Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Life Safety
Deficiencies: 10
Date: Jun 4, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to assess compliance with applicable fire safety codes and regulations.
Findings
The facility failed to maintain several life safety requirements including improper hot water temperature, lack of documentation for semi-annual waterflow alarm testing, missing evidence of 5-year internal investigations and monthly inspections of fire suppression systems, incomplete UL hood suppression and cleaning inspections, failure to conduct monthly emergency light/exit signage testing, inoperable emergency light units, improper storage of oxygen cylinders, missing documentation for fuel-fired heating system inspections, and failure to conduct required fire drills at night and bi-monthly intervals.
Deficiencies (10)
Hot water temperature in the men's common area restroom was 128°F, exceeding the required maximum of 120°F.
Facility could not provide documentation of semi-annual vane type waterflow alarm device testing as required.
Annual fire alarm documentation did not list locations of devices tested; missing 5-year internal investigation and pressure gauge recalibration documentation for fire suppression systems; failed monthly inspections of pressure gauges for wet and dry systems for multiple months.
Missing documentation for one of two semi-annual UL hood suppression system inspections; last documented inspection was 4/18/25 with no prior documentation.
Missing documentation for two semi-annual UL hood cleaning inspections; last documented cleaning was January 20, 2024.
Facility last conducted annual emergency light testing for 90 minutes in January 2024 but failed monthly emergency light/exit signage testing from January through March 2025.
Emergency light units located in stairwell across from room #101 and on both sides of the salon were inoperable.
Two E-size oxygen cylinders were stored directly on the floor and one on top of a file cabinet, not secured in proper carts or racks as required.
Facility lacked documentation for annual inspection of fuel-fired heating systems covering rooftop furnace units.
Facility failed to conduct at least six fire drills annually on a bi-monthly basis including two at night during normal sleeping hours; no drills conducted between July 2024 and April 2025, and none during night hours since April 2024.
Report Facts
Temperature: 128
Date: Apr 18, 2025
Date: Jan 20, 2024
Duration: 90
Fire drills required: 6
Fire drills conducted: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Corrie | Administrator | Named as facility administrator |
| Jeremy Wilson | Survey Team Leader | Named as survey team leader conducting the inspection |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 7, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Skyline Transitional Care Center.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments for residents with serious mental illness, failure to follow professional standards for bowel and bladder care, inadequate assessment prior to bed rail installation, medication errors affecting residents, and improper cleaning and sanitation of kitchen cookware.
Deficiencies (5)
F0641: The facility failed to ensure residents' Minimum Data Set (MDS) assessments included accurate PASRR Level II screening information for 4 of 16 residents reviewed.
F0684: The facility failed to provide appropriate treatment and care for bowel and bladder incontinence for Resident #12, resulting in potential bowel obstruction due to missed medication administration.
F0700: The facility failed to assess Resident #115 for safety risks prior to placement of bed rails, creating potential for entrapment or injury.
F0760: The facility failed to ensure residents were free from significant medication errors for Residents #116 and #117, including improper insulin administration and narcotic medication errors.
F0812: The facility failed to ensure proper cleaning and sanitation of kitchen cookware, which had crusted black residue, risking foodborne illness for 64 residents.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error findings involving Residents #116 and #117 |
| DON | Director of Nursing | Provided statements and education related to medication errors and bed rail assessments |
| MDS Coordinator | Interviewed regarding inaccurate MDS assessments | |
| Social Worker | Confirmed PASRR Level II completion for Resident #8 | |
| Certified Dietary Manager | CDM | Observed and commented on kitchen cookware sanitation |
| Registered Dietitian | Observed kitchen cookware sanitation issues |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 7, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident assessments, treatment and care, medication administration, bed rail safety, food sanitation, and other facility practices.
Findings
The facility was found deficient in ensuring accurate resident assessments, appropriate treatment and care according to physician orders, proper assessment and consent for bed rail use, prevention of medication errors, and sanitation of kitchen cookware. These deficiencies posed potential risks for harm or adverse outcomes to residents.
Deficiencies (5)
F0641: The facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct PASRR Level II screening information for 4 of 16 residents reviewed, risking inaccurate assessments.
F0684: The facility failed to provide appropriate bowel care treatment for Resident #12, not administering Milk of Magnesia suspension as ordered when no bowel movement occurred for 3 days.
F0700: The facility failed to assess Resident #115 for safety risks prior to placement of mobility bars, lacking documentation of assessment and informed consent.
