Boise, ID

Timber Springs Transitional Care

1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $135,944 in total fines with 19 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

1140 North Allumbaugh Street, Boise, ID

(208) 501-7200

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Eduro Healthcare

Operator or chain grouping

Approved since

1986-05-16

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

36 facilities

Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars

Changed ownership

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

0.51

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

1.14

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

1.65

Nurse aide staffing · state 2.47 · national 2.35

Total nurse hours

3.30

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

1.65

RN + LPN hours · state 1.60 · national 1.54

Weekend hours

2.72

Weekend nurse staffing · state 3.47 · national 3.43

Weekend RN hours

0.41

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.17

Reported PT staffing · state 0.11 · national 0.07

Adjusted RN hours

0.53

CMS adjusted RN staffing hours

Adjusted total hours

3.40

CMS adjusted total nurse staffing hours

Case-mix index

1.33

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

3,230

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

45.35

Composite VBP score used to determine payment impact.

Payment multiplier

0.9986

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

9.12

Baseline 19.00% · Performance 17.20% · Measure score 9.12 · Achievement 9.12 · Improvement 8.61

Healthcare-associated infections

4.96

Baseline 6.30% · Performance 6.35% · Measure score 4.96 · Achievement 4.96 · Improvement 0

Total nurse turnover

2.80

Baseline 79.21% · Performance 61.25% · Measure score 2.80 · Achievement 0.59 · Improvement 2.80

Adjusted total nurse staffing

1.26

Baseline 3.17 hours · Performance 3.44 hours · Measure score 1.26 · Achievement 1.26 · Improvement 0.52

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.63%	10.72% 0.1 pts better	No Different than the National Rate · Eligible stays 67 · Observed rate 8.96% · Lower 95% interval 7.38%
Discharge to community	44.47%	50.57% 6.1 pts worse	No Different than the National Rate · Eligible stays 51 · Observed rate 37.25% · Lower 95% interval 33.14%
Medicare spending per beneficiary	0.89	1.02 0.1 pts better
Drug regimen review with follow-up	98.18%	95.27% 2.9 pts better	Numerator 54 · Denominator 55
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 55
Discharge self-care score	52.17%	53.69% 1.5 pts worse	Numerator 24 · Denominator 46
Discharge mobility score	45.65%	50.94% 5.3 pts worse	Numerator 21 · Denominator 46
Pressure ulcers or injuries, new or worsened	1.85%	2.29% 0.4 pts better	Numerator 1 · Denominator 54 · Adjusted rate 2.05%
Healthcare-associated infections requiring hospitalization	6.35%	7.12% 0.8 pts better	No Different than the National Rate · Eligible stays 36 · Observed rate 2.78% · Lower 95% interval 3.3%
Staff COVID-19 vaccination coverage	0.69%	8.2% 7.5 pts worse	Numerator 1 · Denominator 145
Staff flu vaccination coverage	19.39%	42% 22.6 pts worse	Numerator 32 · Denominator 165
Discharge function score	56.52%	56.45% 0.1 pts better	Numerator 26 · Denominator 46
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	36.84%	25.2% 11.6 pts better	Numerator 14 · Denominator 38

