Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Promontory Point Rehabilitation during CMS and state inspections, most recent first.
Failure to Assist Residents With Advance Directive Formulation: Multiple residents had no advance directive in the chart or documented follow-up after social services notes showed they either already had a POA/Living Will or wanted help completing one. Residents with conditions including fx, chronic resp failure, delirium, sepsis, HTN, CKD, AFib, UTI, discitis, and anemia had incomplete documentation, and one care plan had conflicting POA/Living Will information.
The facility failed to maintain infection control practices for respiratory equipment and laundry handling. Two residents had nebulizer mouthpiece and tubing left uncovered on bedside tables, clean bed linens were observed being carried down the hallway uncovered, and staff stated the linens should have been bagged. In the laundry rooms, staff reported CNAs washed laundry and did not always use goggles or aprons, while multiple washers, dryers, vents, and surrounding surfaces had visible buildup. The DON and Administrator also stated there was no cleaning schedule for the personal washers or dryers.
Failure to obtain informed consent before starting a psychotropic medication. A resident with anemia and DM was ordered Bupropion HCl for major depressive disorder, and the MAR showed the medication was given before the psychotropic medication disclosure was signed. The DON stated the resident should have signed the disclosure before receiving the medication.
A resident with diagnoses including acute embolism and thrombosis and anemia had an Albuterol inhaler observed at the bedside, but the record did not show an interdisciplinary team assessment or care plan update for self-administration. The DON stated the resident had not been assessed for self-administration and should not have had the inhaler at the bedside.
Call Light Not Within Reach: A resident with a displaced trimalleolar fracture, MDD, and diabetes was observed sitting in a recliner with the call light cord hanging down the wall and under the bed, out of reach. The resident could not independently reach the call light, and the DON stated the call light should have been within reach but had not been.
The facility failed to document required transfer information, bed-hold notices, and Ombudsman notifications for two residents. One resident with a fracture and delirium was sent to the ED for low BP and low O2 sats, and another resident with weakness and recent sepsis was sent to the ED for cough, SOB, and low O2 sats; neither record showed the bed-hold policy was reviewed, and one record also lacked required transfer info such as care plan goals, med list, and advance directive.
A facility failed to ensure its daily nurse staffing postings were accurate and included both scheduled and actual hours for licensed and unlicensed nursing staff. Surveyors reviewed staffing sheets over several months and found no actual hours documented. The DON/Administrator stated the facility did not document actual hours on the posted sheets and did not keep daily staff schedules because time adjustments were made only on staff time sheets.
Food was found improperly stored and labeled in the kitchen and on resident unit refrigerators. Three uncovered plates of leftover food were left on the tray line area after the prior dinner meal, and resident refrigerator items were observed without proper dating or resident identification. The 100 Hall refrigerator also contained staff drinks, and the DON stated unit refrigerators are for resident items only.
The facility did not ensure the privacy of residents' medical information during medication administration. A computer screen on a medication cart was left open, displaying medical information of three residents at different times. An LPN admitted to not closing the screen, violating the facility's Patient Rights policy.
A resident was observed receiving oxygen without a physician's order, contrary to the facility's policy requiring such orders except in emergencies. The resident had been on low flow oxygen since admission, and an LPN confirmed the absence of an order, highlighting a failure to follow professional standards.
The facility failed to properly label and store medications, as observed in a medication cart and a medication room. A cup of multicolored tablets labeled as Tums was found without a proper container, and a vial of Tuberculin solution lacked an opened date. LPNs acknowledged these oversights, which could lead to residents receiving incorrect or expired medications.
Failure to Assist Residents With Advance Directive Formulation
Penalty
Summary
The facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an Advance Directive. Based on policy review, record review, and staff interview, 9 of 12 reviewed residents did not have an advance directive in the medical record or documentation that advance directive information was provided, discussed, or followed up on with the resident or representative. The facility policy stated that on admission the facility would determine whether the patient had executed an advance directive and, if not, determine whether the patient would like to formulate one. Several resident records showed social services notes documenting that the resident either already had a POA/Living Will or wanted assistance obtaining one, but the records did not contain the actual advance directive or documented follow-up. Resident #2, admitted with a nondisplaced left femur fracture and chronic respiratory failure, stated he had a POA/Living Will and that the facility could obtain a copy, but the record did not show an advance directive or follow-up. Resident #37, admitted with a displaced intertrochanteric fracture and delirium, stated she did not have one and wanted assistance making one, yet the record did not document the completed directive at the time of review. Resident #60, with diabetes and anxiety, and Resident #66, with acute embolism/thrombosis and anemia, both stated they had advance directives and would have family provide copies, but no copies or follow-up documentation were present. Additional records also lacked required documentation. Resident #61, with multiple rib fractures and atrial fibrillation, had no advance directive documented and no social services note showing the resident was asked about one or offered assistance. Resident #3, with UTI and discitis, had a social services note indicating she had a POA/Living Will and would let family know, but no advance directive or follow-up was documented. Resident #17, with sepsis and hypertension, had conflicting documentation in social services and care planning records regarding POA/Living Will status, while the baseline care plan did not address advance directive status. Resident #29, with a fractured pubis and chronic kidney disease, and Resident #52, with a fractured hip and hypertension, also lacked advance directive documentation in the medical record.
