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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

1.32

Registered nurse staffing

LPN hours / resident day

0.89

Licensed practical nurse staffing

Aide hours / resident day

3.30

Nurse aide staffing

Weekend hours

4.85

Weekend nurse staffing

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

0% 2 facilities 2009-10-22
Adamson, James

Operational/Managerial Control · Individual

0% 2 facilities 2009-10-22
Bv Operations LLC.

5% Or Greater Direct Ownership Interest · Organization

0% 2 facilities 2009-10-22
Bv Operations LLC.

General Partnership Interest · Organization

0% 2 facilities 2009-10-22
Haynes, Anna

Operational/Managerial Control · Individual

0% 3 facilities 2020-01-01
Haynes, Anna

Corporate Officer · Individual

0% 3 facilities 2019-01-01
Mvh SNF Holding LLC

5% Or Greater Direct Ownership Interest · Organization

0% 1 facilities 2009-10-22
Mvh SNF Holding LLC

General Partnership Interest · Organization

0% 1 facilities 2009-10-29
Promontory Healthcare Management LLC

Operational/Managerial Control · Organization

0% 3 facilities 2020-01-01
Tcu Management Company LLC

5% Or Greater Direct Ownership Interest · Organization

0% 1 facilities 2009-10-22
Tcu Management Company LLC.

General Partnership Interest · Organization

0% 1 facilities 2009-10-22
Tcu Management Company LLC.

Operational/Managerial Control · Organization

0% 1 facilities 2009-10-22

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

Overall
1 / 5
Health
1 / 5
Staffing
4 / 5
Fines
$43,599
#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

Overall
3 / 5
Health
2 / 5
Staffing
3 / 5
Fines
$13,247
#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

Overall
3 / 5
Health
3 / 5
Staffing
4 / 5
Fines
$8,018

Jump out

Supporting pages