Deficiencies (last 3 years)
Deficiencies (over 3 years)
38.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
385% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 20, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care planning, grievance handling, medication management, and professional standards of quality at Timber Springs Transitional Care.
Findings
The facility was found deficient in multiple areas including failure to involve residents' representatives in care planning timely, inadequate response to resident grievances regarding missing personal items, failure to implement a physician's order for symptom management medication, and administration of an antibiotic beyond the prescribed duration without documented physician authorization.
Deficiencies (4)
Failed to ensure residents' representatives were provided the opportunity to participate in the development of the resident's care plan, resulting in delayed initial care conference.
Failed to ensure grievances were acted upon when facility staff were made aware of residents' missing items, creating potential for psychosocial and physical harm.
Failed to implement a physician's order for Haldol prescribed for symptom management during end-of-life care, creating potential for untreated symptoms.
Administered Keflex antibiotic beyond the prescribed duration without documented physician authorization or clinical justification, creating potential for adverse outcomes.
Report Facts
Residents reviewed: 3
Days delayed for initial care conference: 13
Missing items: 10
Days antibiotic administered: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim DON | Interim Director of Nursing | Provided statements regarding medication order implementation and antibiotic extension |
| Social Worker | Confirmed timing of care conferences and lack of documentation for collaboration with Hospice agency | |
| Administrator | Stated facility procedures for handling missing resident items | |
| Clinical Resource Nurse | Provided information on timing requirements for initial care conferences |
Inspection Report
Annual Inspection
Deficiencies: 15
Date: Sep 12, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey of Timber Springs Transitional Care to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including environmental cleanliness, resident abuse prevention, transfer documentation, assessment accuracy, medication management, respiratory care, dental care, hydration, food safety, staff licensure, and infection control practices.
Deficiencies (15)
Failed to maintain a clean and homelike environment for Resident #2, with persistent foul urine odor and unclean conditions.
Failed to protect residents from abuse; resident-to-resident abuse incident involving Residents #87 and #113 causing harm.
Failed to ensure interventions were implemented to prevent further resident-to-resident abuse incidents involving Residents #87 and #113.
Failed to provide required documentation or notification related to resident transfers for Residents #4 and #79.
Failed to ensure accurate Minimum Data Set (MDS) assessments for Resident #10, omitting diagnoses of dementia and anxiety treatment.
Failed to provide appropriate anticoagulant monitoring for Resident #17, with missed documentation of signs and symptoms.
Failed to follow physician orders for tube feeding for Resident #72, administering incorrect nutritional supplement.
Failed to provide oxygen therapy as ordered for Resident #29, observed without oxygen and oxygen saturation at 80%.
Failed to act upon pharmacist recommendations to discontinue unnecessary medications for Resident #90.
Failed to ensure residents were free from significant medication errors; RN did not assess apical pulse prior to digoxin administration for Resident #50.
Failed to provide routine and emergency dental care timely for Resident #68 with broken tooth and oral pain.
Failed to ensure residents received hydration beverages during dining; Resident #3 observed coughing without a beverage.
Failed to procure food from approved sources and maintain food safety; issues with ice machine cleanliness, glove use, expired food, and dirty cooking equipment.
Failed to ensure all registered nurses were working with valid nursing licenses; RN #1 worked with expired license.
Failed to implement infection prevention and control practices during medication administration, medication storage, and sterile dressing change for Residents #2 and #50.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 98
Shifts worked: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Observed medication administration errors and oxygen therapy noncompliance |
| RN #1 | Registered Nurse | Worked 6 shifts with expired nursing license |
| LPN #4 | Licensed Practical Nurse | Performed sterile dressing change incorrectly for Resident #2 |
| Unit Manager #1 | Confirmed incorrect nutritional supplement administered to Resident #72 | |
| Director of Nursing | DON | Provided multiple statements regarding deficiencies and facility practices |
| Dietary Manager | DM | Interviewed regarding hydration and food safety deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 15
Date: Sep 12, 2025
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with regulatory requirements and standards of care.
Findings
The facility was found deficient in multiple areas including environmental cleanliness, resident abuse prevention, transfer documentation, assessment accuracy, medication monitoring, feeding tube administration, oxygen therapy, medication error prevention, dental care, hydration provision, food safety, staff licensure, and infection control practices.
Deficiencies (15)
Failed to maintain a clean and homelike environment for Resident #2, with persistent foul urine odor and unclean conditions.
