Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Falls Transitional Care Of Cascadia during CMS and state inspections, most recent first.
Food storage, labeling, and meal transport practices were deficient. Staff were observed delivering meal trays with uncovered beverages down the hall, and one SW touched a resident’s brownie after unwrapping it. In the kitchen, surveyors found expired or improperly dated food items in the refrigerator, freezer, and pantry, along with dirty cooler fans and stained coffee carafes.
Infection control practices were not maintained for respiratory equipment, shared equipment, and laundry handling. A resident’s CPAP mask and another resident’s CPAP mask were left uncovered, a nebulizer was left unbagged and visibly soiled, a shared vital sign machine had visible splatter, and staff handled wet underpads, dirty linens, and personal clothing in ways that placed items on the floor or transported them without protective covering.
Resident dignity was not maintained when an LPN administered oral meds to a resident in the dining room while others were present, despite no documentation in the resident’s record allowing that practice. In a separate observation, a CNA entered a resident’s room without knocking or waiting for a response, and the CNO stated staff should knock and wait before entering.
A facility failed to ensure call light access was within reach in 2 shower stalls. Observations found the 100 Hallway and 400 Hallway shower stalls had call light boxes mounted high without call light strings, leaving them out of reach for a resident using the stall. The CRN stated the showers should have accessible call light strings for residents and staff assisting in the shower stall.
A facility failed to maintain a clean, sanitary, and homelike environment when multiple vents and surrounding areas were observed with gray, fuzzy buildup and cobwebs in the dining room, TV room, hallway, and medication room. The CEO stated there was no weekly cleaning schedule, and review of housekeeping and environmental services documents showed vent cleaning was not consistently included, although one checklist did note vents were to be dusted.
A resident with sick sinus syndrome and a lumbar compression fracture was observed using O2 via NC and wearing elbow pads, with orders for continuous PRN O2 and elbow protectors at all times. The care plan did not include these current interventions, and the CRN and CNO stated the plan should have reflected them when ordered.
Failure to provide ordered continuous oxygen for a resident with stroke and chronic respiratory failure with hypoxia. The resident had an order for 3 L/min via NC continuously and a care plan directing staff to give oxygen as ordered, but was observed without the cannula during a Hoyer transfer and ADL care; the CNA applied it only after the surveyor asked about it. The CNO stated CNAs should have had the resident on oxygen during the transfer and ADLs as prescribed.
Incomplete Daily Nurse Staffing Postings: The facility failed to ensure daily posted staffing sheets included accurate nurse staffing information, including actual hours worked by licensed and unlicensed nursing staff. Review of the posted sheets showed no actual staff hours documented across the months reviewed, and the CRN stated the facility had not documented the actual hours and should have.
Unsecured medications were found in a resident’s room and an unlocked treatment cart was observed unattended. A resident with moderate cognitive impairment had Systane eye drops on the bedside table, but the record did not show an order for the drops or a self-administration assessment. An RN stated she forgot to lock the treatment cart, and the CNO confirmed the cart should have been locked when unattended.
A resident with a guardian, diagnosed with Spotted Fever and diabetes, did not receive assistance or documentation regarding the formulation of an Advance Directive. Staff confirmed that no discussion or documentation occurred because the resident had a guardian.
Two residents with serious mental illness diagnoses did not have their conditions accurately reflected in their MDS assessments. The assessments failed to document required diagnoses and PASRR determinations, as confirmed by staff interviews.
A resident with multiple mental health diagnoses, including PTSD, depression, anxiety, and bipolar disorder, was not consistently referred for further evaluation as required by the PASARR program. Documentation errors and missed referrals resulted in the resident not being properly assessed for specialized services, despite ongoing mental health concerns and prescribed medications.
The facility did not resubmit required PASRR Level II documentation for three residents with mental health or intellectual disability diagnoses who remained in the facility beyond the 30-day hospital exemption period. These residents had conditions such as depression, anxiety, major depressive disorder, Parkinson's disease, and borderline personality disorder. Staff confirmed that updated assessments and supporting documents were not sent to the state authority as required.
