Cycle 1
Health 2025-02-21 · Fire 2025-02-21
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Idaho Falls, ID
Eagle Rock Health And Rehabilitation Of Cascadia
3-star overall rating with 3-star inspections with $8,018 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
840 East Elva Street, Idaho Falls, ID
(208) 523-4795
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascadia Healthcare
Operator or chain grouping
Approved since
1981-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.02
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.47 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
1.15
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,809
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9851
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.24
Baseline 19.34% · Performance 18.54% · Measure score 6.24 · Achievement 6.24 · Improvement 2.96
Healthcare-associated infections
1.56
Baseline 5.66% · Performance 7.37% · Measure score 1.56 · Achievement 1.56 · Improvement 0
Total nurse turnover
0
Baseline 41.67% · Performance 65.96% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.68
Baseline 4.19 hours · Performance 4.13 hours · Measure score 3.68 · Achievement 3.68 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.66% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 7.37% · Lower 95% interval 6.64% |
| Discharge to community | 55.38% |
50.57%
4.8 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 51.19% · Lower 95% interval 45.98% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 58 · Denominator 58 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 58 |
| Discharge self-care score | 53.49% |
53.69%
0.2 pts worse
|
Numerator 23 · Denominator 43 |
| Discharge mobility score | 72.09% |
50.94%
21.2 pts better
|
Numerator 31 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 1.72% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 58 · Adjusted rate 1.88% |
| Healthcare-associated infections requiring hospitalization | 7.37% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 8.51% · Lower 95% interval 4.13% |
| Staff COVID-19 vaccination coverage | 13.33% |
8.2%
5.1 pts better
|
Numerator 12 · Denominator 90 |
| Staff flu vaccination coverage | 44.14% |
42%
2.1 pts better
|
Numerator 64 · Denominator 145 |
| Discharge function score | 65.12% |
56.45%
8.7 pts better
|
Numerator 28 · Denominator 43 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 39 · Denominator 39 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.05% |
25.2%
4.1 pts worse
|
Numerator 8 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.1
0.1 pts worse
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
96.8%
0.2 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 97.2% · Q3 100.0% · Q4 100.0% · 4Q avg 97.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.1% |
96.2%
1.1 pts worse
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
2.7%
0.9 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 2.5% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.9% |
13.6%
1.3 pts worse
|
11.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 18.2% · Q3 25.6% · Q4 14.3% · 4Q avg 14.9% |
| Percentage of long-stay residents who lose too much weight | 8.4% |
5.4%
3 pts worse
|
5.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 11.8% · Q3 8.1% · Q4 2.0% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
16.2%
4.4 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 2.9% · Q3 5.0% · Q4 22.6% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
20.5%
7.6 pts better
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 11.5% · Q3 7.1% · Q4 21.6% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.3% |
17.9%
9.4 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 29.9% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.4% |
16.7%
5.7 pts worse
|
14.9%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 18.8% · Q3 12.8% · Q4 40.4% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.8% |
1.5%
5.3 pts worse
|
1.0%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 9.9% · Q3 5.9% · Q4 2.2% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.9%
1.9 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
22.6%
4.9 pts better
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 25.4% · Q3 10.9% · Q4 22.3% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
3.4%
1.2 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 5.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.9% |
90.2%
14.3 pts worse
|
81.7%
5.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.6% · Q2 71.6% · Q3 92.1% · Q4 83.0% · 4Q avg 75.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
11.6%
2.3 pts worse
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 14.1% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.5%
0.8 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 3.8% · Q4 3.3% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.6% |
86.5%
23.9 pts worse
|
79.7%
17.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.8% |
17.5%
2.7 pts better
|
23.9%
9.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 14.1% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-08-25 · Fire 2022-08-25
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-20
F · Potential for more than minimal harm
2024-01-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-21
F · Potential for more than minimal harm
2024-01-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-03-21
F · Potential for more than minimal harm
2024-01-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-21
F · Potential for more than minimal harm
2024-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-21
D · Potential for more than minimal harm
2024-01-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-21
D · Potential for more than minimal harm
2024-01-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-21
D · Potential for more than minimal harm
2024-01-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-21
F · Potential for more than minimal harm
2022-08-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-03-07
F · Potential for more than minimal harm
2022-08-25
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-03-18
D · Potential for more than minimal harm
2022-08-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-03-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-15
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-09-15
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-08
D · Potential for more than minimal harm
2025-09-15
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-10-08
F · Potential for more than minimal harm
2025-02-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-25
G · Actual harm
2024-08-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-08-14
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-01-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-31
D · Potential for more than minimal harm
2024-01-11
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-31
D · Potential for more than minimal harm
2024-01-11
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-01-31
E · Potential for more than minimal harm
2023-03-31
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-04-26
D · Potential for more than minimal harm
2022-08-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-09-30
Penalties and ownership
What sits behind the stars
$8,018
2024-08-14
Fine
Fine · fine $8,018
Fine
Ownership
Cascadia Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Cascadia Hc Group LLC
Operational/Managerial Control · Organization
Cascadia Healthcare LLC
Operational/Managerial Control · Organization
Cascadia Holdco LLC
Operational/Managerial Control · Organization
Cascadia Idaho Operations LLC
Operational/Managerial Control · Organization
Cascadia Services LLC
Operational/Managerial Control · Organization
Davis, Michael
Operational/Managerial Control · Individual
Hammond, Owen
Operational/Managerial Control · Individual
Idaho Falls 840 Realty, LLC
5% Or Greater Security Interest · Organization
Laforte, Stephen
Operational/Managerial Control · Individual
Nelson, Timothy
Operational/Managerial Control · Individual
Thomson, James
Operational/Managerial Control · Individual
White Oak Healthcare Finance LLC
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Life Care Center Of Idaho Falls
Idaho Falls, ID
3-star overall rating with 2-star inspections with $13,247 in total fines with 17 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Teton Healthcare Of Cascadia
Idaho Falls, ID
1-star overall rating with 1-star inspections with Special Focus status with $43,599 in total fines with 23 recent health deficiencies
#3
Promontory Point Rehabilitation
Ammon, ID
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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