23 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
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
3111 Channing Way, Idaho Falls, ID
(208) 529-0067
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
88
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascadia Healthcare
Operator or chain grouping
Approved since
2013-09-05
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
RN hours / resident day
1.16
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.47 · national 3.43
Weekend RN hours
0.69
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
1.17
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
10,339
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.08% · Performance 22.53% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.87% · Performance 8.77% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.82
Baseline 100.00% · Performance 45.00% · Measure score 6.82 · Achievement 4.57 · Improvement 6.82
Adjusted total nurse staffing
1.47
Baseline 3.12 hours · Performance 3.50 hours · Measure score 1.47 · Achievement 1.47 · Improvement 0.93
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 187 · Observed rate 9.09% · Lower 95% interval 7.49% |
| Discharge to community | 49.87% |
50.57%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 192 · Observed rate 47.4% · Lower 95% interval 44.19% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.87% |
95.27%
2.6 pts better
|
Numerator 138 · Denominator 141 |
| Falls with major injury | 0.71% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 141 |
| Discharge self-care score | 64.65% |
53.69%
11 pts better
|
Numerator 64 · Denominator 99 |
| Discharge mobility score | 50.51% |
50.94%
0.4 pts worse
|
Numerator 50 · Denominator 99 |
| Pressure ulcers or injuries, new or worsened | 0.71% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 141 · Adjusted rate 0.67% |
| Healthcare-associated infections requiring hospitalization | 8.77% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 126 · Observed rate 10.32% · Lower 95% interval 5.49% |
| Staff COVID-19 vaccination coverage | 52.54% |
8.2%
44.3 pts better
|
Numerator 62 · Denominator 118 |
| Staff flu vaccination coverage | 85.8% |
42%
43.8 pts better
|
Numerator 139 · Denominator 162 |
| Discharge function score | 57.58% |
56.45%
1.1 pts better
|
Numerator 57 · Denominator 99 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 76 · