Serenity Transitional Care
1134 Cheney Dr West, Twin Falls, ID 83301 · For profit - Limited Liability company · 60 certified beds · (208) 644-7100 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 a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (27) — 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)
- nursing-staff turnover (68%) 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 | 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 held steady at 4 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 | 17.5% | 15.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.0% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 4.8% | 1.2% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.6% | 2.0% | 2.0% | better |
| Long-stay residents with depressive symptoms | 10.3% | 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 | 0.8% | 3.0% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 42.2% | 16.1% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 17.1% | 16.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 97.0% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 3.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.6% | 22.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.6% | 20.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 1.8% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.3% | 86.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.1% | 17.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 5.0% | 12.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.69 | 1.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.60 | 1.66 | 1.80 | 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.
52.9% 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 237 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 77.1% 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 131 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 0.54 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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 | 52.9%CMS range 48.4–59.5 | 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 | 8.6%CMS range 6.1–11.8 | 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 | 77.1% | 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 | 83.2% | 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 | 77.9% | 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 | 95.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.3% | 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 | 5.4%CMS range 3.0–8.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.77 | 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 60 beds and averages 53.5 residents a day — about 89% 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 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 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 3.60 hrs/resident/day on weekends vs 4.03 on weekdays — 11% thinner on weekends. RN hours go from 0.73 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 68% 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 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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2025-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Hoyer lift manual review, interview, and review of the facility's investigation report, it was determined the facility failed to ensure resident safety during Hoyer lift transfers. This was true for 1 of 8 residents (Resident #174) whose record was reviewed for falls. This resulted in harm to Resident #174 when a proper Hoyer lift transfer was not provided. Findings include: Joerns Hoyer User Instruction Manual undated, documented under Warnings, always plan your lifting operations before commencing. Resident #174 was admitted to the facility on [DATE], with multiple diagnoses including dementia and anxiety. On 7/21/24 at 6:26 PM, Resident #174 fell out of a Hoyer lift during transfer resulting in left superior and inferior pubic fractures. On 4/30/25 at 2:15 PM, the DON stated during the Hoyer lift process with Resident #174 on 7/21/24, one of the Hoyer lift legs became stuck under the closet door causing a sling strap webbing loop to slip off one of the Hoyer lift 6 point loop…
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 before2026-06-26 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and document review, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 3 of 3 residents (#73, #77, and #79) observed for dignity. This deficient practice had the potential for residents to experience embarrassment and low feelings of self-worth. Findings include: The facility's Nursing Facility Services and admission Agreement dated 5/14/24, documented on page 24, to protect your right to be treated with dignity and respect include, it is our policy to provide the kind of care to our residents that will maintain and enhance their dignity, individuality, and quality of life. Resident #73 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including multiple fractured ribs and diabetes. On 6/22/26 at 12:07 PM, observed Resident #73 with his hospital name band on his wrist. Resident #73 stated he had recently been at the hospital before coming to this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-06-26 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 4 of 4 residents (#4, #10, #19, and #44) reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when their medications were not administered according to the physician's order. Findings include:a) Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including post-laminectomy syndrome (PLS) (a condition where a patient experiences persistent, new, or recurring back and/or leg pain following spinal surgery) and diabetes.On 6/22/26 at 11:52 AM, Resident #4's medical record documented the following related to bowel care within the last 45 days.- No documented BM from 5/29/26 to 6/7/26- No documented BM from 6/8/26 to 6/11/26- No documented BM from 6/19/26 to 6/23/26Resident #4's medication administration record had no documentation of nursing intervention for BM related issues for 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 · Ecited before2026-06-26 · 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 to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals and follow proper cleaning of medical equipment and handling of linens. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's Hand Hygiene policy dated 12/11/25, documented wash hands with soap and water whenever they are visible dirty, before eating, and after using the restroom. The facility's Glucometer Disinfection policy, revision date 12/11/25, documented the glucometers will be cleaned and disinfected after each used and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. The Quintet AC Blood Glucose Meter Owner's Manual documented: Cleaning and Disinfecting frequency: after each use. 1. Thoroughly wipe the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-26 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews, record review, and policy review it was determined the facility failed to ensure resident's preference for bathing schedule was honored. This was true for 1 of 23 residents (Resident #5) reviewed for choices. This deficient practice had the potential for residents to experience a decreased sense of well-being, lack of self-worth, and frustration when their preference for bathing was not accommodated. Findings include:The facility's Resident Shower policy revision date 12/31/25, documented residents would be provided showers as per request or as per facility schedule protocols and based upon resident safety.Resident #5 was admitted to the facility 7/22/25, with multiple diagnoses including pneumonia and chronic kidney disease.Resident #5's care plan documented that she required partial/moderate assistance with shower/bathing.Resident #5's task form documented she was to receive showers on Tuesdays and Fridays on the day shift.On 6/22/26 at 9:40 AM, Resident #5 stated she usually only gets one shower a week, and would like two showers a week.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-26 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, and staff interview, it was determined the facility failed to ensure as needed (PRN) psychotropic drugs were limited to 14 day use. This was true for 1 of 1 Resident (Resident #4) reviewed for psychotropic medication use. This failure created the potential for residents to be subjected to unnecessary psychotropic medication use. Findings include:The facility's Nursing Facility Services and admission Agreement dated 5/14/24, documented on page 24, to protect your right to be treated with dignity and respect include, we will avoid using physical restraints or psychoactive drugs (chemical restraints) except as required to treat a resident's medical symptoms on a temporary basis.The facility's Use of Psychotropic Medication(s) policy dated 3/3/25, documented psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: PRN orders 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 · D2026-06-26 · 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 a written notice of transfer and bed hold policy was provided to the resident or their representative when residents were transferred to the hospital. This was true for 1 of 2 residents (Resident #12) reviewed for transfers. This deficient practice created the potential for psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfers from the facility. Findings include:The facility's Bed Hold Notice policy dated 3/3/25, documented in the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours or next business day. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record.Resident #12 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-26 · 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 document review, staff interview, and policy review it was determined the facility failed to provide a resident's baseline care plan to the resident or his/her representative for 1 of 1 resident (Resident #73) reviewed for baseline care plan. This failure placed residents and their representatives at risk of not being informed and having input in their care plan. Findings include:The facility's Baseline Care Plan policy, dated 12/24/25, documented 5. A supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative. This will be provided by completion of the comprehensive care plan. 6. The person providing the written summary of the baseline care plan shall: a. Obtain a signature from the resident/representative to verify that the summary was provided.Resident #73 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including multiple fractured ribs and diabetes.Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents maintained a person-centered comprehensive care plan. This was true for 1 of 1 resident (Resident #76) whose record was reviewed for comprehensive care plans. This created the potential for harm when staff were not informed of person-centered care and treatment interventions. Findings include: The facility's Comprehensive Care Plans policy, date reviewed 12/24/25, documented 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident #76 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis (the narrowing of the spaces within the spine), anxiety, and acute respiratory failure. On 6/22/26 at 2:06 PM, Resident #76's care plan had not documented his oxygen interventions. On 6/22/26 at 2:07 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-26 · 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
Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents were given treatment and services to maintain or improve their ability to carry out activities of daily living (ADLs). This was true for 1 of 1 resident (Resident #12) reviewed for decline in ADLs without services. This failure placed residents at risk for decreased range of motion, functional ability, and decreased quality of life. Findings include:The facility's Restorative Nursing Programs dated 12/20/24, documented restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form.On 6/23/26 at 12:33 PM, Resident #12's care plan documented Restorative Nursing Program to provide cues for me to move through tolerated ROM of ALL MAJOR JOINTS. Sci-fit exercise x15 minutes on level 1-2 resistance. x6 to 7 days per week. On 6/23/26 at 11:01 AM, Resident #12's medical record documented restorative services were only provided on 6/15/26, 6/20/26 and 6/21/26, with no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-26 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids 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, interview, policy review, and record review, the facility failed to ensure that parenteral/IV fluids were administered consistently with professional standards of practice. This occurred for 1 of 2 residents (Resident #42) reviewed for IV therapy. Findings include:The facility's Intravenous Therapy policy revision date 12/29/25, documented:12. A doctor's order is obtained before starting IV therapy.13. IV sites are checked every shift or as per facility protocol and PRN for sign and symptoms of infection or inflammation.15. IV documentation is recorded in the nurse's notes and/or Medication Administration Record.Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease and acute respiratory failure.Resident #42's physician's order dated 6/19/26 at 8:45 AM, documented Normal Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush). Use 1 liter intravenously one time only for acute chronic kidney injury for 1 Day infuse over 1…
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 16 citations
- Potential for harm · D2026-06-26 · tag F0732 — isolatedPost nurse staffing information every day.