Two residents with complex medical conditions did not receive respiratory care as ordered, including failure to change oxygen tubing and improper reuse of dropped oxygen cannula tubing by staff, resulting in noncompliance with infection control and physician orders.
Controlled medications were not properly tracked or secured due to missing required signatures on narcotic accountability records for two medication carts. Staff confirmed that two nurses were expected to sign these records when accepting or releasing the carts, but this was not consistently done.
A medication error rate above 5% was identified when a resident did not receive a prescribed chewable Calcium/Vitamin D tablet due to lack of supply, and a Lidocaine patch was not removed after the required 12 hours. An LPN also failed to document the application of the Lidocaine patch with date, time, and initials.
Surveyors found expired mouthwash and omeprazole suspension in the medication storage refrigerator, as well as an undated glucose test solution. The CNO confirmed that these items should have been removed or properly labeled.
Surveyors observed that opened and prepared food items, including dry scalloped potatoes, tea, juice, and pizzas, were not properly dated or stored according to facility policy and the Idaho Food Code. The Culinary Manager acknowledged that these items should have been dated but were not.
A resident with chronic heart and lung conditions had multiple medical record entries indicating oxygen was administered via nasal cannula, despite a physician's order specifying oxygen use only with BIPAP. Nursing staff documented the use of a nasal cannula over an extended period, even though no nasal cannula was present in the resident's room. Facility leadership confirmed these were documentation errors that were not identified or corrected.
The facility failed to maintain proper food handling and sanitation practices, with issues including improper cooling of leftovers, inadequate holding temperatures for cold foods, and unclean kitchen equipment and areas. The walk-in refrigerator was not at the required temperature due to torn gaskets, and the kitchen floor and equipment were found to be dirty. Additionally, cold food items were above the required holding temperature, and dishware had hard water residue.
A facility failed to accurately reflect a resident's condition in the MDS assessment, omitting documentation of scalp wounds despite ongoing treatment and monitoring. The resident, with multiple diagnoses including brain cancer and chronic respiratory failure, had scalp wounds requiring antibiotic treatment. Staff interviews confirmed the presence of these wounds, which were not healing due to hardware on the skull. The MDS Coordinator was unsure if the wounds needed to be documented, leading to an inaccurate assessment.
A facility failed to complete a new Level 1 PASARR for a resident who was newly diagnosed with PTSD, despite having a policy requiring such action for newly identified mental disorders. The resident was admitted with depression and anxiety, and the new diagnosis was documented in a quarterly MDS assessment. Staff acknowledged the oversight, which could potentially impact the resident's access to necessary mental health services.
Two residents in a LTC facility did not receive their prescribed restorative nursing programs, leading to potential declines in their physical abilities. One resident, with multiple sclerosis, did not receive recommended exercises for her knee, while another, with severe cognitive impairment and muscle contractures, was not provided with necessary positioning aids. Staff interviews revealed confusion and lack of communication, resulting in delays and non-compliance with care plans.
A resident with a history of falls and multiple diagnoses, including traumatic brain injury and dementia, did not have a fall mat in place as required by their care plan and physician orders. Observations and staff interviews revealed a lack of awareness and communication regarding the fall prevention measures, leading to the resident being found on the floor on two occasions without the mat in place. The CNO confirmed the mat was listed on the Kardex and should have been used.
The facility failed to provide proper catheter care for two residents, leading to potential risks of UTIs. One resident's catheter bag was consistently positioned incorrectly, contrary to the care plan, while another resident's catheter was not secured with a leg strap as ordered. Staff allowed resident preferences to override care plans without proper documentation or education, and there were inconsistencies in following physician orders and documenting refusals.
A resident with acute respiratory failure was observed receiving oxygen at 3 LPM instead of the prescribed 2 LPM. Staff interviews revealed a lack of adherence to physician orders, with an LPN failing to verify the correct oxygen setting and inaccurately documenting it. The CNO acknowledged the importance of following physician orders.
