Cycle 1
Health 2025-05-01 · Fire 2025-05-01
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Twin Falls, ID
Serenity Transitional Care
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1134 Cheney Dr West, Twin Falls, ID
(208) 644-7100
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-02-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.61
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.47 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,257
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.66
Composite VBP score used to determine payment impact.
Payment multiplier
1.0049
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.25
Baseline 19.60% · Performance 18.07% · Measure score 7.25 · Achievement 7.25 · Improvement 5.44
Healthcare-associated infections
8.15
Baseline 7.09% · Performance 5.40% · Measure score 8.15 · Achievement 8.15 · Improvement 7.58
Total nurse turnover
1.44
Baseline 62.20% · Performance 57.81% · Measure score 1.44 · Achievement 1.44 · Improvement 0.67
Adjusted total nurse staffing
3.43
Baseline 3.73 hours · Performance 4.05 hours · Measure score 3.43 · Achievement 3.43 · Improvement 1.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.58% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 257 · Observed rate 5.45% · Lower 95% interval 6.1% |
| Discharge to community | 52.92% |
50.57%
2.4 pts better
|
No Different than the National Rate · Eligible stays 237 · Observed rate 52.74% · Lower 95% interval 48.36% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.97% |
95.27%
2.7 pts better
|
Numerator 145 · Denominator 148 |
| Falls with major injury | 1.35% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 148 |
| Discharge self-care score | 80.6% |
53.69%
26.9 pts better
|
Numerator 108 · Denominator 134 |
| Discharge mobility score | 70.9% |
50.94%
20 pts better
|
Numerator 95 · Denominator 134 |
| Pressure ulcers or injuries, new or worsened | 1.35% |
2.29%
0.9 pts better
|
Numerator 2 · Denominator 148 · Adjusted rate 1.54% |
| Healthcare-associated infections requiring hospitalization | 5.4% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 2.58% · Lower 95% interval 3.03% |
| Staff COVID-19 vaccination coverage | 0.85% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 117 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 73.13% |
56.45%
16.7 pts better
|
Numerator 98 · Denominator 134 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 51 · Denominator 51 |
| Transfer of health information to patient | 98.78% |
96.28%
2.5 pts better
|
Numerator 81 · Denominator 82 |
| Resident COVID-19 vaccinations up to date | 37.04% |
25.2%
11.8 pts better
|
Numerator 30 · Denominator 81 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.1
0.3 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.8 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.8%
3.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
96.2%
0.8 pts better
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
2.7%
1.9 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.2% |
13.6%
7.4 pts better
|
11.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · Q3 12.9% · Q4 3.1% · 4Q avg 6.2% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
5.4%
4.4 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
16.2%
0.6 pts worse
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 22.7% · Q3 15.4% · Q4 14.3% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.7% |
20.5%
4.2 pts worse
|
16.7%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 26.1% · Q4 25.0% · 4Q avg 24.7% · 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 | 33.0% |
17.9%
15.1 pts worse
|
16.3%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.4% |
16.7%
4.7 pts worse
|
14.9%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.8% · Q2 4.8% · Q3 24.0% · Q4 10.7% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.4% |
1.5%
3.9 pts worse
|
1.0%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 10.8% · Q4 6.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
1.9%
0.8 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.2% · Q3 3.4% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
22.6%
4.2 pts better
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 13.1% · Q3 18.5% · Q4 12.4% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
3.4%
1.4 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.2% · Q3 2.4% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
90.2%
7.1 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 95.7% · Q3 97.2% · Q4 99.5% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
11.6%
6.2 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 4.8% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.3% |
86.5%
3.8 pts better
|
79.7%
10.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
17.5%
About the same
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 15.9% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-05-10 · Fire 2019-05-10
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-05-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-05-01
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-05-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-05-01
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-05-16
E · Potential for more than minimal harm
2024-07-11
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-07-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-07-11
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-07-24
F · Potential for more than minimal harm
2019-05-10
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-03-14
F · Potential for more than minimal harm
2019-05-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-03-11
F · Potential for more than minimal harm
2019-05-10
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2019-03-07
F · Potential for more than minimal harm
2019-05-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-03-10
F · Potential for more than minimal harm
2019-05-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-03-08
F · Potential for more than minimal harm
2019-05-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-03-14
D · Potential for more than minimal harm
2019-05-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-03-13
Inspection history
Recent health citations
G · Actual harm
2025-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-25
F · Potential for more than minimal harm
2025-05-01
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 2025-05-27
D · Potential for more than minimal harm
2025-05-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-05-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-05-01
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 2025-05-27
D · Potential for more than minimal harm
2025-05-01
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 2025-05-27
D · Potential for more than minimal harm
2025-05-01
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 2025-05-27
E · Potential for more than minimal harm
2024-07-11
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-11
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-14
E · Potential for more than minimal harm
2019-05-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-10
F578 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-10
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-10
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-10
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-10
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2019-06-14
Penalties and ownership
What sits behind the stars
Ownership
Bell Property Management, LLC
5% Or Greater Indirect Ownership Interest · Organization
Bell, Jamie
5% Or Greater Direct Ownership Interest · Individual
Bell, Jamie
Operational/Managerial Control · Individual
Bell, Jamie
Corporate Director · Individual
Bell, Jamie
Corporate Officer · Individual
Bell, Troy
5% Or Greater Direct Ownership Interest · Individual
Bell, Troy
Operational/Managerial Control · Individual
Bell, Troy
Corporate Director · Individual
Campione, Buffy
Operational/Managerial Control · Individual
Dopp, Matthew
Operational/Managerial Control · Individual
Serenity Rehabilitation And Care Center, LLC
5% Or Greater Direct Ownership Interest · Organization
Serenity Rehabilitation And Care Center, LLC
Operational/Managerial Control · Organization
Tanabell Health Services, Inc.
Operational/Managerial Control · Organization
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