Cycle 1
Health 2025-03-07 · Fire 2025-03-07
13 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Boise, ID
Shaw Mountain Of Cascadia
3-star overall rating with 2-star inspections with $10,839 in total fines with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
909 Reserve Street, Boise, ID
(208) 343-7717
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
108
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascadia Healthcare
Operator or chain grouping
Approved since
1981-09-01
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 3.47 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.00
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,839
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.65
Composite VBP score used to determine payment impact.
Payment multiplier
1.0084
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.81
Baseline 17.21% · Performance 17.81% · Measure score 7.81 · Achievement 7.81 · Improvement 0
Healthcare-associated infections
6.72
Baseline 5.74% · Performance 5.83% · Measure score 6.72 · Achievement 6.72 · Improvement 0
Total nurse turnover
4.08
Baseline 74.17% · Performance 51.58% · Measure score 4.08 · Achievement 2.96 · Improvement 4.08
Adjusted total nurse staffing
2.85
Baseline 4.33 hours · Performance 3.89 hours · Measure score 2.85 · Achievement 2.85 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.76% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 127 · Observed rate 9.45% · Lower 95% interval 7.44% |
| Discharge to community | 49.52% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 46.61% · Lower 95% interval 41.77% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 98 · Denominator 98 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 98 |
| Discharge self-care score | 55.95% |
53.69%
2.3 pts better
|
Numerator 47 · Denominator 84 |
| Discharge mobility score | 51.19% |
50.94%
0.2 pts better
|
Numerator 43 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 1.02% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 98 · Adjusted rate 1.23% |
| Healthcare-associated infections requiring hospitalization | 5.83% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 2.5% · Lower 95% interval 3.27% |
| Staff COVID-19 vaccination coverage | 11.29% |
8.2%
3.1 pts better
|
Numerator 14 · Denominator 124 |
| Staff flu vaccination coverage | 35% |
42%
7 pts worse
|
Numerator 49 · Denominator 140 |
| Discharge function score | 61.9% |
56.45%
5.4 pts better
|
Numerator 52 · Denominator 84 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 50 · Denominator 50 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 31.11% |
25.2%
5.9 pts better
|
Numerator 14 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.1
0.4 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.1 |
1.6
1.5 pts better
|
1.8
1.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.1 · Observed 0.1 · Expected 2.0 · 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 | 97.8% |
96.2%
1.6 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
2.7%
0.6 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 2.4% · Q4 1.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.2% |
13.6%
13.6 pts worse
|
11.4%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.6% · Q2 25.0% · Q3 16.5% · Q4 23.7% · 4Q avg 27.2% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
5.4%
3.3 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 2.8% · Q4 2.9% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
16.2%
0.6 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 13.9% · Q3 18.1% · Q4 20.8% · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.5% |
20.5%
6 pts worse
|
16.7%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 32.1% · Q3 24.1% · Q4 21.8% · 4Q avg 26.5% · 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 | 10.3% |
17.9%
7.6 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 10.4% · Q3 4.9% · Q4 16.1% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.4% |
16.7%
9.3 pts better
|
14.9%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 9.0% · Q3 7.2% · Q4 2.9% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.5%
1.5 pts better
|
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% · 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 | 29.8% |
22.6%
7.2 pts worse
|
19.8%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 26.5% · Q3 23.0% · Q4 34.9% · 4Q avg 29.8% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.4%
3.4 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
90.2%
9.1 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 99.3% · Q3 100.0% · Q4 99.4% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.0% |
11.6%
3.4 pts worse
|
12.0%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 15.4% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
86.5%
9.3 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 8.8% |
17.5%
8.7 pts better
|
23.9%
15.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 7.7% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
11 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-21 · Fire 2022-10-21
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-07
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 2024-12-02
F · Potential for more than minimal harm
2024-02-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-17
F · Potential for more than minimal harm
2024-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-17
E · Potential for more than minimal harm
2024-02-09
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 2023-11-17
D · Potential for more than minimal harm
2024-02-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-17
D · Potential for more than minimal harm
2022-10-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-03
D · Potential for more than minimal harm
2025-12-30
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-02-03
D · Potential for more than minimal harm
2025-12-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-03
F · Potential for more than minimal harm
2025-03-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
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 2025-04-02
D · Potential for more than minimal harm
2025-03-07
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 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
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 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
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 2025-04-02
D · Potential for more than minimal harm
2025-03-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-02
D · Potential for more than minimal harm
2025-03-07
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 2025-04-02
G · Actual harm
2024-02-09
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-03-18
F · Potential for more than minimal harm
2024-02-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-03-18
F · Potential for more than minimal harm
2024-02-09
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 2024-03-18
F · Potential for more than minimal harm
2024-02-09
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-03-18
E · Potential for more than minimal harm
2024-02-09
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-03-18
E · Potential for more than minimal harm
2024-02-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-03-18
E · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-18
D · Potential for more than minimal harm
2024-02-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-18
D · Potential for more than minimal harm
2024-02-09
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 2024-03-18
D · Potential for more than minimal harm
2024-02-09
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 2024-03-18
D · Potential for more than minimal harm
2024-02-09
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-03-18
E · Potential for more than minimal harm
2022-10-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-21
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-14
D · Potential for more than minimal harm
2022-10-21
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-11-14
Penalties and ownership
What sits behind the stars
$10,839
2024-02-09
Fine
Fine · fine $10,839
Fine
Ownership
Bair, Braden
Operational/Managerial Control · Individual
Cascadia Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Cascadia Services LLC
Operational/Managerial Control · Organization
Hammond, Owen
Operational/Managerial Control · Individual
Laforte, Stephen
Operational/Managerial Control · Individual
Nelson, Timothy
Operational/Managerial Control · Individual
Timberline Ctre Tenant LLC
5% Or Greater Security Interest · Organization
White Oak Healthcare Finance LLC
5% Or Greater Security Interest · Organization
Williams, Ryan
Operational/Managerial Control · Individual
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