Food Storage, Labeling, and Meal Transport Deficiencies
Penalty
Summary
The facility failed to appropriately store, distribute, and label foods. During a kitchen tour, surveyors observed a plastic container of lime juice in the refrigerator with a use-by date of 7/17/26, thick dust and dirt on the cooler fans, an opened package of plant-based burgers in the freezer with a received date but no opened date, and several items in the pantry that were opened or stored past their use-by dates, including scalloped potatoes with an open date of 3/11/26 and a used-by date of 6/11/26, croutons with an open date of 5/13/25 and a use-by date of 6/13/26, and stuffing with an open date of 3/25/26 and a use-by date of 6/25/26. Two coffee carafes were also stored in the pantry with dark brown and thick white stains and product on the outside of the containers. During lunch service, a CNA transported a meal tray with a cup of coffee without a lid or protective covering from the hot cart on the 400-hall to a room four rooms away. The SW was also observed transporting a meal tray with a cup of juice without a lid or protective covering from the hot cart to a room six rooms away, and the SW touched Resident #59's brownie after it was unwrapped. The SW stated she did not think the juice had to be covered and did not realize she could not touch the resident's food. The CM stated the small cups should have had clear lids and the coffee cups should have had white lids when going down the hall, and that staff should not have touched Resident #59's food.
Infection Control Lapses in Respiratory Equipment, Shared Equipment, and Laundry Handling
Penalty
Summary
The facility failed to maintain infection control prevention practices for respiratory equipment, reusable equipment, and laundry handling. The facility’s policies stated that inhalant medication equipment must be cleaned and maintained according to infection control protocols, reusable non-critical equipment must be cleaned and disinfected between resident use, personal clothing must be laundered separately and returned promptly, and oxygen and respiratory supplies must be stored in a plastic bag when not in use. Despite these policies, Resident #67’s CPAP mask was observed uncovered in a bedside nightstand, Resident #53’s CPAP mask was observed uncovered on the bed under a pillow, and Resident #106’s nebulizer was observed on a bedside table not bagged and covered with a gray substance. The CNO stated the resident’s respiratory equipment should have been kept clean and the tubing should have been in a bag. Multiple-use equipment was also observed in an unclean condition, including a vital sign machine on the cross hall with a light brown splattering substance on the base. RN #1 stated the vital sign machine should have been cleaned after each resident use. In addition, laundry handling practices were not maintained when a staff member placed Resident #20’s wet under pad on the floor during incontinent care, CNA #5 placed Resident #7’s dirty clothes and bed linen on the floor, and Laundry Aide #1 carried personal clothes on hangers from the laundry room to a resident room without a protective covering. The Laundry Aide stated the clothes should have been covered.
Resident Dignity Not Maintained During Room Entry and Medication Administration
Penalty
Summary
The facility failed to ensure resident dignity when staff entered a resident room without knocking and waiting for acknowledgement before entering, and when oral medications were administered to Resident #16 in the dining room while other residents were present. Resident #16 was admitted with multiple diagnoses including schizophrenia, anxiety, and paraplegia, and on 7/19/26 at 12:07 PM, LPN #3 approached him in the dining room with a cup of oral medications and gave them to him while he waited for lunch. The resident’s medical record did not document a preference for medications to be administered in the dining room, and the CNO stated on 7/21/26 that Resident #16 should not have received medications there because the record did not document that this was allowed. In a separate observation on 7/19/26 at 10:50 AM, CNA #1 opened and entered a resident room without knocking, and Resident #60 stated that staff sometimes do not knock before entering and that they should knock first. The CNO stated staff should be knocking and waiting for a response from residents before entering their rooms.
Call Light Access Not Within Reach in Shower Stalls
Penalty
Summary
The facility failed to ensure call light access was within reach in 2 shower stalls. During observation, the 100 Hallway shower stall had a call light box mounted on the upper area of the stall without a call light string and was not within reach of a resident using the stall. The 400 Hallway shower stall was also observed with a call light box mounted on the upper area of the stall without a call light string and not within reach of a resident using the stall. The facility's Call Light Response Time policy, revised 10/15/22, stated that call light systems are expected to be available and within reach at the bedside and in toileting and bathing areas. The CRN stated the showers should have a call light box with strings accessible by residents and staff assisting the resident when in the shower stall, and they did not.