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.2	1.1 0.1 pts worse	1.9 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.3	1.6 0.3 pts better	1.8 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.2%	96.8% 1.6 pts worse	93.4% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 93.7% · Q3 97.4% · Q4 94.8% · 4Q avg 95.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	79.5%	96.2% 16.7 pts worse	95.5% 16 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 79.5%
Percentage of long-stay residents experiencing one or more falls with major injury	2.1%	2.7% 0.6 pts better	3.3% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.5% · Q3 1.3% · Q4 1.3% · 4Q avg 2.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	9.4%	13.6% 4.2 pts better	11.4% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 6.7% · Q3 12.0% · Q4 9.6% · 4Q avg 9.4%
Percentage of long-stay residents who lose too much weight	5.1%	5.4% 0.3 pts better	5.4% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.7% · Q3 7.9% · Q4 6.7% · 4Q avg 5.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.5%	16.2% 1.7 pts better	19.6% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 11.7% · Q3 13.0% · Q4 20.8% · 4Q avg 14.5%
Percentage of long-stay residents who received an antipsychotic medication	21.2%	20.5% 0.7 pts worse	16.7% 4.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 23.6% · Q3 22.2% · Q4 21.9% · 4Q avg 21.2% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	35.9%	17.9% 18 pts worse	16.3% 19.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 59.5% · Q3 23.0% · Q4 32.1% · 4Q avg 35.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	27.8%	16.7% 11.1 pts worse	14.9% 12.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 38.7% · Q3 23.6% · Q4 20.3% · 4Q avg 27.8% · 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 · Q1 3.7% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.7%	1.9% 1.2 pts better	1.7% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.0%	22.6% 4.4 pts worse	19.8% 7.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 42.6% · Q3 20.4% · Q4 18.7% · 4Q avg 27.0%
Percentage of long-stay residents with pressure ulcers	4.6%	3.4% 1.2 pts worse	5.1% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 9.0% · Q3 2.1% · Q4 3.6% · 4Q avg 4.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.9%	90.2% 0.7 pts better	81.7% 9.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 89.0% · Q2 90.1% · Q3 93.1% · Q4 91.9% · 4Q avg 90.9%
Percentage of short-stay residents who had an outpatient emergency department visit	5.4%	11.6% 6.2 pts better	12.0% 6.6 pts better	Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.3% · Expected 10.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	4.1%	1.5% 2.6 pts worse	1.6% 2.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.9% · Q3 7.3% · Q4 3.1% · 4Q avg 4.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	82.9%	86.5% 3.6 pts worse	79.7% 3.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 82.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	9.1%	17.5% 8.4 pts better	23.9% 14.8 pts better	Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 7.9% · Expected 20.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-12 · Fire 2024-06-28

19 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2024-06-28 · Fire 2023-05-08

17 health deficiencies

Top issue: Resident Rights (6 deficiencies)

6 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Cycle 3 Health 2023-05-08 · Fire 2019-03-29

31 health deficiencies

Top issue: Nutrition and Dietary (7 deficiencies)

15 fire-safety deficiencies

Top issue: Emergency Preparedness (5 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-06-28

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-03-07

D · Potential for more than minimal harm 2024-06-28

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-03-08

F · Potential for more than minimal harm 2023-05-08

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2023-02-24

F · Potential for more than minimal harm 2023-05-08

K522 · Services Deficiencies

Fire Safety

Have an externally vented heating system.

Corrected 2023-02-24

E · Potential for more than minimal harm 2023-05-08

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2023-02-24

E · Potential for more than minimal harm 2023-05-08

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2023-02-24

D · Potential for more than minimal harm 2023-05-08

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2023-02-24

D · Potential for more than minimal harm 2023-05-08

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-02-24

F · Potential for more than minimal harm 2019-03-29

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2019-01-03

F · Potential for more than minimal harm 2019-03-29

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2019-01-03

F · Potential for more than minimal harm 2019-03-29

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2019-01-03

F · Potential for more than minimal harm 2019-03-29

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2019-01-03

F · Potential for more than minimal harm 2019-03-29

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2019-01-03

F · Potential for more than minimal harm 2019-03-29

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2019-01-03

F · Potential for more than minimal harm 2019-03-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-01-03

F · Potential for more than minimal harm 2019-03-29

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2019-01-03

F · Potential for more than minimal harm 2019-03-29

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2019-01-03

D · Potential for more than minimal harm 2019-03-29

E24 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for volunteers.

Corrected 2019-01-03

D · Potential for more than minimal harm 2019-03-29

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2019-01-03

D · Potential for more than minimal harm 2019-03-29

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2019-01-03

D · Potential for more than minimal harm 2019-03-29

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2019-01-03

D · Potential for more than minimal harm 2019-03-29

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-01-03

D · Potential for more than minimal harm 2019-03-29

K930 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper storage of liquid oxygen.

