Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Serenity Transitional Care during CMS and state inspections, most recent first.
A resident with dementia and anxiety sustained pubic fractures after falling from a Hoyer lift during transfer when the lift's leg became stuck under a closet door and a sling strap slipped off due to inadequate planning and failure to move furniture by CNAs.
Surveyors found that food items in both refrigerated and dry storage areas were not properly labeled, sealed, or discarded by their use by dates. The CDM confirmed that expired ham, sausage, granola, and corn flakes were present, and that lettuce and cheese were not properly sealed, indicating a failure to follow required food storage and labeling standards.
Two residents with urinary drainage bags had their bags left uncovered and visible from the open doorway, and a resident with diabetes and major depressive disorder was addressed by an LPN using her room number instead of her name. The DON and ADON confirmed these actions did not meet expectations for resident dignity.
A resident with multiple chronic conditions was found self-administering Icy Hot for pain relief without a documented assessment of their ability to safely do so, as required by facility policy. The absence of this assessment was confirmed by the CCO.
A resident with obstructive sleep apnea was admitted without documentation of nightly CPAP use in the baseline care plan or a physician order for the device, despite staff assisting with its use. The omission was confirmed by facility leadership.
Controlled medications were not consistently tracked or secured due to missing nurse signatures on Narcotic Accountability Records for two medication carts. An LPN and the ADON confirmed that required signatures were not always documented when medication carts were accepted or released.
Medication and lab draw carts were found unlocked and unattended in multiple areas, with staff confirming these should have been secured. Additionally, a glucose test solution was not dated when opened, contrary to facility and manufacturer protocols.
The facility failed to serve meals on time, affecting several residents, including those with heart failure and dementia. Meals were delayed by up to 90 minutes, leading to complaints and meal refusals. The issue was attributed to staff shortages and time management problems following the departure of the previous dietary manager.
The facility failed to ensure accurate and timely MDS assessments for two residents. One resident's assessment did not reflect their hospice status and prognosis, while another's assessment was delayed due to a misunderstanding about therapy input. The MDS Coordinator and DON confirmed these discrepancies.
Two residents in an LTC facility did not receive adequate meal assistance, leading to potential harm. One resident, with severe cognitive impairment, experienced significant weight loss due to lack of supervision and feeding assistance. Another resident, with dysphagia, did not receive necessary meal cues, resulting in unsafe eating practices. Staff interviews revealed a lack of awareness and adherence to dietary needs and meal assistance requirements.
A facility failed to follow enhanced barrier precautions for a resident with an open wound, increasing the risk of spreading multidrug-resistant organisms. Despite EBP signage, staff did not wear gowns during high-contact care activities, as required by the facility's policy. Staff acknowledged the oversight, citing busyness and lack of awareness, despite having received EBP training.
Failure to Ensure Safe Hoyer Lift Transfer Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure resident safety during a Hoyer lift transfer, resulting in harm to a resident with dementia and anxiety. During the transfer, one of the Hoyer lift legs became stuck under a closet door, which caused a sling strap webbing loop to slip off one of the lift's six-point loop connections. This improper transfer led to the resident falling out of the Hoyer lift and sustaining left superior and inferior pubic fractures. The incident occurred because the CNAs did not move furniture or adequately plan the transfer process, as required by the Hoyer lift user manual. The lack of proper preparation and failure to ensure a clear path for the lift directly contributed to the accident and subsequent injury to the resident.
