Cycle 1
Health 2024-10-03 · Fire 2024-10-03
2 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Montpelier, ID
Bear Lake Memorial Skilled Nursing Facility
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
164 South Fifth Street, Montpelier, ID
(208) 847-4441
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
36
Certified beds
Average residents
28
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1977-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.03
Registered nurse staffing
LPN hours / resident day
0.72
Licensed practical nurse staffing
Aide hours / resident day
2.46
Nurse aide staffing
Weekend hours
3.67
Weekend nurse staffing
RN turnover
20%
Annual RN turnover
Total nurse turnover
38%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0 |
1.1
1.1 pts better
|
1.9
1.9 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
96.8%
About the same
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.2%
3.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
2.7%
0.5 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
13.6%
11.4 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.3% |
5.4%
2.1 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
16.2%
5.5 pts worse
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 29.7% |
20.5%
9.2 pts worse
|
16.7%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 2.2% |
0.1%
2.1 pts worse
|
0.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.2% |
17.9%
0.7 pts better
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
16.7%
3.1 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.5%
0.5 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 5.4% |
1.9%
3.5 pts worse
|
1.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
22.6%
6.6 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.4%
3.4 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.1% |
90.2%
34.1 pts worse
|
81.7%
25.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-20 · Fire 2019-06-20
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2018-01-26 · Fire 2018-01-26
16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-03
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-04-24
F · Potential for more than minimal harm
2024-10-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-24
F · Potential for more than minimal harm
2024-10-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-24
F · Potential for more than minimal harm
2024-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-10-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-10-03
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-10-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-10-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-24
F · Potential for more than minimal harm
2019-06-20
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2018-12-05
E · Potential for more than minimal harm
2019-06-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2018-12-05
E · Potential for more than minimal harm
2019-06-20
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2018-12-05
D · Potential for more than minimal harm
2019-06-20
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2018-12-05
D · Potential for more than minimal harm
2019-06-20
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2018-12-05
D · Potential for more than minimal harm
2019-06-20
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2018-12-05
D · Potential for more than minimal harm
2019-06-20
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2018-12-05
D · Potential for more than minimal harm
2019-06-20
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2018-12-05
D · Potential for more than minimal harm
2019-06-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-12-05
F · Potential for more than minimal harm
2018-01-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2017-08-16
E · Potential for more than minimal harm
2018-01-26
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2017-08-16
D · Potential for more than minimal harm
2018-01-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2017-08-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-03
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-10-03
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-10-23
G · Actual harm
2019-06-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-07-31
E · Potential for more than minimal harm
2019-06-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-07-31
E · Potential for more than minimal harm
2019-06-20
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-06-20
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-06-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-06-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-07-31
D · Potential for more than minimal harm
2019-06-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-07-31
G · Actual harm
2018-01-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2018-03-21
G · Actual harm
2018-01-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-03-21
F · Potential for more than minimal harm
2018-01-26
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2018-03-21
F · Potential for more than minimal harm
2018-01-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2018-03-21
F · Potential for more than minimal harm
2018-01-26
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2018-03-21
E · Potential for more than minimal harm
2018-01-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-03-21
E · Potential for more than minimal harm
2018-01-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2018-03-21
D · Potential for more than minimal harm
2018-01-26
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2018-03-21
D · Potential for more than minimal harm
2018-01-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-03-21
D · Potential for more than minimal harm
2018-01-26
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2018-03-21
D · Potential for more than minimal harm
2018-01-26
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2018-03-21
D · Potential for more than minimal harm
2018-01-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-03-21
D · Potential for more than minimal harm
2018-01-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2018-03-21
D · Potential for more than minimal harm
2018-01-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-03-21
D · Potential for more than minimal harm
2018-01-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2018-03-21
D · Potential for more than minimal harm
2018-01-26
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2018-03-21
Penalties and ownership
What sits behind the stars
Ownership
Beck, Cheryl
5% Or Greater Direct Ownership Interest · Individual
Culver, Craig
5% Or Greater Direct Ownership Interest · Individual
Griffin, Gary
5% Or Greater Direct Ownership Interest · Individual
Rasmussen, Vaughn
5% Or Greater Direct Ownership Interest · Individual
Transtrum, Emily
5% Or Greater Direct Ownership Interest · Individual
Bear Lake County Memorial Hospital
Operational/Managerial Control · Organization
Crane, Leslie
Corporate Officer · Individual
Harris, Mark
Corporate Director · Individual
Hunt, Arel
Operational/Managerial Control · Individual
Hunt, Arel
Corporate Director · Individual
Hunt, Arel
Corporate Officer · Individual
Jacobson, Trevor
Operational/Managerial Control · Individual
Jacobson, Trevor
Corporate Director · Individual
Passey, Cordell
Corporate Director · Individual
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#2
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5-star overall rating with 5-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Maple Springs Senior Living
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