Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Franklin County Transitional Care during CMS and state inspections, most recent first.
Surveyors identified deficiencies in food storage and labeling, including unsealed and undated food items in the walk-in freezer and nourishment room refrigerator. Both the Dietary Coordinator and assistant acknowledged that food items were not properly sealed, dated, or labeled with resident names as required by facility policy and the Idaho Food Code.
The facility did not ensure that residents and their representatives received assistance to exercise their right to formulate Advance Directives, as required by policy. For six residents with various medical conditions, there was no documentation of Advance Directives or evidence that assistance was offered, with the process limited to documenting CPR status. Both the DON and Social Worker confirmed that discussions or confirmations of Advance Directives were not documented during annual reviews.
A resident with multiple diagnoses, including diabetes and stroke, had inconsistent height measurements recorded in the MDS assessments, with entries alternating between 66 inches and 63 inches on different occasions. The administrator could not explain the discrepancies in the documentation.
The facility did not update care plans for two residents after multiple falls and wandering incidents. Despite documented investigations and recommendations by the Fall Committee and staff, interventions were not added to the care plans, and episodes of wandering were not addressed in care planning. The DON and Social Worker confirmed that care plans were not revised as required.
Surveyors found that two resident rooms had sink water temperatures above 120°F, with one resident reporting the water was very hot. Affected individuals included a resident with pneumonia and hemiplegia/hemiparesis after a stroke. These unsafe temperatures were confirmed by direct measurement and placed residents at risk for harm.
Licensed nurses failed to document interventions when a resident's oxygen saturation repeatedly fell below the physician-ordered threshold while on oxygen therapy. Despite multiple low SpO2 readings, nursing staff did not consistently take or record appropriate actions, as confirmed by the DON.
Controlled medications were not properly tracked or secured when a narcotic accountability record for a medication cart was found missing required signatures from two nurses during a review. Both an LPN and the DON confirmed that two nurses should have signed the record when accepting or releasing the cart, but this was not done.
Surveyors observed that a box of lorazepam, a controlled medication, was stored in a medication refrigerator without a separately locked compartment, contrary to requirements. Additionally, glucose test solutions were found undated after opening, and staff confirmed these should have been labeled.
The facility's abuse policy failed to include staff screening and training requirements, and protection measures for residents during investigations. The Administrator confirmed these deficiencies, despite annual abuse training covering required topics.
The facility failed to ensure residents received gradual dose reductions (GDRs) of psychotropic medications or a stop date for as-needed psychotropic medication unless clinically contraindicated. This deficiency was identified for three residents, who were on various psychotropic medications without GDR attempts or stop dates, despite stable moods and lack of identified problem behaviors. The consulting pharmacist did not make GDR recommendations, and the Medical Director confirmed the lack of GDRs and stop dates.
The facility failed to implement an antibiotic stewardship program, leading to the prolonged use of antibiotics without documented rationale for two residents. One resident received Bactrim DS for an undocumented infected hip wound, and another received Ciprodex Otic Suspension for an undocumented tympanic membrane perforation. The Infection Preventionist confirmed the lack of necessary documentation.
Deficient Food Storage and Labeling Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and labeling practices. In the walk-in freezer, a bag of biscuits was found unsealed and exposed to room air, and a large Ziploc bag of sandwiches was not dated. Additionally, there was significant ice buildup on the floor and fans of the walk-in freezer unit. The Dietary Coordinator confirmed that these issues, including improper sealing and dating of food items, needed to be addressed. Further inspection of the nourishment room refrigerator revealed an opened relish container without an open date or resident name, an opened container of homemade jelly/jam with only a year marked on the lid and no resident name, and a Ziploc bag of sliced cheese with no date. The assistant Dietary Coordinator acknowledged that all refrigerated resident food items must be dated and labeled with resident names or be disposed of, which was not done in these instances.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an Advance Directive, as required by facility policy. Record review, policy review, document review, and staff interviews revealed that for six residents, there was no documentation of Advance Directives in their medical records, nor evidence that the facility had offered assistance in formulating such directives. The facility's policy outlined specific procedures for providing information about medical treatment decisions, obtaining signatures, and referring residents to social services for assistance with Advance Directives, but these steps were not documented as completed for the affected residents. For each of the six residents reviewed, including individuals with diagnoses such as dementia, depression, chronic kidney disease, chronic respiratory disease, chronic obstructive pulmonary disease, anoxic brain damage, diabetes, and chronic viral hepatitis, there was a lack of documentation regarding Advance Directives. The only documentation present was related to CPR status, which the DON confirmed was the extent of the facility's process for Advance Directives. The Social Worker also confirmed that during annual admission reviews, there was no documentation that Advance Directives were discussed or confirmed with these residents. Additionally, the facility's document provided to residents, "Your Rights As A Patient To Make Medical Treatment Decisions," only contained information about living wills and durable power of attorney for health care, and did not include documentation declaring the status of an Advance Directive. This incomplete process and lack of documentation were consistent across all six residents reviewed, indicating a systemic failure to follow the facility's own policy and federal requirements regarding Advance Directives.
