Promontory Point Rehab: Call Light Out of Reach - ID
She couldn't get to it on her own. Inspectors documented that on May 26, 2026, at 11:17 in the morning.
The resident, identified in inspection records only as Resident #9, had been admitted to the facility with a displaced trimalleolar fracture, which is a break involving three separate points of the ankle. She also carried diagnoses of major depressive disorder and diabetes. She was sitting with her legs propped up when the inspector arrived. The recliner had been pushed back against the bed. The call light was plugged into the wall, its cord hanging down and tucking under the bed frame, well beyond where she could reach.
Nobody had moved it within reach.
Two days later, on May 28, the facility's Director of Nursing confirmed what the inspection had already made plain. The call light should have been within the resident's reach. It had not been.
That was the entirety of the explanation offered.
The facility's own written policy on call light accessibility states that staff will ensure the call light is within reach of the resident and secured as needed. The policy carries no version date. What it does carry is a clear instruction that, in this case, went unfollowed.
The significance of a call light being out of reach is not abstract. For a resident with a broken ankle who cannot move freely, the call light is the difference between summoning help and waiting in silence. For someone managing diabetes, an episode of low blood sugar can become dangerous quickly. For someone living with major depressive disorder, isolation and helplessness carry their own weight. None of those conditions were unknown to the staff caring for her. All of them were documented in her record.
Federal inspectors cited the failure as a violation of residents' rights, specifically the right to have the means to call for assistance when needed. The level of harm was classified as minimal harm or potential for actual harm, affecting a small number of residents. In this case, one.
That classification reflects the regulatory scale, not the experience of sitting in a chair with a broken ankle, legs elevated, and no way to call anyone.
Promontory Point Rehabilitation is located at 3909 South 25th East in Ammon, a small city in eastern Idaho. The inspection was completed May 28, 2026, and the deficiency was recorded under CMS event ID 135137.
The inspection covered 37 residents for this particular standard. Thirty-six of them had their call lights within reach, or at least no inspector documented otherwise. Resident #9 did not.
There is no record in the inspection report of how long the call light had been positioned out of her reach before the inspector walked in at 11:17 on a Tuesday morning. There is no record of whether she had needed it during that time, or what she did when she did.
What the record shows is a woman with a fractured ankle, propped up in a recliner, with a cord running under the bed, and a facility that had a policy saying exactly what should have been done differently.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Promontory Point Rehabilitation from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
Promontory Point Rehabilitation in Ammon, ID was cited for violations during a health inspection on May 28, 2026.
She couldn't get to it on her own.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.