Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Skyline Transitional Care Center during CMS and state inspections, most recent first.
Improper storage of respiratory devices and incorrect oxygen flow rate. Multiple residents with COPD, respiratory failure, and other respiratory conditions were observed with nebulizer masks or nasal cannulas left on beds, bed sheets, or the floor instead of being stored in bags, and staff acknowledged the devices were not stored appropriately. In another instance, a resident with an order for continuous oxygen was found receiving 3.5 L/min via NC instead of the ordered 2 L/min, and an LPN confirmed the flow rate was incorrect.
Infection control and hand hygiene practices were not followed during resident care for multiple residents. An LPN applied topical treatment and then handed a resident a mouth moisturizer without removing dirty gloves or cleaning hands, a CNA performed incontinence care and handled clean supplies without changing gloves or performing hand hygiene, and an RN began wound care after touching the bed controls and linens without being observed performing hand hygiene or changing gloves; enhanced barrier precautions were also not followed during wound care for one resident.
Incomplete Transfer Documentation: The facility failed to ensure a resident was transferred to the hospital with all required documentation. The record showed the resident, who had muscle weakness, dementia, and a left femur fracture, was sent with the POST, face sheet, and med list, but there was no documentation that care plan goals were provided to the receiving hospital. The DON stated additional transfer documents were typically sent, but neither the DON nor the CRN found evidence that the resident's care plan goals were included.
PASRR screening was not completed accurately for a resident with multiple mental health diagnoses. The resident was admitted with severe protein-calorie malnutrition, major depressive disorder, anxiety disorder, and dementia, but the PASRR level I listed anxiety disorder, mood disorder, and a primary dx of dementia. The Social Services Manager confirmed the resident did not have a primary dx of dementia.
A resident admitted with PTSD, schizoaffective disorder, major depressive disorder, and bipolar disorder had no care area in the person-centered care plan addressing PTSD, despite the diagnosis being present in the medical record. A Social Services assessment also documented no history of trauma, and the Social Services Manager confirmed the care plan did not address the resident’s PTSD or related care needs.
Failure to apply ordered pressure-relieving boots: A resident with ESRD, DM, and a L heel pressure ulcer was observed sleeping in bed without Prevalon boots, even though the care plan and MD order directed the boots to be worn while in bed every shift for skin integrity. The boots were found on the floor at the end of the bed, and an LPN confirmed the resident should have been wearing them.
The facility failed to follow up on a dialysis center recommendation for a resident with ESRD and a respiratory disorder. The resident had a physician-ordered 2,000 mL/day fluid restriction, but the dialysis record recommended 1 liter/day, and the DON stated the recommendation was not processed by the facility.
Failure to provide trauma-informed care services occurred for a resident with PTSD, schizoaffective disorder, major depressive disorder, and bipolar disorder. The care plan did not address PTSD or trauma triggers, and the record had no trauma-informed care evaluation, trauma history, trigger identification, or documentation of the resident’s preferences or refusals about discussing trauma. The DON confirmed the missing evaluation, and the Social Services Manager stated the resident did not wish to talk about it but that this preference was not documented.
The facility failed to ensure adequate monitoring for residents receiving opioid pain medications and did not provide clear PRN pain medication parameters. A resident with diabetes, depression, and HTN had a PRN hydrocodone-acetaminophen order without opioid side-effect monitoring, and the DON said nurses were left to assess on their own. Another resident with chronic pain syndrome and bladder cancer had multiple PRN pain orders without clarification on which medication to use first or monitoring for opioid side effects. A third resident with PTSD, schizoaffective disorder, MDD, and bipolar disorder had PRN acetaminophen, oxycodone, and hydrocodone-acetaminophen orders without instructions for use order, escalation steps, or opioid side-effect monitoring.
The facility failed to properly clean and sanitize kitchen cookware, affecting 64 residents. Baking sheets and frying pans were observed with crusted black residue, which the Certified Dietary Manager could scratch off with her fingernail, indicating inadequate cleaning. This posed a risk of foodborne illnesses due to contaminated equipment.
The facility failed to ensure accurate MDS assessments for four residents, leading to potential negative outcomes. A resident with bipolar disorder and another with schizophrenia had PASRR Level II screenings documented, but their MDS assessments were incorrectly coded as not having received them. Another resident's MDS was inaccurately coded due to a misunderstanding of the PASRR Level II requirements. These inaccuracies were due to misunderstandings or oversights by the MDS Coordinator.
A resident with bowel incontinence and multiple diagnoses, including congestive heart failure, did not receive prescribed bowel care medications, such as Milk of Magnesia, after experiencing constipation for several days. This oversight was confirmed by the DON, indicating a failure to follow physician orders and professional standards of practice.