Infection Control Failures in Respiratory Equipment and Laundry Handling
Penalty
Summary
The facility failed to maintain infection prevention and control practices for respiratory equipment and laundry handling. The Nebulizer Therapy policy directed staff to clean the nebulizer after each use and, once dry, store the nebulizer cup and mouthpiece in a ziplock bag. However, Resident #66's nebulizer mouthpiece and tubing were observed uncovered on the bedside table at 9:56 AM, and Resident #57's nebulizer mouthpiece and tubing were observed uncovered on the bedside table at 10:21 AM. The facility's laundry policy stated laundry equipment would be used and maintained according to manufacturer's instructions, and the washer and dryer manuals required routine cleaning of the washer and lint screen. Despite this, clean bed linens were observed being carried down the hallway uncovered, and the housekeeper stated the linens should have been bagged. In the laundry rooms, staff observations and interviews showed multiple areas and pieces of equipment with visible buildup. A blue apron and goggles in the linen laundry room had a light gray fuzzy film, and CNA #1 stated staff only wore gloves when loading dirty laundry and that CNAs did the laundry with no designated laundry staff. The linen laundry room had gray fuzzy substance on the dryer vent and ceiling, a dry yellow substance on the ceiling above the washing machine, and the personal linen laundry room had gray fuzzy substance on the washer, soap compartment, agitator, lid, wall opening around the water pipes, dryer lint filter compartment, floor behind the dryers, and vents and ceiling around the vents. The Maintenance Director stated floor staff washed the laundry and that goggles and an apron were available but not always used, and he and the housekeeper were responsible for cleaning the laundry rooms weekly. The weekly laundry cleaning/audit documented items such as leaks, drain obstruction, dryer lint vacuuming, dryer function, and room organization, but did not document cleaning of the laundry machines or other areas of the laundry rooms. The Administrator stated there was no cleaning schedule for the personal size washing machines or dryers.
Failure to Obtain Informed Consent Before Psychotropic Medication
Penalty
Summary
The facility failed to ensure informed consent was obtained before initiating psychotropic medication for Resident #60, who was initially admitted and later readmitted with diagnoses including anemia and diabetes. A physician order dated 5/19/26 directed Bupropion HCl 100 mg twice daily, and the May 2026 MAR showed the resident received Bupropion HCl 100 mg at bedtime on 5/19/26. Review of the resident’s signed Psychotropic Medication Administration Disclosure dated 5/20/26 showed Bupropion listed for major depressive disorder, and the DON stated on 5/28/26 that the resident should have signed the disclosure prior to administration of Bupropion HCl but had not.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess whether Resident #66 could self-administer medications, despite having a policy stating that residents may self-administer medications only after the interdisciplinary team determines which medications can be safely self-administered and documents the assessment in the medical record. Resident #66 was admitted and later readmitted with diagnoses including acute embolism and thrombosis and anemia. During observation, an Albuterol inhaler was found lying on the bed linen next to the resident. Review of the medical record showed a physician order for Albuterol Sulfate HFA Inhalation Aerosol Solution, but there was no documented interdisciplinary team assessment or care plan update for self-administration of the Albuterol inhaler. The DON stated that Resident #66 had not been assessed by the interdisciplinary team for self-administration of medications and should not have had the inhaler at the bedside.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure a resident's call light was within reach for Resident #9, who was admitted with diagnoses including displaced trimalleolar fracture, major depressive disorder, and diabetes. During observation, Resident #9 was sitting in a recliner with her legs propped up, and the recliner was positioned with its back against the bed while the call light was plugged into the wall, with the cord hanging down the wall and under the foot of the bed, out of the resident's reach. The resident was unable to independently reach the call light. The facility's Call Lights Accessibility and Timely Response policy stated that staff will ensure the call light is within reach of the resident and secured, as needed. The DON later stated that the resident's call light should have been within reach and had not been.