Inaccurate MDS Assessment Due to Inconsistent Height Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected a resident's status, as evidenced by inconsistent documentation of a resident's height across multiple assessment dates. Specifically, the resident's height was alternately recorded as 66 inches and 63 inches on different MDS assessments, with no explanation for the discrepancies. The issue was identified through observation, interview, and record review, and the facility administrator was unable to provide a reason for the inconsistent height entries. The resident involved had multiple diagnoses, including diabetes and stroke.
Failure to Update Care Plans After Falls and Wandering Incidents
Penalty
Summary
The facility failed to ensure that care plans were revised and updated for residents following significant events, as required by facility policy. For one resident with chronic obstructive pulmonary disease and depression, multiple falls were documented over several months. Although the facility's Fall Committee investigated each incident and recommended specific interventions—such as moving the resident's room, providing a urinal at bedside, adjusting oxygen tubing, and ensuring non-skid footwear—these interventions were not incorporated into the resident's care plan after each fall. The Director of Nursing confirmed that the care plans should have been updated to reflect these interventions but were not. Another resident with dementia and hypertension experienced several wandering incidents, including one where the resident wandered outside the facility. Progress notes documented multiple episodes of wandering, and the admission assessment indicated a history of wandering. However, the resident's care plan did not include documentation of these incidents or interventions to address wandering. Both the Social Worker and Director of Nursing acknowledged that the care plan had not been updated to reflect these issues.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure safe water temperatures in resident rooms, as observed in two out of five rooms checked. Specifically, water temperatures in two resident rooms were found to be above 120 degrees Fahrenheit, with one room measuring 125 degrees F and another at 126 degrees F. A resident with multiple diagnoses, including pneumonia and hemiplegia/hemiparesis following a stroke, reported that the water in his room was very hot. These findings were confirmed through direct measurement of the sink water temperatures during the survey. The State Operations Manual Appendix PP, 483.25d, Table 1, was referenced to illustrate the risk of burns at various water temperatures and exposure times, highlighting that the temperatures found in the resident rooms exceeded safe levels for bathing and could cause harm.
Failure to Document and Intervene for Low Oxygen Saturation
Penalty
Summary
Licensed nurses at the facility failed to demonstrate appropriate competencies in managing oxygen therapy for a resident with multiple diagnoses, including anxiety disorder and dementia. The resident had a physician's order for oxygen via nasal cannula at 2-3L to maintain oxygen saturation (SpO2) above 90%. Despite this order, there were multiple documented instances where the resident's SpO2 levels fell below the prescribed threshold while on oxygen, and no nursing interventions were documented in response to these low readings. The report details several occasions over a period of months where SpO2 values ranged from 84% to 89% while the resident was receiving oxygen, with no evidence that licensed nurses took action or documented any interventions, except for one instance where a nurse instructed the resident to take deep breaths. The Director of Nursing confirmed that staff should have documented interventions for each low SpO2 reading but did not. This deficiency was identified for four out of fifteen licensed nurses and had the potential to affect all residents assessed for oxygen therapy.