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 nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:On 6/23/26 at 3:47 PM, during review of the daily staffing sheets, the surveyor observed the facility's name was missing on all of the daily staffing sheets.On 6/23/26 at 4:10 PM, the Chief Clinical Officer stated the facility name should have been on the daily staffing sheets and was not.
- Potential for harm · D2026-06-26 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 residents were monitored appropriately for medication. This was true for 1 of 2 residents (Resident #4) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to the lack of appropriate monitoring. Findings include:The facility's Unnecessary Drugs policy dated 12/30/25, documented under Policy Explanation and Compliance Guidelines, documentation will be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including post-laminectomy syndrome (PLS) (a condition where a patient experiences persistent, new, or recurring back and/or leg pain following spinal surgery) and diabetes.Resident #4's physician's orders for psychotropic medications follow: - DULoxetine HCl Oral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, and staff interviews, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents and were destroyed in a timely manner when they were discontinued to prevent unauthorized access and potential diversion. This was true for 1 of 2 medication storage rooms inspected and 1 of 4 medication carts observed. Findings include: The facility's Storage of Medication policy dated [DATE], documented:- During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.- Schedule II drugs and back-up stock III, IV, and V medications are stored under double-lock and key. The facility's Destruction of Unused Drugs policy dated [DATE], documented all unused, contaminated, or expired prescriptions drugs shall be disposed of in accordance with state laws and regulations. On [DATE] at 6:30 AM, the [NAME] side medication storage room was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-26 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, policy review, and review of the FDA Food Code, the facility failed to ensure food items were dated and labeled. These deficient practices had the potential to impact all residents who received food brought in by family or visitors. This placed residents at risk for potential use of spoiled foods and adverse health outcomes including food-borne illnesses. Findings include:The FDA Food Code Section 3-501.17 stated, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, states 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. Review of the facility's Date Marking for Food Safety policy dated 12/8/25, documented, the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. On 6/23/26 at 11:51 AM, observed in the resident unit refrigerator with RN #2 present: - A container 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 · D2026-06-26 · 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, review of the Food and Drug Administration (FDA) Food Code, and staff interview it was determined the facility failed to ensure trash was contained in the facility's dumpsters with closed lids for two of two outside trash dumpsters and the kitchen garbage cans were properly closed with tight fitting lids.This failed practice created the potential for insect and pest infestation. Findings include:The FDA Food Code Section 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 continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the food establishment.The FDA Food Code Section 5-501.115 Maintaining Refuse Areas and Enclosures - Areas to be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as equipment that is nonfunctional or no longer used; and (B) Litter.On 6/24/26 at 6:55 AM, observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-26 · 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 staff interview, record review, and policy review, it was determined the facility failed to ensure accurate and complete clinical records were maintained for each resident. This was true for 3 of 3 Residents (#76, #77, and #79) reviewed for oxygen administration orders. This deficient practice created the potential for harm should inappropriate care and/or treatment be provided based on inaccurate information in the residents' clinical record. Findings include: The facility's Oxygen Administration policy, dated 12/30/25, documented .Oxygen is administered under orders of a physician.The facility's Documentation in Medical Record policy, dated 12/31/25, documented 4. Principles of documentation include, but are not limited to: b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. Resident #76 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis (the narrowing of the spaces within…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-05-01 · 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 review of the FDA Food Code, observation, and interview, 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 FDA Food Code revised 2022, documents 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 5ºC (41ºF) or less for a maximum of 7 days. On 