Missing Transfer Documentation and Bed-Hold/Ombudsman Notices
Penalty
Summary
The facility failed to ensure that required transfer information, bed-hold notice information, and notice to the State Long-Term Care Ombudsman were documented for 2 of 12 residents reviewed for transfers. The facility’s Bed Hold Notice Before/Upon Transfers policy, revised 12/1/22, states that when a patient is transferred to the hospital or goes on therapeutic leave, the facility will provide written or verbal information about the state bed-hold policy and, in an emergency transfer, provide notice within 24 hours; it also states the facility will keep a signed and dated copy of the bed-hold notice in the patient’s file. Resident #37, who had diagnoses including displaced intertrochanteric fracture and delirium, was transferred to the emergency department for low blood pressure and low oxygen saturation, but the medical record did not document that a bed-hold policy had been reviewed with the resident or representative. Resident #47, who had diagnoses including weakness and recent sepsis, was transferred to the emergency department for increased cough, shortness of breath, and low oxygen saturations, but the record did not document that required pertinent medical information, including care plan goals, medication list, and advance directive, was provided to the receiving hospital, and it also did not document that a bed-hold policy had been presented to the resident or representative. In addition, when the surveyor requested six months of Ombudsman notifications of transfers and discharges, the Administrator stated the facility did not have documentation of those notifications.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure nurse staffing information posted daily was accurate and included both scheduled and actual hours worked by licensed and unlicensed nursing staff. During review of the daily posted staffing sheets for December 2025 through May 2026, surveyors observed that no actual licensed or unlicensed staff hours were documented on the sheets for the six months reviewed. The Administrator stated that the facility had not documented the actual licensed and unlicensed staff hours on the daily posted staffing sheets and that daily staff schedules were not kept because time adjustments were only made on staff time sheets.
Food Storage and Labeling Deficiencies
Penalty
Summary
Food was not appropriately stored, distributed, and labeled in the kitchen and on resident unit refrigerators. On 5/26/26 at 5:52 AM, three uncovered plates of food were observed on the serving counter in the tray line area with the Administrator present: one plate of cooked peas and carrots, one plate of cooked mashed sweet potato-looking orange substance, and one plate of meat and gravy-like off white thick substance. On 5/28/26 at 2:28 PM, the Dietary Manager stated these plates had been left out from the prior dinner meal for the night shift staff and should have been discarded but had not been. On 5/27/26 at 3:43 PM, the 100 Hall resident unit refrigerator contained multiple Ensure bottles that were not dated or labeled with resident name, multiple soda bottles labeled only with resident room number and initials, and three cans of drinks labeled with staff initials. RN #2 stated the refrigerator contents should be labeled with the resident name and date and that staff drinks should not have been in the refrigerator. On 5/27/26 at 4:13 PM, the 200 & 300 Hall resident unit refrigerator contained one large bottle of Gatorade that was not dated or labeled with resident name. On 5/28/26 at 11:22 AM, the DON stated the unit refrigerators are for resident items only and items should have been dated with the resident's room number, first name and last name initial and had not been.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical information during medication administration. This deficiency was observed on the south hall medication cart, where the computer screen was left open displaying medical information of three residents at different times. Specifically, the screen was open to Resident #23's medical information at 7:46 AM, Resident #8's information at 7:54 AM, and Resident #19's information at 7:57 AM. An LPN acknowledged at 8:02 AM that she should have closed the computer screen before leaving the medication cart. This practice was contrary to the facility's Patient Rights policy, which mandates that personal and clinical records be kept private.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice by not obtaining a physician's order for oxygen administration for a resident. The resident, who was admitted with multiple diagnoses including a fracture of the right femur and hypertension, was observed receiving oxygen at 1 liter per minute via nasal cannula without a documented physician's order. The facility's policy required oxygen to be administered under a physician's order, except in emergencies, and to obtain orders as soon as practicable. An LPN confirmed that the resident had been on low flow oxygen since admission without an order, indicating a lapse in following the facility's policy and professional standards.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were labeled, dated, and stored appropriately, as observed during an inspection of the medication storage areas. In one of the medication carts inspected, a cup containing multicolored tablets labeled as Tums was found without a proper container, indicating a lack of adherence to labeling and storage protocols. An LPN present during the inspection acknowledged the absence of a container for the Tums, which should have been provided. Additionally, in the north side medication room, a vial of Tuberculin purified solution was found in the resident medication refrigerator without an opened date. The LPN present confirmed that the vial should have been dated when opened, as per the facility's policy and CDC guidelines. This oversight in labeling and dating medications created the potential for residents to receive incorrect or expired medications, compromising their safety and care.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Teton Healthcare Of Cascadia | 1.7 mi | ★★★★★ | 18 | 0 |
| Life Care Center Of Idaho Falls | 2.5 mi | ★★★★★ | 16 | 0 |
| Eagle Rock Health And Rehabilitation Of Cascadia | 4.5 mi | ★★★★★ | 25 | 0 |
| Syringa Chalet Nursing Facility | 25.4 mi | ★★★★★ | 8 | 0 |
| Bingham Memorial Skilled Nursing & Rehabilitation | 25.5 mi | ★★★★★ | 9 | 0 |
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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.