Unclean vents and common areas
Penalty
Summary
The facility failed to ensure residents were provided with a clean, safe, homelike environment. During observations, the dining room ceiling vents and the area around the vents were seen with a gray, fuzzy substance. Additional observations found a gray, fuzzy substance on the vent in the TV room, a gray, fuzzy substance on the vent in the middle of the 300-hall hallway, and in the medication room cobwebs on the wall above the refrigerators, a gray, fuzzy substance on the ceiling vents, and a dry gray substance on the floor. The facility's Homelike Environment policy, revised 9/17/25, stated under Facility Standards 1.a to maintain a sanitary, orderly, and comfortable interior. The CEO stated the facility did not have a weekly cleaning schedule and acknowledged the vents and area around the vents should have been cleaned. Review of the 100-hall and 400-hall Responsibilities form did not include cleaning of ceiling vents, and the Environmental Services Checklist: Terminal Cleaning of Patient Rooms did not document cleaning of the vents. The Housekeeping Checklist: Daily Cleaning of Resident Rooms did document that the vents were to be dusted, and the Maintenance Manager stated he had an employee who should have cleaned the vents on Fridays and that he had just started working on putting together a cleaning schedule.
Care Plan Not Updated for Oxygen and Elbow Protectors
Penalty
Summary
The facility failed to ensure Resident #52’s care plan was revised to reflect current needs and interventions. The facility’s Comprehensive Care Plans and Conference policy stated that care plans are to be created, reviewed, and revised by an interdisciplinary team familiar with the resident’s status and care needs, with updates made as needed based on the resident’s response to interventions or a change in condition, including when a resident sustains a fall. Resident #52 was admitted with multiple diagnoses including sick sinus syndrome and a wedge compression fracture of the fourth lumbar vertebra. On 7/19/26, the resident was observed lying in bed with oxygen via nasal cannula and elbow pads on both elbows. The medical record included an order for oxygen at 2L/min via nasal cannula continuous PRN and an order for elbow protectors to be worn at all times with placement checked each shift. A skin inspection assessment documented bruising to both upper extremities and scabs to both elbows, with elbow protectors to be worn at all times. However, review of the care plan showed that oxygen use and elbow pads were not documented. The CRN stated on 7/20/26 that the care plan had been updated that day but should have included the oxygen and elbow pads, and the CNO stated the oxygen and elbow pads were not on the care plan until that day and should have been care planned when ordered.
Failure to Provide Ordered Continuous Oxygen
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for Resident #60, who had diagnoses including stroke and chronic respiratory failure with hypoxia. The resident had a physician order dated 3/14/26 for oxygen at 3 L/min via nasal cannula continuously, and the care plan directed staff to give oxygen as ordered by the physician. The facility’s policy required verification of provider orders before initiating or changing oxygen therapy, reflected oxygen use in the care plan, and monitoring of oxygen parameters as needed and/or as ordered. On 7/19/26 at 10:50 AM, Resident #60 was observed without the oxygen cannula in place during a Hoyer lift transfer and while ADL care was being performed at the sink; when the surveyor questioned CNA #3 about the resident’s oxygen, the CNA applied the cannula. On 7/21/26 at 10:30 AM, the CNO stated the CNAs should have had Resident #60 on oxygen during the Hoyer lift transfer and during ADLs as prescribed by the physician.
Incomplete 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 January 2026 through July 2026, no actual licensed or unlicensed staff hours were documented on the sheets for the 7 months reviewed. The State Operations Manual, Appendix PP requires the facility to post the facility name, current date, total number and actual hours worked by licensed and unlicensed nursing staff, and resident census on a daily basis. When interviewed, the CRN stated the facility had not documented the actual licensed and unlicensed staff hours on the daily posted staffing sheets and should have.
