1140 North Allumbaugh Street, Boise, ID 83704 · Ada County · (208) 501-7200
120 certified beds, about 93 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1986
CMS Care Compare ratings, data as of September 1, 2026 · CCN 135098 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on September 12, 2025, inspectors cited 15 health deficiencies (the Idaho average is 10.3, the national average 9.2).
Of 67 health citations since May 2023, 5 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 2 fines totaling $30,654 in the last three years; the largest was $15,327, and the latest is dated September 12, 2025.
Nurses and nurse aides worked 3.27 hours per resident per day, against 4.04 across Idaho and 3.86 nationally. Registered nurses accounted for 0.47 of those hours.
CMS links it to The Ensign Group, an affiliated group of 344 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 67 health citations on file.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure residents' representatives were provided the opportunity to participate in the development of the resident's care plan. This was true for 1 of 3 (Resident #115) whose record was reviewed for comprehensive care plans. This failure resulted in Resident #115's initial care conference being delayed beyond regulatory timeframes, creating the potential for miscommunication and unmet care needs.
Inspectors wroteBased on record review, and staff interview it was determined the facility failed to ensure grievances were acted upon when facility staff were made aware of residents' missing items. This was true for 1 of 3 residents (Resident #29) whose records were reviewed. This deficient practice created the potential for psychosocial and physical harm when Resident #29's personal items were missing and not replaced.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure professional standards of practice were followed. This was true for 1 of 3 residents (Resident #115) whose record was reviewed for medication management. Specifically, the facility did not implement a physician's order for Haldol prescribed for symptom management during end of life care. This failure created the potential for untreated symptoms during the death and dying process.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure residents drug regimens were free from unnecessary medications. This was true for 1 of 3 residents (Resident #115) whose records were reviewed for unnecessary medications. Specifically, the facility administered Keflex (an antibiotic) beyond the prescribed duration without documented physician authorization or evidence of clinical justification. This failure created the potential for adverse outcomes, including the development of multi drug resistant organisms.
Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure resident's right were protected to be free from abuse. This was true for 1 of 1 resident (Resident #87) reviewed for abuse. This failure caused harm to Resident #87 and placed all residents at risk for ongoing abuse and potential physical and psychosocial harm.
Inspectors wroteBased on observation and staff interviews, the facility failed to maintain a clean and homelike environment for 1 of 1 resident (Resident #2) reviewed for environmental conditions. This failure created the potential for embarrassment and psychosocial harm when Resident #2's room was repeatedly observed to have a foul urine odor and unclean conditions.
Inspectors wroteBased on policy review, record review, staff interviews, and Bureau of Facility Standards Long-Term Care Reporting Portal, it was determined the facility failed to ensure interventions were implemented to prevent further resident to resident abuse incidents. This was true for 2 of 5 (Resident #87 and #113) reviewed for resident-to-resident abuse. This failure created the potential to cause psychosocial, verbal, and physical harm to residents residing in the facility.
Inspectors wroteBased on policy review, record review, and staff interviews it was determined the facility failed to ensure pertinent health information was provided to the receiving health facility for 2 of 6 residents (Resident #4 and #79) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if the residents were not treated in a timely manner due to a lack of information provided upon transfer.
Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 3 residents (Resident #10) reviewed for accuracy of MDS assessments. This deficient practice created the potential for residents to not receive appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial needs.
Inspectors wroteBased on record review and staff interview it was determined the facility failed to ensure professional standards of nursing practice were followed 1 of 2 residents (Resident #17) reviewed for anticoagulant (AC) monitoring. This deficient practice created the potential for harm if Resident #17's anticoagulant therapy was not monitored for signs and symptoms of complications.
Inspectors wroteBased on observation, record review, and policy review, the facility failed to ensure physician orders were followed for 1 of 1 residents (Resident #72) reviewed for tube feeding. This failure created the potential for poor nutrition when the incorrect nutritional supplement was administered.