Failed to protect Resident #87 from abuse by Resident #113, resulting in actual harm and risk to other residents.
Failed to ensure interventions to prevent further resident-to-resident abuse incidents for Residents #87 and #113.
Failed to provide required documentation or notification related to resident transfers for Residents #4 and #79.
Failed to ensure accurate Minimum Data Set (MDS) assessments for Resident #10, omitting diagnoses and treatments for anxiety and dementia.
Failed to monitor anticoagulant therapy signs and symptoms for Resident #17 as ordered.
Failed to follow physician orders for feeding tube nutritional supplement for Resident #72, administering incorrect supplement.
Failed to provide oxygen therapy as ordered for Resident #29, with resident observed without oxygen and oxygen saturation at 80%.
Failed to act upon pharmacist recommendations to discontinue unnecessary medications for Resident #90.
Failed to ensure residents were free from significant medication errors; RN did not assess apical pulse prior to digoxin administration for Resident #50.
Failed to provide routine and emergency dental care timely for Resident #68 with broken tooth and oral discomfort.
Failed to ensure residents received hydration beverages during dining; Resident #3 observed coughing without a beverage.
Failed to ensure ice machines and pans were cleaned and sanitized, appropriate glove use, and removal of expired food and spices, placing residents at risk for foodborne illness.
Failed to ensure all registered nurses worked with valid nursing licenses; RN #1 worked 6 shifts with an expired license.
Failed to implement appropriate infection prevention and control practices during medication administration, medication storage, and sterile dressing change for Residents #2 and #50.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 98
Shifts worked with expired license: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Observed medication administration errors including failure to assess apical pulse and cross-contamination |
| RN #1 | Registered Nurse | Worked 6 shifts with expired nursing license |
| LPN #4 | Licensed Practical Nurse | Performed sterile dressing change incorrectly for Resident #2 |
| Unit Manager #1 | Confirmed incorrect nutritional supplement administration for Resident #72 | |
| DON | Director of Nursing | Provided multiple statements regarding deficiencies and confirmed expectations |
| Dietary Manager | Observed hydration and food safety deficiencies |
Inspection Report
Routine
Deficiencies: 17
Date: Jun 28, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, care planning, medication management, safety, and facility environment.
Findings
The facility was found deficient in multiple areas including residents' dignity during dining, advance directive documentation, physician notification of weight changes, environmental cleanliness, grievance investigation, protection from abuse, transfer documentation, care planning, medication administration and review, respiratory care, bed rail use, staffing census posting, medication labeling, and food safety and sanitation.
Deficiencies (17)
Failed to maintain residents' dignity during dining when residents seated at the same table were served meals at different times.
Failed to ensure residents and their representatives received assistance to exercise their right to formulate an advance directive.
Failed to ensure physician was notified of resident weight changes as ordered for timely intervention.
Failed to provide a safe, clean, comfortable and homelike environment; observed dirty equipment and lack of cleaning documentation.
Failed to ensure grievances were investigated and prompt corrective action was taken to resolve them.
Failed to protect residents from sexual abuse; resident was inappropriately touched by another resident.
Failed to provide adequate documentation and convey specific information when residents were transferred or discharged.
Failed to develop and implement comprehensive resident-centered care plans including documentation of dentures and oxygen orders.
Failed to provide appropriate treatment and care according to physician orders; bed rails not installed as ordered and bowel medications not administered as ordered.
Failed to provide safe and appropriate respiratory care; oxygen tubing and nasal cannula were stored unsanitarily.
Failed to ensure prior to placement of bed rails, alternatives were attempted, risks assessed, and consent obtained.
Failed to post accurate census information daily for each shift.
Failed to ensure medications were labeled and dated; expired medications found in storage and undated insulin pens in medication cart.
Failed to ensure kitchen equipment and environment were maintained and food was stored safely and sanitarily, including improper handwashing, food storage on floor, undated food items, and incomplete cleaning schedules.
Failed to ensure licensed pharmacist performed monthly drug regimen review including recognition and reporting of medication irregularities related to PRN psychotropic medication.
Failed to implement gradual dose reductions and limit PRN orders for psychotropic medications to necessary use and duration.
Failed to ensure care was coordinated with hospice provider and delineation of responsibilities between facility and hospice agency.