F0760: The facility failed to prevent significant medication errors for 2 residents, including incorrect insulin administration and narcotic medication errors, with incomplete documentation of monitoring and error causes.
F0812: The facility failed to ensure cleaning and sanitation of kitchen cookware, with crusted black residue observed on baking sheets and frying pans, risking foodborne illness for 64 residents.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 64
Days without bowel movement: 5
Days without bowel movement: 3
Medication error date: 1
Medication error date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error findings for Residents #116 and #117 |
| DON | Director of Nursing | Provided statements and education documentation related to medication errors and bed rail assessment |
| MDS Coordinator | Named in findings related to inaccurate MDS assessments | |
| Social Worker | Confirmed PASRR Level II completion for Resident #8 | |
| Certified Dietary Manager | CDM | Observed unsanitary cookware with Registered Dietitian |
| Registered Dietitian | Observed unsanitary cookware with Certified Dietary Manager |
Inspection Report
Original Licensing
Deficiencies: 8
Date: Nov 1, 2024
Visit Reason
The inspection was conducted as a health care initial licensure inspection combined with a complaint investigation.
Complaint Details
The complaint investigation found that the facility failed to provide written responses to complaints within 30 days and had other deficiencies related to medication orders and resident care.
Findings
The facility was found deficient in multiple areas including incomplete criminal background checks for employees, failure to provide written responses to complaints within 30 days, lack of current medication orders for residents, medication availability issues, improper medication destruction documentation, inadequate resident service agreements, failure to document investigations after resident incidents, and inconsistent offering of snacks and fluids to residents.
Deficiencies (8)
Two of ten employees did not have a Department Criminal History and Background Check; one employee with pending background check worked unsupervised.
Facility did not provide written responses to complainants within 30 days as required.
Four of seven sampled residents' records lacked current, signed medication orders.
Residents' as-needed and scheduled medications were not consistently available in the medication cart.
No witness present for all resident medication destruction and method of destruction was not documented.
Residents' Negotiated Service Agreements did not clearly reflect needs or describe services to be provided.
Administrator did not document investigations or corrective actions after resident incidents including falls.
Residents were not consistently offered snacks and fluids between meals and at bedtime.
Report Facts
Employees without background check: 2
Sampled residents with missing medication orders: 4
Medication patch not available: 7
Medication destruction log signatures: 1
Resident falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Corrie | Administrator | Confirmed that Department Criminal History and Background Checks were not completed and stated verbal responses were given to complainants. |
| Mina Ramirez | Survey Team Leader | Led the health care initial licensure and complaint investigation survey. |
| Resident Care Coordinator | RCC | Stated she destroyed all medications alone unless it was a narcotic substance. |
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Jan 24, 2022
Visit Reason
The inspection was an annual survey to assess compliance with regulatory requirements for nursing home care, including resident rights, abuse prevention, communication, care planning, medication administration, nutrition, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to promote resident self-determination in food choices, inadequate grievance process, failure to prevent abuse and neglect, inaccurate resident assessments, incomplete care plans, failure to provide appropriate communication aids, insufficient activity programs, medication administration errors, improper food handling and storage, failure to timely report COVID-19 cases, and unsafe environmental conditions.
Deficiencies (16)
F 0561: The facility failed to promote and facilitate Resident #4's ability to make food choices, resulting in risk of weight loss and frustration.
F 0585: The facility failed to ensure residents could file grievances anonymously and receive written responses, impacting residents' ability to voice concerns.
F 0600: The facility failed to protect residents from abuse and neglect, including failure to provide communication aids and prevent verbal abuse among residents.
F 0609: The facility failed to timely report suspected abuse and misappropriation of resident property to proper authorities.
F 0610: The facility failed to investigate allegations of abuse, neglect, and misappropriation of resident property for Residents #8 and #35.
F 0641: The facility failed to ensure Resident #12's MDS assessment accurately reflected her pressure ulcers and their staging.
F 0656: The facility failed to include Resident #35's insomnia and related medication use in his care plan.
F 0657: The facility failed to revise and update care plans as residents' needs changed and failed to include residents' representatives in care planning.
F 0676: The facility failed to provide Resident #23 with appropriate treatment and services to maintain or improve communication ability.
F 0679: The facility failed to provide an ongoing activity program designed to meet the interests and support the well-being of residents #4, #23, and #24.