Improper Food Storage and Labeling Practices Identified
Penalty
Summary
Surveyors observed multiple instances of improper food storage and labeling in the facility's kitchen and dry food storage areas. In the walk-in refrigerator, ham and sausage were found with use by dates that had already passed, and both an open bag of lettuce and sliced cheese were not properly sealed. In the dry food storage area, granola and corn flakes were also found in containers with use by dates that had expired. The Certified Dietary Manager (CDM) confirmed that these items should have been used or discarded by their respective use by dates and that the lettuce and cheese should have been properly sealed. These findings indicate that the facility failed to store, distribute, and label foods in accordance with professional standards and the FDA Food Code requirements.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity as evidenced by two residents with uncovered urinary drainage bags that were visible from the open doorway of their rooms. One resident, admitted with pneumonia and urinary tract infection, and another with a history of sepsis, both had their urinary drainage bags left uncovered during observations. The Director of Nursing confirmed that the bags should have been covered but were not. Additionally, a resident with diabetes and major depressive disorder was addressed by an LPN using her room number rather than her name while in the hallway, which was acknowledged by the Assistant Director of Nursing as not being the appropriate practice.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed and evaluated for cognitive and physical ability to self-administer medications, as required by facility policy. The policy stated that residents may only self-administer medications after an interdisciplinary team determines it is safe. A resident with chronic kidney disease, COPD, and immunodeficiency was observed with an open, uncapped bottle of Icy Hot on the bedside table and reported self-administering the medication for shoulder pain. Review of the resident's medical record showed no documentation of a self-administration assessment for the Icy Hot. The Chief Clinical Officer confirmed that an assessment should have been completed but was not.
Failure to Include CPAP Use in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included a resident's need for CPAP equipment upon admission. The resident, who had diagnoses including obstructive sleep apnea and bipolar disorder, was observed with a CPAP device in his room and reported that nursing staff assisted him with its use nightly. However, the baseline care plan did not document the use of the CPAP, and there was no physician order in the medical record for its nightly use. The Chief Clinical Officer confirmed that nursing staff did not request a physician's order or include the CPAP in the care plan at the time of admission.
Failure to Document Controlled Medication Accountability
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by missing licensed nurse signatures on Narcotic Accountability Records for two of four medication carts reviewed. During an audit of the [NAME] hall medication cart, it was observed that 11 required nurse signatures were not documented on the Narcotic Accountability Record covering a 20-day period. Additionally, an audit of the East hall medication cart revealed one missing nurse signature on the corresponding record. Interviews with an LPN and the ADON confirmed that two nurses were expected to sign the Narcotic Accountability Record when accepting or releasing the medication cart, but this procedure was not consistently followed.
Failure to Secure Medications and Properly Label Biologicals
Penalty
Summary
Surveyors observed that medication and lab draw carts were left unlocked and unattended in multiple locations within the facility, including the East hall and [NAME] hall. Staff interviews confirmed that these carts contained items such as needles, draw tubes, and medications, and that they should have been locked when not in use or when unattended, but were not. Additionally, a set of glucose test solutions was found without a date indicating when it was opened. Staff, including the ADON and DON, acknowledged that glucose test solutions should be dated upon opening and discarded after three months per manufacturer recommendations, but this was not done.
Delayed Meal Service in LTC Facility
Penalty
Summary
The facility failed to ensure that resident meals were served according to the designated meal schedule, impacting four out of five residents interviewed. The facility's policy required that residents receive at least three meals daily without extensive time lapses between meals. However, observations and interviews revealed that meals were consistently served late, with lunch and dinner being delayed by up to 90 minutes. This failure had the potential to impact residents at risk for nutritional compromise, hunger, low blood sugar levels, or inadequate nutritional support. Resident #111, with multiple diagnoses including heart failure and transient cerebral ischemic attack, reported that meals were often late, with lunch served 45 minutes late and dinner 62 minutes late. Resident #30, diagnosed with hepatic encephalopathy, also reported that dinner meals were served as late as 7:00 PM, and lunch as late as 2:00 PM. Resident #20, with a history of traumatic subdural hemorrhage and heart failure, declined a late lunch served at 3:00 PM, stating it was too late to eat. Resident #29, with dementia and other diagnoses, received meals 52 and 62 minutes late on separate occasions. The facility's Resident Council minutes and grievance reports indicated ongoing issues with meal service timing, including ingredient shortages and staff miscommunication. The new Certified Dietary Manager (CDM) acknowledged the problem, attributing it to staff shortages and time management issues following the departure of the previous dietary manager. The Registered Dietitian (RD) was also aware of the complaints and was working with the previous dietary manager to find a solution.