Report Facts
Residents affected: 2
Residents affected: 6
Residents affected: 2
Residents affected: 63
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 5
Residents affected: 63
Residents affected: 1
Residents affected: 63
Expired medications: 5
Undated insulin pens: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Confirmed failure to notify physician of weight changes and discussed other findings |
| Director of Physical Therapy | Assessed residents for bed rail use and consent; signed siderail assessments | |
| LPN #1 | Licensed Practical Nurse | Inspected medication storage room and commented on expired medications |
| LPN #2 | Licensed Practical Nurse | Commented on undated insulin pens in medication cart |
| Infection Preventionist | IP | Reported grievance incident involving Resident #16 |
| Social Worker | SW | Discussed advance directive policy and resident reviews |
| Food Service Manager | FSM | Verified kitchen sanitation issues and cleaning schedule deficiencies |
| Dietary Supervisor | DS | Commented on food dating practices and kitchen sanitation |
Inspection Report
Routine
Deficiencies: 16
Date: Jun 28, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, care planning, medication management, safety, and facility environment.
Findings
The facility was found deficient in multiple areas including residents' dignity during dining, advance directive documentation, physician notification of weight changes, cleanliness of equipment, grievance investigation, protection from abuse, transfer documentation, care planning, medication administration and review, respiratory care, bed rail use, staffing census posting, and food safety and sanitation.
Deficiencies (16)
Failed to maintain residents' dignity during dining when residents at the same table were served meals at different times.
Failed to ensure residents and representatives received assistance to formulate advance directives.
Failed to notify physician timely of resident weight changes as ordered for 2 residents.
Failed to provide a safe, clean, homelike environment; observed dirty equipment and lack of cleaning documentation.
Failed to investigate and resolve resident grievance regarding missing medication.
Failed to protect resident from sexual abuse by another resident; facility took corrective actions.
Failed to provide adequate documentation and communication during resident transfers to hospital for 3 residents.
Failed to develop and implement comprehensive resident-centered care plans including documentation of dentures and oxygen orders.
Failed to provide treatment according to physician orders; bed rails not installed as ordered and bowel medications not administered as ordered.
Failed to provide safe and appropriate respiratory care; oxygen tubing and nasal cannula were stored unsanitarily.
Failed to ensure proper assessment, consent, and documentation for bed rail use for 2 residents.
Failed to post accurate daily census information for each shift.
Failed to ensure pharmacist performed monthly drug regimen review and reported medication irregularities related to PRN psychotropic medication.
Failed to ensure medications were labeled and dated; expired medications found and insulin pens undated.
Failed to maintain kitchen equipment and environment and store food in a safe and sanitary manner; multiple food safety violations observed including improper handwashing, food storage on floor, undated food items, and incomplete cleaning schedules.
Failed to ensure care was coordinated with hospice provider and delineation of duties between facility and hospice agency was documented.
Report Facts
Residents affected: 1
Residents affected: 6
Residents affected: 2
Residents affected: 63
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 63
Residents affected: 1
Medication items: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Confirmed communication with physicians should be recorded; reviewed multiple deficiencies and findings |
| Director of Physical Therapy | Conducted siderail assessments and discussed risks with residents | |
| LPN #1 | Licensed Practical Nurse | Present during medication room inspection; stated uncertainty about expired medication checks |
| LPN #2 | Licensed Practical Nurse | Commented on insulin pen dating practices |
| Social Worker | SW | Discussed advance directive policy and resident reviews |
| Infection Preventionist | IP | Reported grievance incident and submitted statement to DON |
| Food Service Manager | FSM | Verified kitchen cleaning practices and food storage issues |
| Dietary Supervisor | DS | Verified food dating practices and kitchen staff footwear |
Inspection Report
Routine
Deficiencies: 22
Date: May 8, 2023
Visit Reason
The inspection was a routine survey of Timber Springs Transitional Care to assess compliance with regulatory requirements including medication self-administration, resident rights, notification of changes in condition, abuse prevention, care planning, nursing staffing, dietary services, and other aspects of resident care.
Findings
The facility was found deficient in multiple areas including failure to assess and document residents' ability to self-administer medications, failure to ensure resident rights such as accessible light switches, failure to notify family members timely of changes in condition, failure to provide required Medicare notices, failure to investigate abuse allegations thoroughly, failure to complete comprehensive assessments after significant changes, failure to revise care plans as residents' conditions changed, failure to provide appropriate pressure ulcer care, failure to provide adequate catheter care, failure to provide nutrition and fluids as ordered, failure to ensure sufficient nursing staff and charge nurse coverage, failure to post nurse staffing information, failure to provide palatable and properly prepared food meeting residents' dietary needs and preferences, and failure to ensure food safety related to unpasteurized eggs.