Unsecured Medications and Unlocked Treatment Cart
Penalty
Summary
The facility failed to ensure medications available for residents were stored appropriately. During observation, a bottle of Systane artificial tears eye drops was found on Resident #101’s bedside table. Resident #101 was admitted with multiple diagnoses including urinary tract infection and bacteremia, and the admission MDS documented a BIMS score of 9, indicating moderate cognitive impairment. The facility’s Self-Administration of Medication policy stated residents may self-administer medications only when it is determined to be safe and appropriate, with assessment of the resident’s ability to manage medication independently and safely, including whether bedside storage is appropriate. A review of Resident #101’s medical record did not document an order for the Systane eye drops, and it also did not document a self-administration of medication assessment. In addition, an unlocked and unattended treatment cart was observed on the 400 Hall. RN #1 stated she had forgotten to lock the treatment cart door after coming out of a resident’s room, and the CNO stated the wound care treatment cart should have been locked when unattended by a licensed nurse.
Failure to Assist Resident with Advance Directive Due to Guardianship
Penalty
Summary
The facility failed to ensure that a resident and their representative were provided assistance to exercise their right to formulate an Advance Directive. Record review revealed that a resident, admitted with diagnoses including Spotted Fever due to Rickettsia rickettssi and diabetes, had a POST and a Letter of Guardianship in their medical record, but there was no documentation of an Advance Directive or evidence that the facility had offered assistance to the resident or their guardian in formulating one. During staff interview, a CRN confirmed that because the resident had a guardian, Advance Directives were not discussed and no related documentation existed.
Inaccurate MDS Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident with diagnoses including PTSD, major depressive disorder, and anxiety, the PASRR Level II assessment documented a serious mental illness, but the admission and quarterly MDS assessments did not indicate this diagnosis under the relevant sections. Specifically, the MDS did not reflect the PTSD diagnosis and incorrectly marked that the resident was not considered to have a serious mental illness by the PASRR process. For another resident with major depressive disorder and orthopedic conditions, the admission MDS assessment also failed to indicate that the resident was considered by the PASRR Level II process to have a serious mental illness. These inaccuracies were confirmed during staff interviews, where it was acknowledged that the MDS assessments should have been completed differently to accurately reflect the residents' diagnoses and PASRR determinations.
Failure to Refer Resident for Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident for further evaluation as required by the Pre-admission Screening and Resident Review (PASARR) program when the resident was diagnosed with major mental illness and related conditions. Record review showed that the resident had multiple diagnoses, including post-traumatic stress disorder (PTSD), depression, anxiety, and bipolar disorder, with several PASARR Level I and II screenings conducted over time. Despite documentation of these mental health diagnoses and prescribed medications, several PASARR II forms indicated that no further evaluation for specialized services was needed, and concerns related to mental health were not always documented. Additionally, inconsistencies were found in the documentation of PTSD on the Minimum Data Set (MDS) assessments. Staff interviews revealed that errors in the PASARR process were not identified or corrected in a timely manner. The Social Services Manager acknowledged missing errors on previous PASARR forms, and facility leadership confirmed that staff should have identified and addressed these errors. As a result, the resident was not consistently referred for appropriate evaluation by the state-designated authority, as required for individuals with major mental illness or related conditions.
Failure to Resubmit PASRR Level II for Residents Exceeding 30-Day Exemption
Penalty
Summary
The facility failed to resubmit the PASRR Level II evaluations for residents who were initially admitted under a 30-day hospital exemption but whose stays exceeded 30 days. This deficiency was identified through record review and staff interviews, and it was found to be true for three residents. For each of these residents, the original PASRR Level II documentation indicated that if the resident remained in the facility beyond 30 days, the facility was required to submit updated information, including the most current MDS, physician orders, social notes, and psychiatric information, to the state-designated authority (BLTC). However, this resubmission did not occur as required. The residents involved had significant medical and mental health diagnoses, including depression, anxiety, major depressive disorder, autonomic nervous system disorder, Parkinson's disease, and borderline personality disorder. Staff interviews confirmed that the required documentation was not submitted for these residents when their stays exceeded 30 days. Facility leadership acknowledged that the oversight should have been identified and addressed earlier, but the necessary updates were not made in a timely manner.