Inspectors wroteBased on observation, staff interviews, record review, and policy review, the facility failed to ensure oxygen therapy was provided as ordered by the physician for 1 of 2 residents (Resident #29) reviewed for oxygen therapy. This failure created the potential for adverse health outcomes, including poor oxygenation and impaired concentration, when Resident #29 was not receiving oxygen therapy as prescribed.
Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to ensure the Medical Director and Director of Nursing Services acted upon pharmacist recommendations for 1 of 5 residents (Resident #90) reviewed for unnecessary medications. This failure created the potential for adverse effects and for residents to continue receiving medications without clinical justification.
Inspectors wroteBased on observation and staff interviews, the facility failed to ensure that residents were free from significant medication errors for 1 of 5 residents (Resident #50) observed during medication administration. This failure created the potential for harm when RN #3 did not assess Resident #50's apical pulse (a pulse point on your chest that gives the most accurate reading of your heart rate) prior to administering digoxin, a medication known to affect heart rate.
Inspectors wroteBased on representative interview, record review, and staff interview it was determined the facility failed to ensure residents obtained routine and emergency dental care to 1 of 1 resident (Resident #68) reviewed for timely dental care. This deficient practice created the potential for harm if the resident's nutritional status was altered or if she developed an infection related to dental damage.
Inspectors wroteBased on observation and staff interview it was determined the facility failed to ensure resident's received hydration beverages during dining. This was true for 1 of 18 residents (Resident #3) observed coughing without a hydration beverage. This deficient practice created the potential for harm if hydration was not provided during meals.
Inspectors wroteBased on observation, record review, staff interview, and the Food and Drug Administration (FDA) Food Code, it was determined the facility failed to ensure: a) ice machines and pans were cleaned and sanitized, b) appropriate glove use was followed by employees, and c) stored food and spices were not expired. This was true for 98 resident's who consumed food stored and prepared by the facility. This deficient practice placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.
Inspectors wroteBased on review of the Division of Occupational Licenses database, facility personnel records, staffing schedules, and staff interviews it was determined the facility failed to ensure all registered nurses were working with a valid nursing license. This deficient practice had the potential to significantly harm residents if licensed nurses did not have the knowledge, competencies, and skill sets to provide care and respond to resident's needs.
Inspectors wroteBased on observation, staff interviews, and review of the Left Ventricular Assist Device (LVAD) Management Manual, the facility failed to implement appropriate infection prevention and control practices during medication administration, medication storage, and a sterile dressing change for 2 of 2 residents (#2 and #50) reviewed for infection control. This failure created the potential for cross-contamination, infection, and life-threatening complications.
Inspectors wroteBased on policy review, record review, review of the State Agency's Long Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure residents' rights were protected to be free from sexual abuse. This was true for 1 of 9 residents (Resident #63) reviewed for abuse. Application of the reasonable person concept caused harm to Resident #63 when she was inappropriately touched by Resident #42.
Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 63 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.
Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an advanced directive. This was true for 6 of 16 residents (#12, #24, #42, #50, #54, and #55) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning.
Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a safe, clean, homelike environment. This was true for all 63 residents who resided in the facility whose environment was observed. This deficient practice created the potential for harm if: a) residents were embarrassed by dirty equipment and/or felt the lack of cleanliness in the facility was unacceptable, disrespectful, or undignified, and b) cross-contamination from spread of microorganisms.
Inspectors wrote2. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure and liver disease. A progress note, dated 1/3/24 at 7:52 PM, documented Resident #42 had a change in condition: shortness of breath. A physician's order, dated 1/3/24, documented to send Resident #42 to the emergency room for evaluation and treatment. A Transfer form Document Checklist, dated 1/3/24 at 7:47 PM, was not completed. Resident #42's record did not include documentation pertinent medical information was provided to the receiving hospital. On 6/27/24 11:28 AM, the DON stated the resident's orders, resident profile, POST, DPOA (Durable Power of Attorney) forms, E-INTERACT form, progress note, any labs or x-rays are sent to the hospital with the resident. Two copies of these forms are made and sent with the resident. [...]
Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled and dated; this was true for 1 of 2 medication storage rooms and 1 of 2 medication carts inspected. This failure created the potential for residents to receive expired medications with decreased efficacy.
Inspectors wroteBased on observation, and resident and staff interview, it was determined the facility failed to maintain or enhance residents' dignity during dining when residents seated at the same table were served their meals at different times. This was true for 1 of 2 residents (Resident #5) observed during dining in the facility. This failure had the potential to cause a decrease in resident's sense of self worth and psychosocial wellbeing.
Inspectors wroteBased on record review and resident and staff interview, it was determined the facility failed to ensure the physician was notified of resident weight changes as ordered. This was true for 2 of 6 residents (#12 and #48) reviewed for timely physician notification. This placed Resident #12 and Resident #48 at risk of experiencing complications related to unexpected weight changes.
Inspectors wroteBased on policy review, record review, review of facility grievances, and resident and staff interview, it was determined the facility failed to ensure grievances were investigated and prompt corrective action was taken to resolve them. This was true for 1 of 1 resident (Resident #16) reviewed for grievances. This failure created the potential for psychological harm if residents' grievances were not acted upon.
Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 1 of 16 residents (Resident #27) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plan.
Inspectors wrote2. Resident #27 was admitted to the facility on [DATE], with multiple diagnosis including heart failure and kidney disease. A physician order, dated 4/25/24, documented Resident #27 was to have half side rails x 2 to the right and left side of his bed to enable bed mobility. On 6/28/24 at 9:10 AM, with the DON present, Resident #27's bed was observed with no half side rails. On 6/28/24 at 9:13 AM, the DON stated Resident #27 should have had half side rails on her bed and the bed half side rails should have been documented in her care plan. On 6/28/24 at 1:14 PM, LPN #2 stated Resident #27 did not have half side rails on her bed and she should have. Based on record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 2 of 16 residents (#27 and #53) reviewed for quality of care. [...]
Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure respiratory equipment was stored in a sanitary manner. This was true for 1 of 1 resident (Resident #27), reviewed for respiratory services. This created the potential for respiratory infections due to growth of pathogens (organisms that cause illness) in respiratory treatment equipment.
Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure that prior to the placement of bed rails, alternatives to bed rails were attempted, individual residents were thoroughly assessed for the risk of entrapment, and consent was in place. This was true for 2 of 3 residents (#47 and #56) reviewed for bed rails. This failure created the potential for harm due to the risk of entrapment and due to lack of opportunity for the resident and/or their representative to make an informed decision regarding the use of bed rails.
Inspectors wroteBased on policy review, staff interview, and record review, it was determined the facility failed to ensure the pharmacist recognized and reported medication irregularities related to PRN psychotropic medication. This was true for 1 of 5 residents (Resident #16) whose medications were reviewed. This failure created the potential for harm should residents receive medications that were unnecessary, ineffective, or used for excessive duration.
Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure PRN anti-psychotic medications were limited to 14 days. This was true for 1 of 5 residents (Resident #16) reviewed for unnecessary medications. This deficient practice created the potential for harm if residents receive PRN anti-psychotics medications that were unwarranted, ineffective, or used for excessive duration.
Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure care was coordinated with a hospice provider and duties of the hospice provider and the facility were delineated. This was true for 1 of 3 residents (Resident #56) reviewed for hospice care. This failure created the potential for Resident #56 to receive inadequate care due to a lack of coordination between the facility and the hospice agency.
Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure census information was accurate and posted daily for each shift. This failed practice had the potential to affect the 63 residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's census levels.
Inspectors wroteBased on policy reviews, record review, observations and interviews, it was determined the facility failed to ensure residents were not served foods at high risk for transmission of food borne illness. This was true for 2 of 73 residents (#20 and #53) reviewed, who dined in the facility. This deficient practice placed Resident #20 and Resident #53 in immediate jeopardy of serious harm, impairment, or death related to Salmonellosis, an infection with Salmonella bacteria that causes diarrhea, fever and stomach pains when they consumed undercooked, unpasteurized whole shell eggs.
Inspectors wroteBased on policy review, record review, review of the State Agency's Long Term Care Reporting Portal, review of facility documents, and staff interview, it was determined the facility failed to ensure residents were free from abuse by other residents and staff. This was true for 4 of 8 residents (Residents #53, #60, #63, and #233) reviewed for abuse and neglect. This failure resulted in the potential for residents to ongoing abuse and potential harm.
Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed to prevent the development and worsening of a wound. This was true for 3 of 9 residents (Residents #1, #326, and #329) reviewed for pressure ulcers. This failure resulted in harm when Resident #1, Resident #326, and Resident #329 developed new pressure ulcers, and Resident #326 and Resident #329's pressure ulcers worsened.
Inspectors wroteBased on policy review, obsevation, record review, review of the Resident Council meeting minutes and staff interview, it was determined the facility failed to ensure there were sufficient numbers of staff available at all times to provide nursing and related services to meet the residents' needs and a charge nurse was identified for all shifts. This was true for 5 of 74 residents (#2, #40, #61, #62 and #69) reviewed for staffing concerns and had the potential to affect all resident in the facility. This created the the potential for physical and psychosocial harm if residents did not receive appropriate care or received a delay of care.
Inspectors wroteBased on policy review, observations, record review, and staff interview, it was determined the facility failed to provide a well-balanced diet that met residents nutritional and special dietary needs for 21 residents (#2, #11, #22, #26, #32, #36, #37, #41, #42, #43, #45, #47, #56, #57, #58, #59, #62, #68, #70, #72, and #176) of 74 residents residing in the facility. This resulted in residents on mechanical soft diets being served more restricted foods than their diets required and the same items repeatedly, residents on cardiac diets receiving regular foods they should not have received; and residents on renal diets receiving regular diets without any modifications.
Inspectors wroteBased on observation, record review, and staff and resident interview, it was determined the facility failed to ensure menus met the nutritional needs of the residents and menus were followed for 2 residents (Residents #10 and #40), approximately half of the residents who ate on the second floor (52 residents lived on the second floor), and to residents on regular diets (40 residents) of 74 residents residing in the facility. This put residents at risk of not having their nutritional needs met or being on a more restrictive diet than required.
Inspectors wroteBased on policy review, review of Food Committee meeting minutes, and staff interview, it was determined the facility failed to ensure concerns from the Food Committee meetings were documented and the Activity Director addressed. This deficient practice placed residents at risk of ongoing frustration and decreased sense of self-worth when their concerns were not promptly addressed by the facility.
Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to give the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage to 3 of 3 residents (Residents #58, #66, and #178) reviewed who were admitted to the facility with Medicare coverage.
Inspectors wroteBased on policy review, observation, record review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as needed. This was true for 4 of 26 residents (#10, #18, #19, #61, and #329) whose care plans were reviewed. This created the potential for harm if care and/or services were not provided appropriately due to inaccurate information in the care plan.
Inspectors wrote3. Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including lymphedema (a condition that results in swelling of the leg or arm due to blockage in the lymphatic system which is part of the immune system), Parkinson's disease ( disorder of the central nervous system that affects movement), hemiparesis (weakness of one side of the body), hemiplegia (paralysis of one side of the body), and dysarthria (difficulty speaking) following a stroke. A physician order, dated 11/29/19, directed staff to provide her nail care every Monday night. On 5/1/23 at 9:18 AM, Resident #19's representative stated Resident #19's fingernails on her left hand were too long and asked the staff to trim them. Resident #19's fingernails on her left hand were observed on 4/30/23 at 3:36 PM, 5/1/23 at 9:22 AM, and 5/2/23 at 9:01 AM. [...]