A facility failed to assess a resident for entrapment risk before installing bed rails, as required by their policy. The resident was observed with mobility bars in an upright position, but their record lacked documentation of an assessment. The DON confirmed the resident was not assessed prior to installation.
Two residents experienced significant medication errors due to lapses in medication administration practices. One resident with diabetes was given the wrong type of insulin, while another received oxycodone instead of her prescribed medication. Both incidents lacked proper documentation on how the errors occurred and the residents' conditions before interventions.
Improper Storage of Respiratory Devices and Incorrect Oxygen Flow Rate
Penalty
Summary
Respiratory devices were not stored properly for multiple residents. Resident #9, who had COPD, chronic respiratory failure, and generalized muscle weakness, was observed with a nebulizer mask laying on the bed on two separate occasions, and staff stated it should have been stored in a plastic bag. Resident #26, who had COPD, respiratory failure, and pulmonary embolism, was observed with a nasal cannula on the floor beside the bed while the resident was stepping on it, and staff stated the device should have been stored in a bag. Resident #23, who had acute respiratory failure and pulmonary edema and had an order for oxygen at 2-5 liters via nasal cannula continuously, was observed with a nasal cannula lying on top of the bed blankets while being pushed in a wheelchair. Resident #28, who had a respiratory disorder and end stage renal disease, was observed with a nasal cannula lying directly on the bed sheets, and staff stated nasal cannulas should be stored in a labeled bag. Resident #89, who had COPD, chronic respiratory failure, and bronchiectasis, had a physician order for oxygen at 2 liters via nasal cannula continuously. The resident was observed with the nasal cannula in place while the oxygen flow was set at 3.5 liters per minute. An LPN checked the order, confirmed the flow rate was set above the ordered amount, and corrected it to 2 liters per minute. The report also cited a policy stating medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant, and an NIH article noting oxygen is a drug with specific doses and adverse effects at high doses.
Infection Control and Hand Hygiene Failures During Resident Care
Penalty
Summary
The facility failed to ensure adherence to infection control and prevention practices during wound care and activities of daily living for 3 residents. Facility policy for hand hygiene, reviewed in 2/2025, required alcohol-based hand rub or soap and water before and after direct resident contact, before moving from a contaminated body site to a clean body site during resident care, after handling dressings or contaminated equipment, and after removing gloves. During observation, staff did not follow these practices when moving between dirty and clean tasks, creating the conditions cited by surveyors for deficient infection control practice. Resident #48 had diagnoses including dementia, COPD, and muscle weakness and had an order for Venelex ointment to the buttocks. An LPN applied the ointment while wearing gloves, then did not remove the dirty gloves or perform hand hygiene before handing the resident a Biotene mouth moisturizer from the bedside table. Resident #64, who had diagnoses including muscle weakness, dementia, and need for assistance with personal care, was observed during incontinence care when a CNA cleaned the resident, removed soiled items, then handled clean chucks and a clean brief from the bedside table without changing gloves or performing hand hygiene first. Resident #6, who had diagnoses including severe protein calorie malnutrition, major depressive disorder, anxiety disorder, and dementia, was observed during wound care when an RN adjusted the bed and removed blankets, then proceeded with wound cleansing and dressing application without being observed performing hand hygiene or changing gloves before starting wound care. The report also states Resident #6 was not observed following enhanced barrier precautions during wound care.
Incomplete Transfer Documentation
Penalty
Summary
The facility failed to ensure that residents were transferred to the hospital with all required documentation. For Resident #64, who was admitted to the facility and later readmitted with diagnoses including muscle weakness, dementia, and a left femur fracture, the record showed she was admitted to the hospital after sustaining injuries from a ground level fall. A progress note documented that the resident's POST, face sheet, and medication list were sent with paramedics during the transfer. The resident's medical record did not include documentation that her care plan goals were provided to the receiving healthcare institution. During interview, the DON stated that bed hold agreements, face sheets, POST/advance directive, history and physical, recent labs/imaging, medication list, and two copies of the eMAR were to be sent with residents, and that the facility also called the receiving healthcare institution to give a report. When asked specifically about Resident #64's transfer, the DON stated the POST, face sheet, and medication list were sent, and both the DON and CRN stated they did not see documentation that the resident's care plan goals were sent.
Inaccurate PASRR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for one resident reviewed for PASRRs. Resident #6 was admitted with multiple diagnoses including severe protein-calorie malnutrition, major depressive disorder, anxiety disorder, and dementia. The resident’s PASRR level 1 dated 5/19/26 documented anxiety disorder, mood disorder, and a primary diagnosis of dementia. During record review and staff interview on 6/12/26 at 10:35 AM, the Social Services Manager confirmed that Resident #6 did not have a primary diagnosis of dementia and stated she would complete a new PASRR level I.