Corrected 2019-01-03

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-20

F553 · Resident Rights Deficiencies

Health

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Corrected 2025-12-12

D · Potential for more than minimal harm 2025-11-20

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-12-12

D · Potential for more than minimal harm 2025-11-20

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-12-12

D · Potential for more than minimal harm 2025-11-20

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-12-12

G · Actual harm 2025-09-12

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 2025-12-12

D · Potential for more than minimal harm 2025-09-12

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-12

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-12

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-12

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-12

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 2025-10-17

D · Potential for more than minimal harm 2025-09-12

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-12

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 2025-10-17

D · Potential for more than minimal harm 2025-09-12

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-12

F790 · Quality of Life and Care Deficiencies

Health

Provide routine and 24-hour emergency dental care for each resident.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-12

F807 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-12

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 2025-10-17

D · Potential for more than minimal harm 2025-09-12

F839 · Administration Deficiencies

Health

Employ staff that are licensed, certified, or registered in accordance with state laws.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-12-12

G · Actual harm 2024-06-28

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 2023-10-06

F · Potential for more than minimal harm 2024-06-28

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 2024-08-02

E · Potential for more than minimal harm 2024-06-28

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 2024-08-02

E · Potential for more than minimal harm 2024-06-28

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-08-02

E · Potential for more than minimal harm 2024-06-28

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 2024-08-02

E · Potential for more than minimal harm 2024-06-28

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 2024-08-02

D · Potential for more than minimal harm 2024-06-28

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-08-02

D · Potential for more than minimal harm 2024-06-28

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-08-02

D · Potential for more than minimal harm 2024-06-28

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-08-02

D · Potential for more than minimal harm 2024-06-28

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 2024-08-02

D · Potential for more than minimal harm 2024-06-28

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-08-02

D · Potential for more than minimal harm 2024-06-28

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-08-02

D · Potential for more than minimal harm 2024-06-28

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 2024-08-02

D · Potential for more than minimal harm 2024-06-28

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 2024-08-02

D · Potential for more than minimal harm 2024-06-28

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 2024-08-02

D · Potential for more than minimal harm 2024-06-28

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2024-08-02

C · Minimal harm 2024-06-28

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-08-02

J · Immediate jeopardy 2023-05-08

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 2023-06-09

G · Actual harm 2023-05-08

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 2023-06-09

G · Actual harm 2023-05-08

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-06-09

F · Potential for more than minimal harm 2023-05-08

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2023-06-09

F · Potential for more than minimal harm 2023-05-08

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2023-06-09

F · Potential for more than minimal harm 2023-05-08

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2023-06-09

E · Potential for more than minimal harm 2023-05-08

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2023-06-09

E · Potential for more than minimal harm 2023-05-08

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2023-06-09

E · Potential for more than minimal harm 2023-05-08

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 2023-06-09

E · Potential for more than minimal harm 2023-05-08

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-06-09

E · Potential for more than minimal harm 2023-05-08

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-08-28

E · Potential for more than minimal harm 2023-05-08

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 2023-06-09

E · Potential for more than minimal harm 2023-05-08

F758 · Pharmacy Service Deficiencies

Health

Corrected 2023-08-28

E · Potential for more than minimal harm 2023-05-08

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-06-09

E · Potential for more than minimal harm 2023-05-08

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 2023-06-09

E · Potential for more than minimal harm 2023-05-08

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-05-08

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-05-08

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-05-08

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-08-28

D · Potential for more than minimal harm 2023-05-08

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-08-28

D · Potential for more than minimal harm 2023-05-08

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-05-08

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-05-08

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 2023-06-09

D · Potential for more than minimal harm 2023-05-08

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-05-08

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-05-08

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-05-08

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-06-09

D · Potential for more than minimal harm 2023-05-08

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 2023-06-09

D · Potential for more than minimal harm 2023-05-08

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2023-08-28

D · Potential for more than minimal harm 2023-05-08

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 2023-08-28

C · Minimal harm 2023-05-08