Failure to Provide Safe and Appropriate Respiratory Care and Adhere to Infection Control Practices
Penalty
Summary
The facility failed to provide respiratory care services as ordered by the physician and did not adhere to infection control and prevention practices for two residents requiring respiratory support. For one resident with autonomic nervous system disorder, Parkinson's disease, and borderline personality disorder, the care plan required weekly changes of disposable oxygen tubing and related supplies. However, observations revealed that the oxygen concentrator tubing and bubbler had not been changed as scheduled, with the last change documented over a week prior. The responsible nurse assigned the task to CNAs and only spot-checked a few rooms, failing to verify that the supplies for this resident had been changed. In another instance, a resident with congestive heart failure and chronic respiratory failure with hypoxia was observed when a CNA dropped the oxygen cannula tubing on the ground while filling the resident's portable oxygen unit. The CNA then picked up the tubing and reconnected it to the oxygen unit without replacing it, contrary to infection control protocols. The CNA acknowledged the error, and the charge nurse confirmed that the tubing should have been replaced before reuse.
Failure to Properly 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 narcotic accountability records for two of three medication carts reviewed. During audits of the 400 Hall and 100 Hall medication carts, it was observed that required signatures from two licensed nurses were not documented on the narcotic accountability records for multiple days. Staff interviews confirmed that two nurses were expected to sign the records when accepting or releasing the medication carts, but this procedure was not consistently followed. These findings were based on direct observation and staff statements during the survey.
Medication Error Rate Exceeds 5% Due to Missed and Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 5.71% error rate during observed medication administration. For one resident, a prescribed daily dose of Calcium 600mg/Vitamin D 10 mcg in chewable form was not administered because the facility did not have the chewable tablets available. Additionally, the same resident's physician order for a Lidocaine 4% patch to be applied to the left leg base for 12 hours in the morning and removed in the evening was not followed; the patch was not removed after 12 hours as required. The LPN also did not date, time, or initial the Lidocaine patch upon application, as is standard practice. These actions and omissions were confirmed through staff interviews and direct observation.
Expired Medications and Unlabeled Biologicals Found in Medication Storage
Penalty
Summary
Surveyors observed that medications and biologicals in the facility's medication storage room were not properly managed according to professional standards. Specifically, a bottle of mouthwash and two bottles of omeprazole suspension were found in the medication refrigerator with expiration dates that had already passed, and these expired items had not been removed. Additionally, a set of glucose test solutions was found without a date indicating when it was opened. The Chief Nursing Officer (CNO) confirmed that the expired medications should have been removed and that the glucose test solution should have been dated when opened.
Failure to Properly Date and Store Food Items
Penalty
Summary
Surveyors determined that the facility failed to store food in a safe and sanitary manner, as required by the Idaho Food Code and the facility's own policies. During observations, an opened container of dry scalloped potatoes with a use-by date that had already passed was found in the dry food storage room. In the walk-in refrigerator, an undated container of tea and a tray of individually poured cups of juice, along with the tray itself, were not dated. Additionally, in the walk-in freezer, a bag containing pizzas that had been opened was not dated. The Culinary Manager confirmed that these food items should have been properly dated but were not.
