferences. Findings include: Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (an irregular heart rhthym). He was readmitted on [DATE], following a brief hospitalization related to the atrial fibrillation and had a coronary angioplasty with stent placement. An angioplasty is a minimally invasive procedure to unblock arteries. Resident #49's annual MDS assessments, dated 11/13/18, documented his hearing and vision were adequate and his speech was clear, he understood others and they…
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 · D2018-12-03 · 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 staff interview, record review, review of the facility's admission packet, and policy review, it was determined the facility failed to ensure residents were provided written information regarding Advance Directives in a language they could understand and assisted them to formulate Advance Directives. This was true for 1 of 24 residents (Resident #1) who were reviewed for Advance Directives. The failure increased the risk Resident #1's health care preferences would not be honored if she became incapacitated and unable to communicate her wishes. Findings include: The facility's Advance Directives policy, dated 2/2018, documented The resident has a right to execute or refuse to execute an advance directive, which stipulates how decisions regarding his or her medical care are made. Residents have the right to self-determination regarding their medical care. This includes .to direct his or her own medical treatment, including withholding or withdrawing life sustaining treatment. The State Operations Manual…
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 · D2018-12-03 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, home health provider staff interview, resident representative interview, it was determined the facility failed to ensure appropriate information was communicated to a home health care provider upon the discharge of a resident. This was true for 1 of 5 residents (Resident #157) who were reviewed for discharge from the facility. The deficient practice created the potential for harm if home health services were not provided as ordered for the resident. Findings include: Resident #157 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including Lewy Body dementia (abnormal protein deposits), congestive heart failure, chronic pain, abnormalities of gait and mobility, muscle weakness, dysphagia (difficulty swallowing), and severe protein-calorie malnutrition. A physician's order, dated 4/14/17, documented May discharge home with home health physical therapy [PT], occupational therapy [OT], and nursing. Resident #157's Discharge summary,…
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 before2018-12-03 · 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 observation, resident interview, staff interview, and record review, it was determined the facility failed to ensure the baseline care plan included communication as a potential barrier for 1 of 3 residents (Resident #1) who were non-English speaking and who were reviewed. The failure created the potential for harm if the care and services provided did not meet her needs or was contrary to her wishes due to lack of direction regarding her preferred language. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including a pelvic fracture, generalized muscle weakness, acute kidney failure, and major depressive disorder. Resident #1's most recent MDS assessment, dated 8/22/18, documented her preferred language was Spanish and she preferred a spanish interpreter to communicate with health care staff and the physician. Resident #1's Baseline Care Plan and Initial Discharge Plan, dated 5/24/18, did not document her preferred language or identify interventions for…
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 before2018-12-03 · 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, resident and staff interview, and record review, it was determined the facility failed to ensure the care plan was revised to reflect a resident's current status and needs. This was true for 1 of 24 residents (Resident #1) whose care plans were reviewed. The failure to revise Resident #1's care plan when her dialysis access device site changed created the potential for harm if her care was not provided and/or decisions were made based on inaccurate information. Findings include: Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including acute kidney failure. On 11/27/18 at 2:55 PM, Resident #1 said she had just returned from dialysis. She showed the surveyor her dialysis access device in her right upper arm, and where she had a previous access device on her left upper chest. A clean, dry, and intact dressing was on the right arm access site. Resident #1 said the facility staff did not check her access device after dialysis and she was the one who removed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-12-03 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 interview, staff interview, and record review, it was determined the facility failed to ensure activities met the interests and supported the physical, mental, and psychosocial well-being of each resident. This was true for 1 of 24 residents (Resident #1) who were reviewed for activities. This failure created the potential for residents to become bored or depressed when she was not provided with meaningful engagement throughout the day. Findings include: Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including a pelvic fracture, generalized muscle weakness, acute kidney failure, and major depressive disorder. Resident #1's quarterly MDS assessment, dated [DATE], documented her preferred language was Spanish and she needed or wanted an interpreter to communicate with health care staff. Her hearing and vision were adequate and her speech was clear. Her cognition was modified independent (some difficulty in new situations only). It was very important to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-12-03 · 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 record review, policy review, observation, resident interview, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 5 of 25 residents (#39, #46, #50, #258, and #260) who were reviewed for standards of practice. This failure created the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices. Findings include: 1. The Nursing 2018 Drug Book included specific recommendations for crushing medications. One recommendation stated crushing certain oral medications may alter the drug's effect causing overdose or other adverse reactions. Before crushing a medication, always check with the pharmacist and established references. The facility's Oral Medication Administration policy, dated 11/2017, documented staff will check for specific prescriber orders to crush medications. Crush medications, if indicated, for a resident only after referring to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-12-03 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services 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 observation, resident interview, staff interview, and record review, review of the facility/dialysis provider agreement, and review of facility policy, it was determined the facility failed to ensure physician orders and the care plan related to dialysis care and services were updated and implemented when the access device site changed, and that pre and post-dialysis assessments were consistently completed for 1 of 1 resident (Resident #1) who was reviewed for dialysis. The failure created the potential for harm if undetected complications went untreated or there was a delay in treatment. Findings include: The facility/dialysis provider agreement, made and entered into on 10/18/07, documented, .Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents at the time of transfer to Center [dialysis provider]. This information, shall include . Treatment presently being provided to the Designated Resident, including medications and any…
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 before2018-12-03 · 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
Based on policy review, observation, and staff interview, it was determined the facility failed to ensure expired medications were not available for administration to residents. This was true for 1 resident (#4), 2 of 2 medication storage rooms, and 1 of 4 medication carts reviewed for storage and labeling medication. This failure had the potential for harm should residents receive expired medications with decreased efficacy, potency, and safety. Findings include: The U.S. Food and Drug Administration (FDA) website, updated on 9/6/18, and accessed on 12/3/18, included specific recommendations for expired medication. One recommendation documented the medicine expiration date was a critical part of deciding if the product was safe to use and would work as intended. The expiration date reflects the time period during which the product was expected to remain stable, or retain its identity, strength, quality, and purity, when it was properly stored according to its labeled storage conditions. The FDA recommended the safest route to always use medications that are not expired. 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 · D2018-12-03 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to implement the antibiotic stewardship protocol for 1 of 2 residents (Resident #50) who were reviewed for antibiotic use. This deficient practice created the potential for harm should residents receive ineffective or unnecessary treatment for a suspected urinary tract infection. Findings include: Review of the Antibiotic Stewardship protocol, dated 3/2017, documented nurses are to complete a suspected UTI (Urinary Tract Infection) SBAR (Situation, Background, Assessment, Recommendation) document before contacting the physician for orders. Resident #50 was admitted to the facility on [DATE], with multiple diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms. Resident #50's physician orders, dated 11/28/18 at 9:30 AM, documented Start Ceftin (a medication to fight bacteria) 250 milligrams by mouth BID (twice daily) x 10 days if not already started on something. Review of Resident #50's preliminary urine culture report,…
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.
- No harm found · C2018-12-03 · tag F0732 — widespreadPost nurse staffing information every day.
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 posted daily nurse staffing information was complete. This failure created the potential for harm for all residents living in the facility, their family members, and/or visitors if they wanted to know the facility's staffing levels in comparison to the number of residents in the facility to ensure enough staff were present to meet the needs and cares of those residents. Findings include: On 11/26/18 at 3:06 PM, 11/27/18 at 9:06 AM, and 11/28/18 at 10:35 AM, the resident census was observed to be blank on the facility's posted nurse staffing information. On 11/28/18 at 10:35 AM, the Administrator accompanied the surveyor to the area where the nurse staffing information was posted. The Administrator said the resident census information was blank on the posted nurse staffing information. On 11/28/18 at 11:09 AM, the Administrator and the RDCS were present when the Staffing Coordinator (SC) said she had just added the resident census information to the retained nurse staffing information 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.
“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 LIFE CARE CENTERS OF AMERICA — 194 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 | 3 of 5 | 3.4 | -0.4 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 193 homes this chain runs (chain average 3.4★, per CMS)
Showing 40 of 193; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DEVELOPERS INVESTMENT COMPANY II, INC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 12/27/2007 |
| PRESTON, FORREST | Individual | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 03/31/2000 |
| BUTNER, NANCY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 09/16/2018 |
| LARSEN, JARED | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/20/2025 |
| MOETULU, AMANDA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 04/07/2023 |
| FRANCO, MARK | Individual | CORPORATE DIRECTOR | since 09/12/2025 |
| LAY, LISA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 02/09/2018 |
| SMITH, FRANK | Individual | CORPORATE DIRECTOR | since 06/19/2025 |
| CROSS, CINDY | Individual | CORPORATE OFFICER | since 03/31/2000 |
| HENRY, TERRY | Individual | CORPORATE OFFICER | since 03/31/2000 |
| SWANKER, RICHARD | Individual | CORPORATE OFFICER | since 04/01/2011 |
| THURMOND, JOAN | Individual | CORPORATE OFFICER | since 09/22/2000 |
| BRIDGEVIEW MEDICAL INVESTORS, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/31/2000 |
| LIFE CARE CENTERS OF AMERICA, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/20/2025 |
| DOPP, MATTHEW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/24/2026 |
| FLETCHER, TODD | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| PRESTON, AUBREY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
| ZIEGLER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/13/2024 |
CMS files one row per role, so the 28 rows in the source record cover these 18 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.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% 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 $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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 135113. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-09, 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.