Deficiencies (22)
Failure to assess and document residents' ability to self-administer medications, including Resident #20's albuterol inhaler self-administration and documentation.
Failure to ensure resident rights such as accessible light switches for Resident #61.
Failure to notify family members timely of changes in condition for Residents #2, #19, and #231.
Failure to provide Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (CMS-10055) to residents discharged from Medicare Part A coverage.
Failure to provide a sanitary environment related to a cat litter box in Resident #380's room.
Failure to ensure residents were free from abuse by other residents and staff, including incidents involving Residents #53, #60, #63, and #233.
Failure to timely report suspected abuse, neglect, or injury of unknown origin and failure to investigate thoroughly for Residents #19 and #61.
Failure to ensure safe and effective transfer of Resident #8 to hospital with necessary documentation.
Failure to complete comprehensive assessments when residents experienced significant changes in condition for Residents #61 and #329.
Failure to revise and update care plans to reflect current needs for Residents #10, #18, #19, #61, and #329.
Failure to provide bathing, nail care, and oral care consistent with residents' needs for Residents #10, #19, #40, and #326.
Failure to follow professional nursing standards including timely neurological assessments after falls or head injuries for Residents #2, #19, #61, #66, and #327.
Failure to provide consistent pressure ulcer preventive care including barrier cream use, wound assessment, and repositioning for Residents #1, #326, and #329.
Failure to provide catheter care and appropriate urinary care to Residents #3 and #10, increasing risk for urinary tract infections.
Failure to provide nutrition and fluids as ordered for Resident #64 receiving tube feeding.
Failure to ensure oxygen therapy was provided per physician orders for Resident #66.
Failure to ensure sufficient nursing staff and charge nurse coverage for all shifts, impacting multiple residents.
Failure to post nurse staffing information daily and maintain records for review.
Failure to provide a well-balanced diet meeting residents' nutritional and special dietary needs, including mechanical soft, cardiac, and renal diets, and failure to follow menus and provide palatable food at proper temperatures.
Failure to ensure therapeutic diets were prescribed and followed for Residents #22 and #70.
Failure to obtain and honor residents' food preferences and dislikes, and failure to provide choices and alternates, impacting multiple residents.
Failure to ensure food safety by serving unpasteurized eggs that were not fully cooked to Residents #20 and #53, resulting in immediate jeopardy.
Report Facts
Medication reviews missed: 5
Nurse staffing days without RN coverage: 44
Menu changes: 45
Days with incomplete behavior monitoring: 9
Days with incomplete behavior monitoring: 7
Days with incomplete behavior monitoring: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nursing Assistant | Named in abuse investigation for Resident #63 involving rough incontinence care. |
| CNA #10 | Certified Nursing Assistant | Named in abuse investigation for Resident #233 involving disrespectful and aggressive behavior. |
| CNA #13 | Certified Nursing Assistant | Named in abuse investigation for Resident #60 involving inappropriate hand gesture. |
| RN #2 | Registered Nurse | Failed to document and notify regarding Resident #19's bruise. |
| LPN #4 | Licensed Practical Nurse | Confirmed Resident #61's unaddressed forehead injury and oxygen order for Resident #66. |
| LPN #5 | Licensed Practical Nurse | Observed disconnected feeding tube and restarted feeding for Resident #64. |
| LPN #1 | Licensed Practical Nurse | Stated neuro checks should be done immediately after falls. |
| DON | Director of Nursing | Multiple statements regarding deficiencies including notification, neuro checks, staffing, and dietary issues. |
| DM | Dietary Manager | Provided information on menu planning, dietary concerns, and food safety. |
| LSW | Licensed Social Worker | Discussed behavior monitoring and food preference assessments. |
Inspection Report
Routine
Deficiencies: 26
Date: May 8, 2023
Visit Reason
The inspection was a routine survey of Timber Springs Transitional Care to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including medication self-administration documentation, resident rights accommodations, notification of family for changes in condition, nutritional and dietary services, abuse prevention and investigation, staffing sufficiency, and pressure ulcer care. Several residents were found to have unmet needs or improper care related to these areas.
Deficiencies (26)
Facility failed to assess residents for self-administration of medication and maintain documentation for Resident #20 and #61.
Facility failed to ensure Resident #61's light switch was within reach, posing risk of falls or accidents.