Inaccurate Oxygen Therapy Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure accurate data entry in a resident's medical record, specifically for a resident with chronic congestive heart failure and chronic obstructive pulmonary disease. The resident had a physician's order for BIPAP with home settings and oxygen at 2 liters with humidification. However, multiple entries in the resident's medical record documented the use of oxygen via nasal cannula, which was inconsistent with the physician's order and the actual care provided. These entries were made by various nursing staff over a period of time. Upon review, it was observed that there was no nasal cannula present in the resident's room, and the Chief Nursing Officer confirmed that the oxygen order was for use with BIPAP only. The Clinical Registered Nurse acknowledged that the documentation of oxygen via nasal cannula was a documentation error and should have been identified and corrected. This inaccurate documentation resulted in the resident's medical record not reflecting the actual care provided.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to proper procedures for cooling leftovers, maintaining appropriate food holding temperatures, and ensuring cleanliness and maintenance of kitchen equipment and areas. During a kitchen tour, it was observed that the walk-in refrigerator was not maintaining the required temperature, measuring at 48 degrees F, due to torn gaskets. The floor of the refrigerator was also found to be dirty with food debris and rust. Additionally, the range ovens and walls around the steam table and coffee station were soiled, and the kitchen floor had scuff marks, cracked tiles, and food debris. These conditions were acknowledged by the staff, indicating a lack of adherence to the facility's sanitation policies. Furthermore, the facility did not follow proper cooling procedures for leftovers, as evidenced by breakfast gravy placed in the refrigerator that remained at 65 degrees F after five hours, contrary to the policy requiring cooling to 41 degrees F within six hours. Cold food items on the breakfast tray line were also found to be above the required holding temperature of 41 degrees F, with items like pears, strawberries, and cottage cheese measuring between 43 and 46 degrees F. Additionally, beverage pitchers and dishware were noted to have a white residue due to hard water, which had not been addressed for several months. These deficiencies in food handling and sanitation practices placed residents at risk for potential food contamination and adverse health outcomes.
Inaccurate MDS Assessment for Resident with Scalp Wounds
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, identified as Resident #16. This resident was admitted with multiple diagnoses, including brain cancer, right hemiplegia and hemiparesis following a stroke, and chronic respiratory failure with hypoxia. The quarterly MDS assessment documented that the resident was severely cognitively impaired and rarely able to make herself understood. However, the assessment failed to document the presence of current open lesions or wounds, despite physician orders and care plans indicating the need for topical antibiotic treatment for scalp wounds and monitoring for signs of infection. The resident's medical records, including physician orders and progress notes, indicated ongoing treatment and monitoring for scalp wounds, which were not reflected in the MDS assessment. Interviews with staff, including an LPN and a nurse practitioner, confirmed the presence of scalp wounds that had been present for over a year and were not healing due to hardware on the skull. The MDS Coordinator, who had recently started working remotely, was unsure if the MDS coding instructions required the resident's skin wounds to be documented in the assessment. This oversight in the MDS assessment process had the potential for negative outcomes due to the inaccurate reflection of the resident's condition.
Failure to Complete New PASARR for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure a new Level 1 Preadmission Screening and Resident Review (PASARR) was completed for a resident who had a newly identified mental illness. This deficiency was identified for one resident, who was admitted with diagnoses including depression and anxiety. A quarterly MDS assessment later documented that the resident was moderately cognitively impaired and had a diagnosis of Post Traumatic Stress Disorder (PTSD). Despite this new diagnosis, the resident's record did not include documentation of a new Level 1 PASARR being completed. The facility's PASARR policy requires that any resident with a newly evident or possible serious mental disorder be referred to the appropriate state-designated mental health authority for review. However, the staff, including the SSM, CNO, and CEO, acknowledged that a new PASARR Level 1 should have been completed following the resident's new PTSD diagnosis. The failure to complete the necessary PASARR assessment could potentially result in the resident not receiving specialized services for their mental health needs.