Inspectors wrote2. The Neurological Assessment policy, dated 2018, documented neurological assessments were indicated as follows: - Upon physician order; - Following an unwitnessed fall; - Following a fall or other accident/injury involving head trauma and - When indicated by resident's condition. The policy stated also stated, When assessing the neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures). This may be indicative of increasing intracranial pressure (ICP). Any change in vital signs or /neurological status in a previously stable resident should be reported to the physician immediately. This policy was not followed. [...]
Inspectors wroteBased on policy review, review of facility staffing and staff interview, it was determined the facility facility failed to ensure an RN was on duty for eight consecutive hours per day, seven days a week. This failure created the potential for harm if routine and/or emergency nursing needs went unmet and had the potential to affect all 74 residents living in the facility.
Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure residents receiving psychotropic medication had resident-specific target behaviors identified and monitored. This was true for 4 of 7 residents (#10, #12, #19, and #61) reviewed for unnecessary medications. This deficient practice created the potential for harm if residents received medications that may result in negative outcomes without clear indication of need.
Inspectors wroteBased on policy review, observation, record review, and resident and staff interview, it was determined the facility failed to serve palatable food to 8 of 8 residents (Residents #7, #13, #19, #25, #30, #34, #61, and #66) who were interviewed about food temperature and taste. This had the potential to create dissatisfaction with meals and decrease residents' quality of life.
Inspectors wroteBased on policy review, observation, record review, and resident and staff interview, it was determined the facility failed to obtain food preferences and dislikes from residents upon admission and on an ongoing basis and failed to serve preferred foods, offer choices, and provide selected foods which directly impacted 11 of 11 residents (Residents #7, #10, #19, #25, #30, #34, #38, #57, #61, #63, and #66) who were interviewed about food preferences. This had the potential to impact all residents who consumed food by mouth who resided in the facility. In addition, alternates were not always available and/or residents had to wait an extended time to receive them. These failures created the potential for dissatisfaction with meals and decreased quality of life.
Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure physician-ordered therapeutic diets were followed for 2 of 2 residents (Residents #22 and #70) whose renal diets were reviewed. This resulted in residents on renal diets receiving regular diets.
Inspectors wroteBased on policy review, observation, record review, and resident and staff interviews, it was determined the facility failed to assess whether residents had the ability to self-administer their medications for 2 of 4 residents (Residents #20 and #61) reviewed for self-administration of medications. This failure created the potential for adverse effects if medications were self administered inappropriately by the residents.
Inspectors wroteBased on policy review, observation, record review, and resident and staff interview, it was determined the facility failed to ensure a resident's light switch in the room was within reach for 1 of 1 resident (Resident #61) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident experienced falls or accidents because the room was dark and not being able to sleep when the room was too bright.
Inspectors wrote3. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease (a movement disorder that affects the nervous system), muscle weakness, and history of falling. Resident #2's care plan, dated 12/8/20, documented Resident #2 was at risk for falls r/t [related to] impaired mobility, fall prior to admission resulting in left femur [thigh bone] fracture, self-transferring, impaired cognition with poor safety awareness, elimination needs, pain, and medication regimen. A nurse's note, dated 11/18/22 at 9:00 PM, stated Resident #2 had an unwitnessed fall in her room on 11/18/22 at 8:30 PM. Resident #2 was on the floor between her wheelchair and bed and sustained a cut to her head with a moderate amount of bleeding and the nurse provided wound care by placing steri-strips (adhesive skin closure strips) to the skin opening. [...]
Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a sanitary environment. This was true for 1 of 1 resident (Resident #380) reviewed for a sanitary environment. This deficiency created the potential for cross contamination from spread of microorganisms.