Care Plan Did Not Address PTSD Diagnosis
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed to reflect Resident #27’s diagnosed needs. Resident #27 was admitted with multiple diagnoses including Post-Traumatic Stress Disorder (PTSD), schizoaffective disorder, major depressive disorder, and bipolar disorder. A Social Services Assessment/Evaluation dated 5/27/26 documented that the response to whether the resident had experienced trauma or had a history of trauma was NO. Review of the resident’s comprehensive person-centered care plan showed no care area addressing PTSD, even though the diagnosis was present in the medical record. On 6/12/26 at 10:33 AM, the Social Services Manager confirmed the care plan did not address the resident’s PTSD diagnosis or how to care for the resident’s PTSD.
Failure to Apply Ordered Pressure-Relieving Boots
Penalty
Summary
The facility failed to ensure necessary pressure-relieving boots were consistently applied as ordered to prevent development of pressure injuries and promote skin integrity. This involved Resident #1, who was admitted and later readmitted with multiple diagnoses including end stage renal disease, diabetes, and a pressure ulcer of the left heel. The facility’s Skin and Wound Monitoring and Management Policy stated that residents without pressure injury should not develop one unless unavoidable, and that residents with pressure injuries should receive necessary services to promote healing and prevent new, avoidable pressure injuries. Resident #1’s care plan, revised 1/14/26, directed staff to apply Prevalon boots, and a physician order dated 3/9/26 documented that the boots were to be worn while in bed every shift for skin integrity. On 6/10/26, Resident #1 was observed sleeping in bed without the Prevalon boots on, and the boots were noted on the floor at the end of the bed. Later that day, an LPN confirmed the order required the boots while in bed every shift and, after going to the room with the surveyor, stated the resident was not wearing them and should have been wearing them while in bed.
Failure to Process Dialysis Fluid Restriction Recommendation
Penalty
Summary
The facility failed to follow up on dialysis center recommendations for Resident #28, who was admitted with multiple diagnoses including a respiratory disorder, end-stage renal disease, and need for assistance with personal care. A physician order dated 4/24/26 documented a 2,000 mL/day fluid restriction, with 920 mL/day of drinks on the tray provided by the kitchen and 1,080 mL/day provided by nursing. Review of the resident’s dialysis record dated 6/1/26 documented a recommendation for a fluid restriction of 1 liter (1,000 mL/day). During an interview on 6/11/26 at 2:37 PM, the DON stated that when the facility received recommendations, they would be reviewed and implemented, and after reviewing Resident #28’s record, stated the dialysis center’s recommendation was not processed by the facility.
Failure to Document Trauma-Informed Care Evaluation
Penalty
Summary
Failure to provide trauma-informed care services occurred for one resident with diagnoses including PTSD, schizoaffective disorder, major depressive disorder, and bipolar disorder. The resident’s comprehensive care plan did not include a focused care area for PTSD or for triggers that could cause re-traumatization. The record also contained no trauma-informed care evaluation and no documentation of the resident’s trauma history, identified trauma triggers, or preferences or refusals related to discussing trauma. The record did not show that the resident declined to discuss trauma history or that the resident was offered the opportunity to discuss trauma-related triggers. The DON confirmed the record lacked a trauma-informed care evaluation, and the Social Services Manager stated she had evaluated the resident but did not complete a trauma-informed care evaluation and did not document the resident’s stated preference not to discuss trauma-related triggers.
Inadequate Monitoring and Unclear PRN Pain Medication Orders
Penalty
Summary
The facility failed to ensure that residents receiving pain medications had adequate monitoring and clear medication parameters. For Resident #24, who was admitted with diagnoses including diabetes, depression, and hypertension, the physician ordered Hydrocodone-Acetaminophen 5-325 mg every 4 hours as needed for pain, but the record contained no documentation of opioid side-effect monitoring. On 6/12/26, the DON confirmed there was no monitoring in place for adverse side effects related to opioid use and stated that nurses were left to assess on their own. Resident #19, admitted with chronic pain syndrome and bladder cancer, had physician orders dated 4/24/26 for Morphine Sulfate 30 mg every 6 hours as needed for pain, Oxycodone HCl 10 mg every 4 hours as needed for pain, and Tylenol 325 mg, 2 tablets every 6 hours as needed for pain. The record did not include documentation that the facility was monitoring for opioid side effects, and on 6/12/2026 the DON stated the pain medication orders should have been clarified to direct staff which medication to use for the reported level of pain and that no monitors were in place. Resident #27, admitted with PTSD, schizoaffective disorder, major depressive disorder, and bipolar disorder, had PRN orders for acetaminophen, oxycodone, and hydrocodone-acetaminophen without instructions for which medication to try first, when each should be used, or escalation steps for pain management; the DON confirmed the orders did not specify which medication should be given first and that there was no opioid side-effect monitoring in place.