Failure to Implement Restorative Nursing Programs
Penalty
Summary
The facility failed to implement a restorative nursing program for two residents, leading to potential declines in their physical abilities. Resident #308, who was admitted with multiple sclerosis and other conditions affecting mobility, was recommended for a restorative nursing program after being discharged from physical therapy. Despite the recommendation, the program was not initiated, and the resident did not receive the necessary exercises for her right knee, which was sore and stiff. Interviews with staff revealed confusion and lack of communication regarding the implementation of the program, resulting in a delay that could cause increased stiffness and discomfort for the resident. Resident #47, who was severely cognitively impaired and had muscle contractures, was also not receiving the prescribed restorative interventions. The resident's care plan included the use of a small abductor wedge, a ball for neck support, and hand splints to prevent further contractures and skin breakdown. Observations showed that these interventions were not being applied, and staff interviews indicated a lack of awareness and documentation regarding the resident's needs and refusals. The deficiency in providing restorative nursing services was attributed to a lack of follow-up and communication among staff members. The Director of Rehabilitation Services and the Chief Nursing Officer acknowledged the oversight and the importance of adhering to physician orders and therapy recommendations. The failure to implement the restorative programs as planned created a potential for residents to experience a decline in their physical condition, which was not documented or addressed in a timely manner.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement a fall intervention for a resident with multiple diagnoses, including traumatic brain injury and dementia, who was at high risk for falls. The resident's care plan and physician orders specified the use of a low bed with a fall mat on the floor for safety. However, during observations, the fall mat was not in place next to the resident's bed, and staff interviews revealed a lack of awareness regarding the requirement for the mat. The resident had a history of falls, and on two occasions, was found on the floor without the fall mat in place. Interviews with staff, including a CNA, RN, LPN, and the CNO, indicated confusion and lack of communication regarding the resident's fall prevention measures. The CNO confirmed that the fall mat was listed on the Kardex and should have been in place, as per the care plan and physician order. The failure to ensure the fall mat was in place as required by the care plan and physician order constituted a deficiency in providing adequate supervision and preventing accident hazards for the resident.
Failure to Provide Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to potential risks of urinary tract infections. Resident #158, who was admitted with a history of sepsis related to a urinary tract infection and obstructive uropathy, had a physician's order to keep his catheter bag below the bladder for proper drainage. However, observations revealed that the catheter bag was consistently positioned at waist level on the resident's wheelchair, contrary to the care plan. Despite staff awareness of the correct positioning, they allowed the resident's preference to override the care plan without proper documentation or education on the potential consequences. Resident #39, admitted with obstructive and reflux uropathy, had a physician's order to secure his indwelling catheter with a leg strap to prevent movement and urethral traction. Observations on multiple occasions showed that the catheter was not secured with a leg strap, and the resident confirmed that staff were not following the order. An LPN admitted to documenting that catheter care was provided without verifying if the tubing was secured, highlighting a lapse in adherence to physician orders and documentation protocols. Interviews with staff, including CNAs, LPNs, and the CNO, revealed inconsistencies in following physician orders and documenting resident refusals. The facility's policy required documentation of refusals and notification of the physician, which was not consistently followed. The lack of adherence to care plans and physician orders for both residents created a potential risk for urinary tract infections due to improper catheter care.
Failure to Administer Oxygen Therapy Per Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy according to the physician's orders. This deficiency was identified for a resident who was admitted with multiple diagnoses, including acute respiratory failure with hypercapnia. The physician's order specified that the resident should receive oxygen at 2 liters per minute (LPM) via nasal cannula continuously. However, observations on three consecutive days revealed that the resident was receiving oxygen at 3 LPM, contrary to the physician's order. Interviews with staff members, including an LPN and the ACON, indicated a lack of awareness and adherence to the physician's orders. The ACON was unsure of the correct oxygen setting without reviewing the orders, and the LPN admitted to not closely checking the oxygen setting, despite documenting that it was at the correct level. The CNO confirmed that staff should follow physician orders and not incorrectly sign off on the MAR/TAR. This oversight created the potential for the resident to experience hyperoxia due to the excess supply of oxygen.
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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 Twin Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Serenity Transitional Care | 3.3 mi | ★★★★★ | 17 | 0 |
| Oak Creek Rehabilitation Center Of Kimberly | 4.2 mi | ★★★★★ | 27 | 0 |
| Bridgeview Estates | 9.2 mi | ★★★★★ | 0 | 0 |
| Cascades At Desert View | 16 mi | ★★★★★ | 24 | 0 |
| Lincoln County Care Center | 26.4 mi | ★★★★★ | 21 | 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 October 2026) and official state health department websites.