Promontory Point Rehab: Transfer Notice Failures - ID
That document, a bed-hold notice, is supposed to travel with a resident every time they leave for the hospital. It tells them how long their room will be held. It tells them they can return. For a resident already disoriented to time and place, already frightened, the notice is one of the few concrete assurances a nursing home can offer.
Resident 37 never got it. Neither did Resident 47.
Inspectors from the Centers for Medicare and Medicaid Services visited Promontory Point on May 28, 2026, and reviewed transfer records for 12 residents. Two of those records showed the same gap. The administrator confirmed both, one after the other, in interviews that morning and afternoon.
Resident 47 had been admitted with weakness and recent sepsis, a condition in which the body's own response to infection begins destroying its own tissue. On April 7, she was transferred to the emergency department with an increasing cough, shortness of breath, and falling oxygen levels. The hospital received her. What it apparently did not receive was her medication list, her care plan goals, or her advance directive.
Those documents are what allow a receiving hospital to understand who a patient is, what she wants, and what she's already been through. Without them, clinicians are working without a map. The inspector found no documentation in Resident 47's record that any of it had been sent.
When the administrator was asked about it on May 28 at 1:11 p.m., she said the record should have contained that documentation. It did not.
The bed-hold notice failure was confirmed separately for Resident 47 at 11:34 a.m. the same day. The administrator confirmed Resident 37's missing notice at 11:09 a.m. Four hours of interviews, two residents, the same answer twice: it should have happened, and it didn't.
The facility's own policy, last revised in December 2022, is clear on the point. In an emergency transfer, the notice goes out within 24 hours. A signed and dated copy stays in the resident's file. For both residents, inspectors found no such copy.
There was a third problem, and in some ways it was the most striking.
On May 28 at 12:07 p.m., an inspector asked for six months of the facility's notifications to the State Long-Term Care Ombudsman, the office that exists specifically to advocate for nursing home residents during transfers and discharges. Twenty-six minutes later, the administrator said the facility didn't have them.
Not incomplete records. Not partial records. No documentation at all.
The Ombudsman notification requirement exists because transfers and discharges are among the most vulnerable moments in a nursing home resident's life. They are moments when residents can be lost between systems, when paperwork determines whether someone gets to come home, when an advance directive sitting in a file at the nursing home can go unread by the doctors who need it most. The Ombudsman is supposed to know when those moments happen.
For at least six months at Promontory Point, nobody was telling them.
CMS rated the violations at the minimal harm level, meaning inspectors found potential for adverse outcomes rather than documented injury. Resident 37 was readmitted to the facility after her emergency visit. The inspection report does not say what happened to Resident 47 after her April transfer, whether she returned, whether the hospital had what it needed, whether her advance directive was ever located.
The report does not say.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 21, 2026 · Our methodology
Promontory Point Rehabilitation in Ammon, ID was cited for violations during a health inspection on May 28, 2026.
That document, a bed-hold notice, is supposed to travel with a resident every time they leave for the hospital.
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.