Cycle 1
Health 2026-01-28 · Fire 2025-01-23
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Rexburg, ID
Madison Carriage Cove Short Stay Rehabilitation
4-star overall rating with 3-star inspections with $11,297 in total fines with 8 recent health deficiencies
410 West 1st North, Rexburg, ID
(208) 359-7676
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
35
Certified beds
Average residents
26
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2015-04-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.38
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
2.44
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 3.47 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.27
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,049
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.53
Composite VBP score used to determine payment impact.
Payment multiplier
1.0157
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.10
Baseline 16.69% · Performance 17.21% · Measure score 9.10 · Achievement 9.10 · Improvement 0
Healthcare-associated infections
7.61
Baseline 6.09% · Performance 5.56% · Measure score 7.61 · Achievement 7.61 · Improvement 4.35
Total nurse turnover
5.25
Baseline 67.21% · Performance 42.86% · Measure score 5.25 · Achievement 5.09 · Improvement 5.25
Adjusted total nurse staffing
2.25
Baseline 5.11 hours · Performance 3.72 hours · Measure score 2.25 · Achievement 2.25 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.53% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 185 · Observed rate 3.78% · Lower 95% interval 5.74% |
| Discharge to community | 64.1% |
50.57%
13.5 pts better
|
Better than the National Rate · Eligible stays 181 · Observed rate 70.72% · Lower 95% interval 58.11% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.96% |
95.27%
0.7 pts better
|
Numerator 95 · Denominator 99 |
| Falls with major injury | 2.02% |
0.77%
1.2 pts worse
|
Numerator 2 · Denominator 99 |
| Discharge self-care score | 64% |
53.69%
10.3 pts better
|
Numerator 48 · Denominator 75 |
| Discharge mobility score | 74.67% |
50.94%
23.7 pts better
|
Numerator 56 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 2.02% |
2.29%
0.3 pts better
|
Numerator 2 · Denominator 99 · Adjusted rate 3.03% |
| Healthcare-associated infections requiring hospitalization | 5.56% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 1.77% · Lower 95% interval 2.72% |
| Staff COVID-19 vaccination coverage | 2.6% |
8.2%
5.6 pts worse
|
Numerator 2 · Denominator 77 |
| Staff flu vaccination coverage | 15.29% |
42%
26.7 pts worse
|
Numerator 13 · Denominator 85 |
| Discharge function score | 68% |
56.45%
11.5 pts better
|
Numerator 51 · Denominator 75 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 63 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 32.65% |
25.2%
7.4 pts better
|
Numerator 16 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.8%
3.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
2.7%
0.8 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 35.3% |
13.6%
21.7 pts worse
|
11.4%
23.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.3% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.4%
5.4 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.0% |
16.2%
2.2 pts better
|
19.6%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
20.5%
11.4 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.3% |
17.9%
0.6 pts better
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.8% |
16.7%
4.1 pts worse
|
14.9%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.5%
0.1 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.7% |
1.9%
5.8 pts worse
|
1.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.5% |
22.6%
8.1 pts better
|
19.8%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.5% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
3.4%
1.6 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
90.2%
4 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.7% · Q2 96.5% · Q3 96.5% · Q4 94.0% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
11.6%
About the same
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 10.8% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.1% |
86.5%
2.6 pts better
|
79.7%
9.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.2% |
17.5%
5.3 pts better
|
23.9%
11.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 10.8% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-01-23 · Fire 2024-05-03
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2024-05-03 · Fire 2022-10-07
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-28
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 2026-02-16
E · Potential for more than minimal harm
2026-01-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-16
D · Potential for more than minimal harm
2026-01-28
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2026-02-16
G · Actual harm
2025-01-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-12
F · Potential for more than minimal harm
2025-01-23
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 2025-02-12
D · Potential for more than minimal harm
2025-01-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-23
F578 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-23
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-23
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-23
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 2025-02-12
D · Potential for more than minimal harm
2025-01-23
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-23
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-02-12
D · Potential for more than minimal harm
2024-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-05-03
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-05-14
D · Potential for more than minimal harm
2023-03-27
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2023-04-19
Penalties and ownership
What sits behind the stars
$11,297
2025-01-23
Fine
Fine · fine $11,297
Fine
Ownership
Bell, Jamie
Corporate Officer · Individual
Bell, Troy
Corporate Director · Individual
Djt Rehab Property, LLC
5% Or Greater Direct Ownership Interest · Organization
Djt Rehab Property, LLC
General Partnership Interest · Organization
Djt Rehab Property, LLC
Operational/Managerial Control · Organization
Madison Co Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Madison Co Memorial Hospital
General Partnership Interest · Organization
Madison Co Memorial Hospital
Operational/Managerial Control · Organization
Tanabell Health Services, Inc.
Operational/Managerial Control · Organization
Thueson, David
5% Or Greater Direct Ownership Interest · Individual
Thueson, David
General Partnership Interest · Individual
Thueson, David
Operational/Managerial Control · Individual
Thueson, Jenelle
5% Or Greater Direct Ownership Interest · Individual
Thueson, Jenelle
General Partnership Interest · Individual
Thueson, Jenelle
Operational/Managerial Control · Individual
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#3
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