The Vardell Report.Timber Springs Transitional Care

Across 4 inspections from May 2023 to November 2025, state surveyors documented 67 findings at Timber Springs Transitional Care; 67 have a recorded correction; CMS lists 2 enforcement actions in the window.

Inspections

4

2023–2025, complaint and standard

Findings

67

Deficiencies cited by state inspectors

Corrected

67

Of 67 findings, with a recorded correction date

Penalties

2

2 fines; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Nov 202025

   Complaint investigation

   4 findings

   • F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Level DNo actual harm, potential for moreCorrected Dec 12, 2025
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Dec 12, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Dec 12, 2025
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Dec 12, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Sep 122025

   Standard health inspection

   15 findings

   The same visit included a complaint investigation.

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Dec 12, 2025
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F839Employ staff that are licensed, certified, or registered in accordance with state laws.Level DNo actual harm, potential for moreCorrected Oct 17, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Dec 12, 2025

   Enforcement Action

   Civil money penalty, $15,327 imposed September 12, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 12, 2025, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $15,327 imposed September 12, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 12, 2025, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Jun 282024

   Standard health inspection

   17 findings

   The same visit included a complaint investigation.

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Oct 6, 2023
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Aug 2, 2024
   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level ENo actual harm, potential for moreCorrected Aug 2, 2024
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Aug 2, 2024
   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level ENo actual harm, potential for moreCorrected Aug 2, 2024
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Aug 2, 2024
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
   • F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
   • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
   • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Aug 2, 2024
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Aug 2, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. May 82023

   Standard health inspection

   31 findings

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level JImmediate jeopardyCorrected Jun 9, 2023
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Jun 9, 2023
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jun 9, 2023
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Jun 9, 2023
   • F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level FNo actual harm, potential for moreCorrected Jun 9, 2023
   • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level FNo actual harm, potential for moreCorrected Jun 9, 2023
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Jun 9, 2023
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level ENo actual harm, potential for moreCorrected Jun 9, 2023
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Jun 9, 2023
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jun 9, 2023
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Aug 28, 2023
   • F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level ENo actual harm, potential for moreCorrected Jun 9, 2023
   • F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level ENo actual harm, potential for moreCorrected Aug 28, 2023
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Jun 9, 2023
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level ENo actual harm, potential for moreCorrected Jun 9, 2023
   • F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.Level ENo actual harm, potential for moreCorrected Jun 9, 2023
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Aug 28, 2023
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level DNo actual harm, potential for moreCorrected Aug 28, 2023
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Jun 9, 2023
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Jun 9, 2023
   • F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Level DNo actual harm, potential for moreCorrected Aug 28, 2023
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Aug 28, 2023
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Jun 9, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   A Clean, Homelike Setting, Cited in Three Inspections

   Inspectors cited F584 in May 2023, June 2024 and September 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242525F584 across all 4 inspections, oldest to newest
2. 2

   Protection From Abuse and Neglect, Cited in Three Inspections

   Inspectors cited F600 in May 2023, June 2024 and September 2025. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242525F600 across all 4 inspections, oldest to newest
3. 3

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in May 2023, June 2024 and September 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242525F684 across all 4 inspections, oldest to newest
4. 4

   Respiratory Care, Cited in Three Inspections

   Inspectors cited F695 in May 2023, June 2024 and September 2025. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242525F695 across all 4 inspections, oldest to newest
5. 5

   Citation F756, Cited in Three Inspections

   Inspectors cited F756 in May 2023, June 2024 and September 2025. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242525F756 across all 4 inspections, oldest to newest
6. 6

   Kitchen and Food Safety, Cited in Three Inspections

   Inspectors cited F812 in May 2023, June 2024 and September 2025. This citation covers how food is stored, prepared and served. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242525F812 across all 4 inspections, oldest to newest
7. 7

   Telling Families About Changes, Cited in Two Inspections

   Inspectors cited F580 in May 2023 and June 2024. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242525F580 across all 4 inspections, oldest to newest
8. 8

   Grievances, Cited in Two Inspections

   Inspectors cited F585 in June 2024 and November 2025. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242525F585 across all 4 inspections, oldest to newest
9. 9

   Investigating Alleged Violations, Cited in Two Inspections

   Inspectors cited F610 in May 2023 and September 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242525F610 across all 4 inspections, oldest to newest
10. 10

    Citation F622, Cited in Two Inspections

    Inspectors cited F622 in May 2023 and June 2024. The agency describes it this way: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242525F622 across all 4 inspections, oldest to newest
11. 11

    Post nurse staffing information every day, Cited in Two Inspections

    Inspectors cited F732 in May 2023 and June 2024. The agency describes it this way: Post nurse staffing information every day. None rose above level C (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242525F732 across all 4 inspections, oldest to newest
12. 12

    Psychotropic Medications, Cited in Two Inspections

    Inspectors cited F758 in May 2023 and June 2024. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242525F758 across all 4 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in three inspections, most seriously at level E.

2. 02

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in three inspections, most seriously at level G.

3. 03

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in three inspections, most seriously at level E.

4. 04

   Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

   Respiratory Care: cited in three inspections, most seriously at level D.

5. 05

   What changed after F756 was cited, and how do you check it now?

   Citation F756: cited in three inspections, most seriously at level D.

6. 06

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in three inspections, most seriously at level J.

7. 07

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in two inspections, most seriously at level D.

8. 08

   How do we file a grievance, who answers it, and how quickly?

   Grievances: cited in two inspections, most seriously at level D.

9. 09

   When an allegation is made, who investigates it, and how are residents protected in the meantime?

   Investigating Alleged Violations: cited in two inspections, most seriously at level D.

10. 10

    What changed after F622 was cited, and how do you check it now?

    Citation F622: cited in two inspections, most seriously at level E.

11. 11

    What changed after F732 was cited, and how do you check it now?

    Post nurse staffing information every day: cited in two inspections, most seriously at level C.

12. 12

    How many residents take psychotropic medications, and how often are doses reviewed for reduction?

    Psychotropic Medications: cited in two inspections, most seriously at level E.

13. 13

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in May 2023.

14. 14

    What led to the 2025 fine, and has it been paid?

    A $15,327 civil money penalty was imposed September 12, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Idaho state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Idaho state survey agency

  Inspection May 8, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Idaho state survey agency

  Inspection Jun 28, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Idaho state survey agency

  Inspection Sep 12, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Idaho state survey agency

  Inspection Nov 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 135098

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.