Inspectors wrote2. Resident #61 was admitted to the facility on [DATE], with multiple diagnoses including cerebral ischemia (acute brain injury that results from impaired blood flow to the brain) and unsteadiness. A quarterly MDS assessment, dated 1/27/23, documented Resident #61 was cognitively intact. On 5/1/23 at 9:32 AM, Resident #61 stated he fell about a month ago and smashed the middle of his forehead. The fall was witnessed by three staff members, and there were no vital signs were taken or any assessments performed for him. Resident #61 stated he walked back to his bed by himself after the fall. The first staff member who checked him was CNA #6 the following day. Resident #61 stated the CNA #6 asked him why he had blood all over his face. Resident #61 was observed with a small raised area in the middle of his forehead when Resident #61 mentioned and pointed to it. [...]
Inspectors wrote2. Resident #61 was admitted to the facility on [DATE], with multiple diagnoses including cerebral ischemia (acute brain injury that results from impaired blood flow to the brain) and unsteadiness on feet. A quarterly MDS assessment, dated 1/27/23, documented Resident #61 was cognitively intact. On 5/1/23 at 9:32 AM, Resident #61 stated he fell about a month ago and smashed the middle of his forehead. The fall was witnessed by three staff members, and there were no vital signs were taken or any assessments performed for him. Resident #61 stated he walked back to his bed by himself after the fall. The first staff member who checked him was CNA #6. The following day, Resident #61 stated the CNA #6 asked him why he had blood all over his face. Resident #61 was observed with a small raised area in the middle of his forehead when it was mentioned and pointed to. [...]
Inspectors wroteBased on policy review, staff interview, and record review, it was determined the facility failed to ensure information was provided to the receiving hospital for 1 of 3 residents (Resident #8) reviewed for transfer. This deficient practice had the potential to cause harm if the residents were not treated in a timely manner due to lack of information.
Inspectors wroteBased on record review and interview, it was determined the facility failed to complete comprehensive assessments when residents experienced a significant change in their health and functional status. This was true for 2 of 26 residents (Residents #61 and #329) reviewed for the comprehensive assessment process. This failure had the potential for harm if facility staff did not timely recognize significant changes in residents' health status and needs.
Inspectors wroteBased on observation, record review, and resident and staff interview, it was determined the facility failed to ensure residents urinary care needs were met to decrease the risk of UTI. This was true for 2 of 5 residents (#3 and #10) reviewed for UTI and/or indwelling catheter. This failed practice placed residents at risk for UTI.
Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure nutrition and fluids were administered as ordered b y the physician for 1 of 1 resident (Resident #64) identified by the facility as receiving nutrition and fluids by tube feeding (a tube inserted through the abdomen into the stomach). This resulted in the potential for a resident to experience weight loss, poor nutritional status, and dehydration.
Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident received oxygen therapy per physician's orders. This was true for 1 of 1 (Resident #66) reviewed for respiratory care. This failure put Resident #66 at risk for oxygen toxicity (breathing oxygen at increased pressures, resulting in cell damage and death).
Inspectors wroteBased on document review and staff interview, the facility failed to assure a licensed pharmacist reviewed each residents' medications at least monthly, and the physician/prescriber addressed the medications irregularities identified by the pharmacist. This was true for 2 of 7 residents (#14 and #31) whose medications were reviewed. These deficient practices created the potential for harm if residents' medications were administered without a clinical rationale.
Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure nutritional assessments were completed. This was true for 1 of 4 residents (Resident #380) whose records were reviewed for nutritional assessments. This failure created the potential for residents to experience malnutrition.
Inspectors wroteBased on observation, policy review, record review, and resident and staff interview, it was determined the facility failed to ensure documentation of self-administration of medication was maintained. This was true for 1 of 3 residents (Resident #20) reviewed for self-administration of medication. This created the potential for harm if Resident #9 did not receive medications as ordered.
Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure nurse staffing information was posted daily for each shift, kept for review for 18 months, and accessible for residents and visitors. This failed practice had the potential to affect the 74 residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.