Improper Cleaning of Kitchen Cookware
Penalty
Summary
The facility failed to ensure the proper cleaning and sanitation of kitchen cookware, which had the potential to affect the 64 residents consuming food prepared by the facility. During an observation with the Certified Dietary Manager (CDM) and Registered Dietitian, baking sheets and frying pans were found to have a crusted black residue. Although the staff claimed that the cookware was cleaned and sanitized using appropriate food service methods, the CDM was able to scratch off the residue with her fingernail, indicating that the cleaning was not thorough. This deficiency placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food services equipment.
Inaccurate MDS Assessments Due to Misunderstanding of PASRR Level II Screenings
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for four residents, which could lead to negative outcomes due to inaccurate assessments. Resident #1, diagnosed with bipolar disorder, depression, anxiety, opioid dependence, and tobacco use, had two PASRR Level II screenings documented in her electronic medical record. However, her MDS assessments incorrectly indicated that she did not receive a PASRR Level II screening. The MDS Coordinator believed the form used was not considered a true Level II screening. Similarly, Resident #25, with major depressive disorder, schizophrenia, and anxiety, had a PASRR Level II documented in her record, but her MDS assessment was incorrectly coded as not having received a PASRR Level II screening. Resident #27, diagnosed with schizoaffective disorder, had a PASRR Level II completed, but his MDS assessment was incorrectly coded as not having a completed PASRR Level II. The MDS Coordinator stated this was because the PASRR Level II indicated no further evaluation was required. Resident #8, with bipolar disorder and depression, had a PASRR Level II completed, but her MDS assessment was not coded to reflect this. The MDS Coordinator acknowledged the oversight, and the Social Worker confirmed the PASRR Level II had been completed. These inaccuracies in the MDS assessments were due to misunderstandings or oversights by the MDS Coordinator regarding the PASRR Level II screenings.
Failure to Administer Prescribed Bowel Care
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident with bowel and bladder incontinence, leading to a potential risk of bowel obstruction. The resident, who was admitted with diagnoses including congestive heart failure and chronic respiratory failure with hypoxia, had specific physician orders for managing constipation. These orders included the administration of Colace, Milk of Magnesia (MOM), Dulcolax suppository, and Fleet Enema, each to be used sequentially based on the resident's bowel movement status. Despite these orders, the resident's bowel movement records indicated periods of constipation, specifically from February 15 to February 19 and February 25 to February 27, without documentation of MOM being administered as required after three days without a bowel movement. The resident reported experiencing constipation, and the Director of Nursing confirmed that the MOM should have been given according to the physician's order, highlighting a lapse in following the prescribed bowel care regimen.
Failure to Assess Resident for Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that a resident was thoroughly assessed for the risk of entrapment prior to the placement of bed rails. This deficiency was identified for one resident who was observed with two mobility bars in an upright position. The facility's policy required that appropriate alternatives be attempted before installing bed rails and that an interdisciplinary team assess the resident for entrapment risk if alternatives failed. Additionally, informed consent was to be obtained from the resident or their representative. However, the resident's record lacked documentation of such an assessment, and the Director of Nursing confirmed that the resident had not been assessed prior to the installation of the mobility bars.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by incidents involving two residents. Resident #116, who has diabetes, was mistakenly administered 33 units of Novolog, a rapid-acting insulin, instead of Lantus, a long-acting insulin. This error occurred while LPN #1 was training a Medication Assistant Certified (MAC) on insulin preparation. Although immediate corrective actions were taken, such as administering glucose gel and monitoring blood glucose levels, the incident report lacked documentation on how and why the error occurred, as well as the resident's condition before the intervention. Additionally, there was no documentation of the blood glucose monitoring that was reportedly conducted every 15-30 minutes. Resident #117, who has diabetes and schizophrenia, received an incorrect medication, oxycodone, instead of her prescribed medication. This error was self-reported by LPN #1, who was distracted by another resident's request for pain medication. The incident report did not specify how the error occurred or what medication was initially intended for Resident #117. The DON confirmed the error was discovered during narcotic medication reconciliation. Both incidents highlight deficiencies in medication administration practices and documentation within the facility.
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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 Boise
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cascadia Of Boise | 1.1 mi | ★★★★★ | 11 | 0 |
| Life Care Center Of Boise | 1.1 mi | ★★★★★ | 0 | 0 |
| Timber Springs Transitional Care | 1.5 mi | ★★★★★ | 19 | 0 |
| Sunterra Springs Riverview | 2 mi | ★★★★★ | 11 | 0 |
| Life Care Center Of Treasure Valley | 2.7 mi | ★★★★★ | 0 | 0 |
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