Inaccurate and Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents accurately reflected their status at the time of the assessment and were completed within the required timeframe. Resident #30 was admitted with multiple diagnoses, including hepatic encephalopathy, and was on hospice care from the time of admission. However, the admission MDS assessment inaccurately documented the resident as cognitively intact and did not reflect the resident's hospice status or prognosis of six months or less. This discrepancy was confirmed by the MDS Coordinator and the Director of Nursing (DON) during interviews. Resident #211, admitted with diagnoses including stroke, weight loss, and a cancerous tumor of the pancreas, had an admission MDS assessment that was not completed by the required date. The MDS Coordinator acknowledged that the assessment was not submitted on time due to a misunderstanding about the need for therapy input, despite the resident being on hospice and not requiring therapy. The Assistant Director of Nursing (ADON) expressed an expectation for timely submission of assessments but admitted to a lack of knowledge about MDS assessments.
Failure to Provide Adequate Meal Assistance
Penalty
Summary
The facility failed to provide adequate meal assistance and recommendations for two residents, leading to potential harm due to dehydration and unplanned weight loss. Resident #29, who was severely cognitively impaired and at risk for weight fluctuations, experienced significant weight loss over a two-month period. Despite recommendations for close supervision, verbal cues, and feeding assistance, staff did not assist Resident #29 during meals on multiple occasions. Observations showed that Resident #29 was not seated at the assistance table as required, and staff failed to provide necessary cues or cut up food, resulting in poor meal intake. Resident #39, diagnosed with moderate protein-calorie malnutrition and dysphagia, also did not receive the required meal assistance. Despite having specific recommendations for meal supervision and cueing, staff did not follow these guidelines during meal observations. Resident #39 was observed taking large bites and not drinking between bites, which led to coughing incidents. Staff failed to intervene or provide the necessary cues to ensure safe eating practices. Interviews with staff revealed a lack of awareness and adherence to the residents' dietary needs and meal assistance requirements. The Assistant Director of Nursing (ADON) and other staff members were not fully informed about the residents' conditions and the necessary interventions. The Speech Therapist and Registered Dietitian (RD) had provided recommendations and care plans, but these were not consistently implemented by the staff, contributing to the deficiencies observed.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed for a resident, increasing the risk of spreading multidrug-resistant organisms. The facility's policy required the use of gowns and gloves during high-contact resident care activities, such as changing briefs or assisting with toileting. Resident #48, who had multiple diagnoses including a stroke and an open wound on the right lower leg, was placed on EBP as per physician orders. The care plan for Resident #48 included EBP with signage posted outside the room indicating the need for gown and glove use during specific care activities. On the day of the observation, EBP signage was present outside Resident #48's door, but staff members CNA #1 and NA #1 did not adhere to the protocol. They assisted the resident with peri care while wearing gloves but failed to wear gowns as required. NA #1 acknowledged the oversight, stating they were busy and should have worn gowns. CNA #1, who also provided care, did not notice the EBP sign and was unaware of the need to wear a gown, despite having received EBP training. This lapse in following the facility's infection control policy was confirmed during interviews with the staff involved.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 42 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Twin Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Falls Transitional Care Of Cascadia | 3.3 mi | — | 0 | 0 |
| Oak Creek Rehabilitation Center Of Kimberly | 7.4 mi | — | 27 | 0 |
| Bridgeview Estates | 10.1 mi | — | 0 | 0 |
| Cascades At Desert View | 13.2 mi | — | 2 | 0 |
| Lincoln County Care Center | 24.6 mi | — | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Serenity Transitional Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.