Facility failed to document and address concerns from Food Committee meetings, leading to resident frustration.
Facility failed to immediately notify family members of changes in condition for Residents #2, #19, and #231.
Facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (CMS-10055) to residents discharging with Medicare Part A coverage.
Facility failed to provide a sanitary environment related to a cat litter box in Resident #380's room.
Facility failed to ensure residents were free from abuse by staff and other residents, including incidents involving Residents #53, #60, #63, and #233.
Facility failed to timely report suspected abuse, neglect, or injury of unknown origin for Residents #19 and #61.
Facility failed to thoroughly investigate allegations of abuse and injury of unknown origin for Residents #19 and #61.
Facility failed to ensure information was provided to the receiving hospital for Resident #8 during transfer.
Facility failed to complete comprehensive assessments when residents experienced significant changes in condition for Residents #61 and #329.
Facility failed to revise and update care plans to reflect current needs for Residents #10, #18, #19, #61, and #329.
Facility failed to provide bathing, nail care, and oral care consistent with residents' needs for Residents #10, #19, #40, and #326.
Facility failed to ensure professional nursing standards were followed including timely neurological assessments and adherence to physician orders for Residents #2, #19, #61, #66, and #327.
Facility failed to provide consistent pressure ulcer preventive care including barrier cream use and repositioning for Residents #1, #326, and #329.
Facility failed to ensure residents' urinary care needs were met to decrease risk of urinary tract infection for Residents #3 and #10.
Facility failed to ensure nutrition and fluids were administered as ordered for Resident #64 receiving tube feeding.
Facility failed to ensure oxygen therapy was provided per physician orders for Resident #66.
Facility failed to ensure sufficient nursing staff and charge nurse coverage to meet residents' needs.
Facility failed to post nurse staffing information daily and maintain records for 18 months.
Facility failed to ensure residents on mechanical soft, cardiac, and renal diets received meals consistent with their prescribed diets and preferences.
Facility failed to ensure menus met nutritional needs, were followed, and reviewed by a dietitian.
Facility failed to ensure food was palatable, attractive, and served at safe and appetizing temperatures for residents.
Facility failed to ensure residents' food preferences and dislikes were obtained, honored, and alternates provided timely.
Facility served unpasteurized whole shell eggs that were not fully cooked to Residents #20 and #53, placing them in immediate jeopardy of food borne illness.
Facility failed to ensure documentation of self-administration of medication was maintained for Resident #20.
Report Facts
Deficiencies cited: 45
Residents affected: 74
Residents affected: 26
Residents affected: 9
Residents affected: 7
Residents affected: 5
Residents affected: 8
Residents affected: 11
Residents affected: 2
Residents affected: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #6 | Mentioned in relation to Resident #61 fall and medication self-administration | |
| LPN #4 | Mentioned in relation to Resident #61 light switch and oxygen therapy | |
| DON | Director of Nursing | Mentioned in relation to multiple findings including notification of family, neuro checks, medication documentation, and staffing |
| DM | Dietary Manager | Mentioned in relation to food service, menu planning, and dietary concerns |
| LSW | Licensed Social Worker | Mentioned in relation to Food Committee concerns and psychotropic medication monitoring |
| Administrator | Mentioned in relation to abuse reporting and food service concerns | |
| CNA #8 | Mentioned in relation to abuse incident with Resident #63 | |
| CNA #13 | Mentioned in relation to abuse incident with Resident #60 | |
| CNA #10 | Mentioned in relation to abuse incident with Resident #233 | |
| CNA #15 | Mentioned in relation to catheter care for Resident #10 | |
| LPN #1 | Mentioned in relation to catheter care and neuro checks | |
| LPN #2 | Mentioned in relation to staffing and medication self-administration | |
| LPN #3 | Mentioned in relation to charge nurse staffing | |
| CNA #5 | Mentioned in relation to PureWick catheter care | |
| CNA #7 | Mentioned in relation to PureWick catheter care and resident transfers | |
| CNA #9 | Mentioned in relation to abuse incident with Resident #233 | |
| CNA #11 | Mentioned in relation to abuse incident with Resident #233 | |
| CNA #12 | Mentioned in relation to abuse incident with Resident #60 | |
| CNA #14 | Mentioned in relation to abuse incident with Resident #60 | |
| Therapy Staff #1 | Mentioned in relation to ROHO cushion assessment | |
| Therapy Staff #2 | Mentioned in relation to ROHO cushion assessment |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 18, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
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