F 0684: The facility failed to follow professional standards of practice for medication administration for Residents #3, #10, #17, #33, and #35, including bowel care, pain management, insulin timing, and catheter care.
F 0756: The facility failed to ensure timely action was taken to address drug regimen review irregularities identified by the consultant pharmacist for Resident #35.
F 0806: The facility failed to accommodate Resident #8's gluten-free meal preference and provide appropriate meal alternatives.
F 0812: The facility failed to properly date, label, monitor, and discard food items in the kitchen and resident food refrigerators, risking food contamination.
F 0885: The facility failed to timely notify residents' representatives and families of new COVID-19 positive cases and cumulative updates as required.
F 0921: The facility failed to ensure a safe environment by allowing use of non-UL certified power strips and unsafe placement of power strips covered by pillows in Resident #39's room.
Report Facts
Weight loss percent: 13.28
Days without bowel movement: 5
Days without bowel movement: 4
Pressure ulcer size cm: 1.5
Pressure ulcer size cm: 6
Pressure ulcer size cm: 0.4
Pressure ulcer size cm: 5
Pressure ulcer size cm: 2
Pressure ulcer size cm: 0.5
Number of COVID-19 positive staff: 3
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Mar 5, 2020
Visit Reason
The inspection was conducted to investigate complaints related to failure to document Advance Directives, failure to notify physicians timely of residents' change of condition, failure to provide transfer/discharge notifications, failure to provide bed hold notices, failure to revise care plans accurately, failure to provide adequate bathing and respiratory care, and failure to monitor psychotropic medication use.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to document Advance Directives, failure to notify physicians timely of residents' change of condition, failure to provide transfer/discharge notifications including to the Ombudsman, failure to provide bed hold notices, failure to revise care plans accurately, failure to provide adequate bathing and respiratory care, and failure to monitor psychotropic medication use.
Findings
The facility failed to ensure residents' records included Advance Directives or documentation of discussion, timely physician notification of change of condition, proper transfer/discharge notifications including to the Ombudsman, provision of bed hold notices, accurate and updated care plans, adequate bathing and respiratory care, and appropriate monitoring of psychotropic medications. These failures created potential or actual harm to residents.
Deficiencies (10)
F578: The facility failed to ensure residents' records included an Advance Directive or documentation that one was discussed or offered for 5 of 24 residents reviewed.
F580: The facility failed to notify the physician of a resident's change of condition in a timely manner, resulting in actual harm to Resident #19 who was admitted to ICU for septic shock.
F623: The facility failed to provide timely written notification of transfer or discharge to residents, representatives, and the Ombudsman for 2 residents reviewed.
F625: The facility failed to provide written bed hold notices to residents or representatives upon transfer to hospital for 2 residents reviewed.
F657: The facility failed to develop and revise care plans accurately and hold quarterly care conferences for 3 of 16 residents reviewed.
F657: The facility failed to revise care plans to reflect current toileting status for 3 residents reviewed.
F677: The facility failed to provide bathing as needed for 2 of 16 residents reviewed, resulting in potential for skin breakdown and psychosocial harm.
F684: The facility failed to obtain emergent care timely for Resident #19, who was harmed by delayed physician notification of change of condition leading to septic shock.
F695: The facility failed to provide safe and appropriate respiratory care for 2 residents, including incorrect oxygen settings and inadequate CPAP mask cleaning.
F758: The facility failed to ensure appropriate monitoring of a resident receiving antidepressant medication for insomnia, lacking documentation of sleep monitoring.
Report Facts
Residents reviewed for Advance Directive documentation: 24
Residents reviewed for care plan accuracy: 16
Residents reviewed for bathing care: 16
Residents reviewed for respiratory care: 2
Residents reviewed for psychotropic medication monitoring: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Interviewed regarding change of condition notification and transfer notifications |
| Medical Director | Interviewed regarding expectations for physician notification of change of condition | |
| RCM #1 | Interviewed regarding care plan revisions and bathing care | |
| Social Worker | Interviewed regarding Advance Directive discussions and Ombudsman notifications | |
| Recreation Therapist | Interviewed regarding Advance Directive discussions and Ombudsman notifications | |
| CNA #1 | Interviewed regarding oxygen therapy and CPAP mask cleaning | |
| CNA #2 | Interviewed regarding oxygen therapy and CPAP mask cleaning | |
| Administrator | Interviewed regarding bed hold policy notification |
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