Cycle 1
Health 2025-02-12 · Fire 2025-02-12
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Ammon, ID
Promontory Point Rehabilitation
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3909 South 25th East, Ammon, ID
(208) 528-4000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
50
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Promontory Healthcare
Operator or chain grouping
Approved since
2010-10-14
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
3 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.32
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
3.30
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
5.51
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
2.21
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.85
Weekend nurse staffing · state 3.47 · national 3.43
Weekend RN hours
0.99
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.54
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.36
CMS adjusted RN staffing hours
Adjusted total hours
5.69
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
223
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
77.29
Composite VBP score used to determine payment impact.
Payment multiplier
1.0252
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.39
Baseline 18.22% · Performance 18.01% · Measure score 7.39 · Achievement 7.39 · Improvement 1.30
Healthcare-associated infections
10
Baseline 5.36% · Performance 4.89% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
5.80
Performance 4.73 hours · Measure score 5.80 · Achievement 5.80 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.89% |
10.72%
2.8 pts better
|
No Different than the National Rate · Eligible stays 393 · Observed rate 4.07% · Lower 95% interval 5.87% |
| Discharge to community | 65.02% |
50.57%
14.4 pts better
|
Better than the National Rate · Eligible stays 399 · Observed rate 72.18% · Lower 95% interval 62.37% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.67% |
95.27%
3.4 pts better
|
Numerator 222 · Denominator 225 |
| Falls with major injury | 1.33% |
0.77%
0.6 pts worse
|
Numerator 3 · Denominator 225 |
| Discharge self-care score | 63.74% |
53.69%
10.1 pts better
|
Numerator 116 · Denominator 182 |
| Discharge mobility score | 86.26% |
50.94%
35.3 pts better
|
Numerator 157 · Denominator 182 |
| Pressure ulcers or injuries, new or worsened | 1.78% |
2.29%
0.5 pts better
|
Numerator 4 · Denominator 225 · Adjusted rate 2.41% |
| Healthcare-associated infections requiring hospitalization | 4.89% |
7.12%
2.2 pts better
|
No Different than the National Rate · Eligible stays 224 · Observed rate 1.79% · Lower 95% interval 2.63% |
| Staff COVID-19 vaccination coverage | 10.47% |
8.2%
2.3 pts better
|
Numerator 9 · Denominator 86 |
| Staff flu vaccination coverage | 75.73% |
42%
33.7 pts better
|
Numerator 78 · Denominator 103 |
| Discharge function score | 74.73% |
56.45%
18.3 pts better
|
Numerator 136 · Denominator 182 |
| Transfer of health information to provider | 97.78% |
95.95%
1.8 pts better
|
Numerator 44 · Denominator 45 |
| Transfer of health information to patient | 98.32% |
96.28%
2 pts better
|
Numerator 176 · Denominator 179 |
| Resident COVID-19 vaccinations up to date | 25.41% |
25.2%
0.2 pts better
|
Numerator 31 · Denominator 122 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
90.2%
5.3 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 98.5% · Q3 95.4% · Q4 94.3% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
11.6%
1.6 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 12.7% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 0.6% · Q4 0.5% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
86.5%
9 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.3% |
17.5%
1.2 pts better
|
23.9%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 13.7% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-08 · Fire 2024-03-08
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2019-03-15 · Fire 2019-03-15
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-12
K791 · Miscellaneous Deficiencies
Fire Safety
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Corrected 2024-09-05
D · Potential for more than minimal harm
2025-02-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-09-05
D · Potential for more than minimal harm
2025-02-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-03-08
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-09-06
F · Potential for more than minimal harm
2024-03-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-06
F · Potential for more than minimal harm
2024-03-08
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2023-09-06
F · Potential for more than minimal harm
2024-03-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-06
F · Potential for more than minimal harm
2024-03-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-06
E · Potential for more than minimal harm
2024-03-08
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-09-06
E · Potential for more than minimal harm
2024-03-08
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-09-06
D · Potential for more than minimal harm
2024-03-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-06
F · Potential for more than minimal harm
2019-03-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2018-04-11
F · Potential for more than minimal harm
2019-03-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-04-06
E · Potential for more than minimal harm
2019-03-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-04-23
D · Potential for more than minimal harm
2019-03-15
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2018-05-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-12
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-12
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 2025-03-06
E · Potential for more than minimal harm
2024-03-08
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 2024-04-11
E · Potential for more than minimal harm
2024-03-08
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 2024-04-11
E · Potential for more than minimal harm
2024-03-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-08
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-08
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 2024-04-11
D · Potential for more than minimal harm
2024-03-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-08
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 2024-04-11
D · Potential for more than minimal harm
2024-03-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-11
G · Actual harm
2019-03-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-04-15
F · Potential for more than minimal harm
2019-03-15
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 2019-04-15
E · Potential for more than minimal harm
2019-03-15
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 2019-04-15
E · Potential for more than minimal harm
2019-03-15
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 2019-04-15
E · Potential for more than minimal harm
2019-03-15
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 2019-04-15
E · Potential for more than minimal harm
2019-03-15
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 2019-04-15
D · Potential for more than minimal harm
2019-03-15
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-03-15
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 2019-04-15
D · Potential for more than minimal harm
2019-03-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-03-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-03-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-03-15
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-03-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-03-15
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-15
C · Minimal harm
2019-03-15
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2019-04-15
C · Minimal harm
2019-03-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-04-15
Penalties and ownership
What sits behind the stars
Ownership
Adamson, James
5% Or Greater Direct Ownership Interest · Individual
Adamson, James
Operational/Managerial Control · Individual
Bv Operations LLC.
5% Or Greater Direct Ownership Interest · Organization
Bv Operations LLC.
General Partnership Interest · Organization
Haynes, Anna
Operational/Managerial Control · Individual
Haynes, Anna
Corporate Officer · Individual
Mvh SNF Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Mvh SNF Holding LLC
General Partnership Interest · Organization
Promontory Healthcare Management LLC
Operational/Managerial Control · Organization
Tcu Management Company LLC
5% Or Greater Direct Ownership Interest · Organization
Tcu Management Company LLC.
General Partnership Interest · Organization
Tcu Management Company LLC.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Teton Healthcare Of Cascadia
Idaho Falls, ID
1-star overall rating with 1-star inspections with Special Focus status with $43,599 in total fines with 23 recent health deficiencies
#2
Life Care Center Of Idaho Falls
Idaho Falls, ID
3-star overall rating with 2-star inspections with $13,247 in total fines with 17 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Eagle Rock Health And Rehabilitation Of Cascadia
Idaho Falls, ID
3-star overall rating with 3-star inspections with $8,018 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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