Failure to Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by missing signatures on the narcotic accountability record for one of two medication carts reviewed. During an audit of the Hall B medication cart, it was observed that the narcotic accountability record covering a ten-day period did not have the required two licensed nurse signatures to document acceptance or release of the medication cart. Both an LPN and the Director of Nursing confirmed that two nurses should have signed the record when the cart was accepted or released. This lapse in documentation was identified through record review and staff interviews.
Controlled Medications Not Properly Secured; Biologicals Not Labeled When Opened
Penalty
Summary
Surveyors found that controlled medications, specifically a box of lorazepam (a Schedule IV controlled substance), were stored on a medication refrigerator shelf that did not have a separately locked compartment for controlled drugs, as required. Although both the medication refrigerator and cabinet were locked, there was no additional locked compartment inside the refrigerator for controlled substances. Additionally, biologicals such as glucose test solutions were observed to be undated when opened. Staff interviews confirmed that the glucose test solution bottles should have been dated upon opening, but this was not done.
Deficient Abuse Policy
Penalty
Summary
The facility failed to ensure their abuse policy included screening and training of employees, and protection for residents during an investigation. The policy, dated 5/18/20, did not include screening requirements of staff to prevent abuse, nor did it specify to whom, how, and when to report incidents of abuse and neglect. Additionally, the policy lacked details on how the facility would protect a resident during an investigation of an allegation of abuse. During an interview, the Administrator confirmed that the abuse policy was lacking in these areas, although annual abuse training for employees covered all required topics.
Failure to Implement Gradual Dose Reductions and Stop Dates for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents received gradual dose reductions (GDRs) of psychotropic medications or a stop date ordered for as-needed psychotropic medication unless clinically contraindicated. This deficiency was identified for three residents. Resident #8, who was admitted with anxiety and depression, had been on escitalopram for over two years without any GDR recommendations or attempts, despite not displaying the identified problem behaviors. Resident #13, also with anxiety and depression, had no GDRs for Seroquel and no stop date or reevaluation for as-needed Ativan after 14 days of use. Additionally, Resident #18, with depression, was on multiple psychotropic medications without GDR attempts and had no diagnosis justifying the use of Risperdal for a movement disorder or psychotic disorder. The records showed that the consulting pharmacist did not make GDR recommendations for these residents, and the Medical Director confirmed the lack of GDRs and stop dates for the medications in question. Resident #8's care plan included monitoring for depressive symptoms and behaviors, but no changes were recommended in the psychotropic medication review forms over multiple months. Resident #13's psychotropic medication review forms also showed no changes recommended, and the resident's moods were stable. However, the resident's record did not include GDRs for Seroquel or a stop date for Ativan. Resident #18's care plan documented a behavior management plan for depressive and anxiety symptoms, but the resident had not demonstrated these symptoms since November 2023. Despite this, the resident's record did not include GDRs for Risperdal, Bupropion, and Venlafaxine. The Medical Director and Director of Nursing confirmed the consulting pharmacist did not make GDR recommendations for these residents, and there was no stop date for the as-needed Ativan ordered for Resident #13.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program, resulting in the continued use of antibiotics without a documented rationale for two residents. Resident #8, who was admitted with multiple diagnoses including dementia and anxiety, received Bactrim DS for an infected hip wound for over two years without any documentation of an infected hip wound in his record. Similarly, Resident #13, admitted with diagnoses including anxiety and chronic kidney disease, was prescribed Ciprodex Otic Suspension for a tympanic membrane perforation, despite no documentation of a ruptured eardrum in his record. The Infection Preventionist confirmed the lack of documentation for both residents, indicating a failure to ensure appropriate use of antibiotics.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Preston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oneida County Hospital & Long Term Care Facility | 20.5 mi | ★★★★★ | 12 | 0 |
| Maple Springs Senior Living | 22.6 mi | ★★★★★ | 12 | 0 |
| Rocky Mountain Care - Logan | 23.5 mi | ★★★★★ | 14 | 0 |
| Logan Regional Hospital Transitional Care Unit | 23.7 mi | ★★★★★ | 2 | 0 |
| Sunshine Terrace Skilled Nursing | 24.9 mi | ★★★★★ | 16 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.