4/28/25 at 9:45 AM, observed the following in the walk-in refrigerator with the CDM present: - Ham with use by date of 4/25/25. - Roll of sausage with a use by date of 4/19/25. - Open bag of lettuce not properly sealed. - Sliced…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-01 · 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 observations and interviews, it was determined that the facility failed to treat each resident with respect and dignity. This was true for a) 2 of 5 residents (#22 and #45) who had uncovered urinary drainage bags and b) 1 of 19 Residents (Resident #50) who was addressed by a room number not her name. This deficient practice had the potential for residents to experience embarrassment, and low feelings of self-worth. Findings include: a) The following was observed for uncovered urinary drainage bags. Resident #22 was admitted on [DATE], with multiple diagnoses including pneumonia and urinary tract infection. On 4/29/25 at 9:34 AM, Resident #22's urinary drainage bag was uncovered and visible from the open doorway of his room. On 5/1/25 at 8:26 AM, the DON stated the urinary drainage bag should have been covered and was not. Resident #45 was admitted on [DATE], and readmitted on [DATE], with multiple diagnoses to include sepsis (a life-threatening condition that occurs when the body's response to an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-01 · 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 policy review, observation, record review, and interviews, it was determined the facility failed to ensure 1 of 1 resident (Resident #28), was assessed and evaluated for cognitive and physical ability to self-administer medications. This failure created the potential for adverse outcomes if Resident #28 self-administered medication inappropriately. Findings include: The facility's policy, Resident Self-Administration of Medication dated 12/16/24, documented a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, COPD (a progressive lung disease making it hard to breath), and immunodeficiency (when a body's immune system is more susceptible to infections). On 4/29/25 at 10:38 AM, observed an open, uncapped bottle of Icy Hot (a topical pain relief medication) on Resident #28's bedside table.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-01 · 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, record review, and interview, it was determined the facility failed to ensure a baseline care plan was developed and implemented to include resident sleep apnea equipment needs. This was true for 1 of 19 residents (Resident #164) reviewed for baseline care plans. This failure placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plans. Findings include: Resident #164 was admitted to the facility on [DATE], with multiple diagnoses including obstructive sleep apnea and bipolar disorder. On 4/29/25 at 8:29 AM, observed a continuous positive airway pressure (CPAP) device in Resident #164's room on his bedside table. On 4/29/25 at 8:30 AM, Resident #164 stated nursing staff help him put his CPAP on each night. Resident #164's baseline (initial) care plan dated 4/24/25, had not documented he uses a CPAP nightly. Resident #164's medical record had not documented a physician order to use his CPAP nightly. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-01 · 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 interviews, 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 4 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 4/28/25 at 1:50 PM, during [NAME] hall medication cart audit, observed the Narcotic Accountability Record, dated 4/8/25 to 4/28/25, with 11 licensed nurse signatures not documented. On 4/28/25 at 1:53 PM, LPN #3 stated two nurses should have signed the Narcotic Accountability Record when they accepted the medication cart or released the medication cart. On 4/30/25 at 7:55 AM, during East hall medication cart audit, observed the Narcotic Accountability Record, dated 4/15/25 to 4/30/25, with one licensed nurse signature not documented. On 4/30/25 at 7:57 AM, the ADON stated two nurses should have signed the Narcotic Accountability Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-01 · 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 observations and staff interviews, it was determined the facility failed to ensure medications and lab draw supplies were properly stored in a locked compartment, and biologicals were labeled when opened. These deficient practices created the potential for undetected access to medications by unauthorized personnel and use of expired biologicals. Findings include: 1. The following was observed for unlocked medication cart. On [DATE] at 9:52 AM, observed the lab draw cart located on the East hall was unlocked. On [DATE] at 9:58 AM, LPN #1 stated the lab draw cart contained needles and draw tubes and it should have been locked but was not. On [DATE] at 11:38 AM, observed the [NAME] hall nursing medication cart was left unlocked without a nurse present. On [DATE] at 11:42 AM, RN #1 stated the medication cart should not have been left unlocked. On [DATE] at 1:42 PM, observed [NAME] hall medication cart had been left unlocked and unattended. On [DATE] at 1:44 PM, RN #1 stated the medication cart should have…