23 fire safety citations on file: 2 on June 28, 2024, 6 on May 8, 2023, 15 on March 29, 2019.
| Date | Penalty | Amount or length |
|---|---|---|
| September 12, 2025 | Fine | $15,327 |
| September 12, 2025 | Fine | $15,327 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Idaho | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.27 | 4.04 | 3.86 |
| Registered nurses | 0.47 | 0.86 | 0.69 |
| All nursing staff on weekends | 2.79 | 3.49 | 3.42 |
| Nurse aides | 1.73 | ||
| Licensed practical nurses | 1.07 | ||
| Nursing staff turnover (share who left in a year) | not reported | 50.3% | 45.8% |
| Registered nurse turnover | not reported | 40.9% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.89 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.47 on weekdays and 2.79 on weekends, 20% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.54 in April to June 2025 to 3.27 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.27 | 0.47 | 3.47 | 2.79 | 0.0% | 0 of 90 | 93 |
| Jul to Sep 2025 | 3.30 | 0.51 | 3.53 | 2.72 | 0.0% | 0 of 92 | 96 |
| Apr to Jun 2025 | 3.54 | 0.60 | 3.84 | 2.78 | 8.9% | 0 of 91 | 90 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Idaho, Jan to Mar 2026 | 3.90 | 0.80 | 4.11 | 3.37 | 4.9% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Idaho, all employers | |||
| CNAs (nursing assistants) | $18.58 | $17.45 to $22.23 | 7,910 |
| LPNs and LVNs | $30.67 | $28.04 to $35.60 | 1,880 |
| Registered nurses | $44.45 | $38.90 to $49.19 | 16,880 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Idaho | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 23.1 | 15.6 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.2 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.6 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.9 | 3.0 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 5.3 | 1.8 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 26.9 | 16.1 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.1 | 3.2 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 21.1 | 20.1 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 10.8 | 17.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 7.8 | 12.3 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.0 | 1.2 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.8 | 1.7 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Timber Springs Transitional Care's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (44.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
44.5% this home
No different from the national rate
US median of homes 51.5% · Idaho: 18 better, 3 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 51 eligible stays.
10.6% this home
No different from the national rate
US median of homes 10.7% · Idaho: 3 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 67 eligible stays.
6.3% this home
No different from the national rate
US median of homes 7.1% · Idaho: 1 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 36 eligible stays.
48.4% this home
Median of homes: Idaho62.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 62 residents counted.
1.3% this home
Median of homes: Idaho0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 75 residents counted.
2.6% this home
Median of homes: Idaho1.1% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 74 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Idaho98.1% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 15 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: RUSSET RIDGE HEALTHCARE LLC. CMS links this home to The Ensign Group, a group of 344 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Pennant Healthcare LLC | Direct ownership interest | Organization | 05/22/2025 | |
| The Ensign Group Inc | Indirect ownership interest | Organization | 05/22/2025 | |
| Allen, Daniel | Managing control - governing body | Individual | 07/01/2025 | |
| Arnell, Paul | Managing control - governing body | Individual | 07/01/2025 | |
| Burnam, Soon | Managing control - governing body | Individual | 05/22/2025 | |
| Burnam, Soon | Corporate officer | Individual | 05/22/2025 | |
| Keetch, Chad | Corporate officer | Individual | 03/01/2011 | |
| Allen, Daniel | Operational/managerial control | Individual | 07/01/2025 | |
| Arnell, Paul | Operational/managerial control | Individual | 07/01/2025 | |
| Farnsworth, Stephen | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 07/29/2025 | |
| Port, Barry | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 06/25/2025 | |
| Crane Creek Health Holdings LLC | Adp of the SNF | Organization | 07/01/2025 | |
| Ensign Services Inc | Adp of the SNF | Organization | 05/22/2025 | |
| Standard Bearer Healthcare Op LP | Adp of the SNF | Organization | 04/01/2025 | |
| Allen, Daniel | Adp of the SNF | Individual | 06/25/2025 | |
| Arnell, Paul | Adp of the SNF | Individual | 06/25/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Idaho. NursingHomeClear cannot take or act on complaints.