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 · E2024-07-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, review of Resident Council minutes, review of facility grievances, and resident and staff interview, it was determined the facility failed to ensure resident meals were served following the facility's designated meal schedule. This was true for 4 of 5 residents (#20, #29, #30, and #111) interviewed for concerns with food. This failure had the potential to impact residents in the facility who were at risk for nutritional compromise and had the potential to harm residents if they experienced hunger, low blood sugar levels, or did not receive adequate nutritional support for healing or weight loss. Findings include: The facility's policy titled, Frequency of Meals, dated 8/22/23, documented, The facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals.l. The facility has scheduled three regular mealtimes, comparable to normal mealtimes in the community, per day and has scheduled three regular snack times. 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 · D2024-07-11 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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, staff interview, it was determined the facility failed to ensure a resident's MDS assessment accurately reflected their status at the time of the assessment (Resident #30) and a resident's comprehensive MDS assessment was completed prior to the required completion date (Resident #211). This was true for 2 of 2 residents whose MDS assessments were reviewed. This failure created the potential for harm if care decisions were based upon inaccurate or lack of information. Findings include: The facility's policy titled, Conducting an Accurate Resident Assessment, revised 12/22/23, stated, The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas .each individual assessor is responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status . 1. Resident #30 was admitted 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 · D2024-07-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review. policy review, and staff interview, the facility failed to ensure residents received meal assistance or were provided meal recommendations. This was true for 2 of 5 residents (#29 and #39) reviewed for nutritional status. This failure created the potential for harm if residents became dehydrated and they experienced unplanned weight loss. Findings include: The facility's policy titled, Weight Monitoring, revised 1/2/24, documented interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. 1. Resident #29 was admitted on [DATE], with multiple diagnoses including dementia, fractures and other multiple trauma, hypothyroidism, and history of skin cancer. A significant change MDS assessment, dated 6/16/24, documented Resident #29 was severely cognitively impaired. Resident #29's 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 · Dcited before2024-07-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review, and staff interview, the facility failed to ensure enhanced barrier precautions were followed. This was true for 1 of 1 resident (Resident #8) reviewed. This failure increased the risk of spreading multidrug resistant organisms. Findings include: The facility's policy titled, Enhanced Barrier Precautions, dated 5/6/24 states, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .'Enhanced barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .High-contact resident care activities include .changing briefs or assisting with toileting . Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including stroke and right lower leg open wound. Resident #48's Clinical…
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 TANABELL HEALTH SERVICES — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.0 | ≈ chain avg |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 2.2 | +0.8 vs chain |
| Quality measures | 5 of 5 | 4.2 | +0.8 vs chain |
The other 4 homes this chain runs (chain average 3.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SERENITY REHABILITATION AND CARE CENTER, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 06/01/2023 |
| BELL, JAMIE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 09/01/2018 |
| BELL PROPERTY MANAGEMENT, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 06/01/2023 |
| BELL, TROY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2018 |
| TANABELL HEALTH SERVICES, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2018 |
| CAMPIONE, BUFFY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2017 |
| DOPP, MATTHEW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2018 |
CMS files one row per role, so the 19 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
This home reported $852K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in ID
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Idaho Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 135143. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-26, 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 →
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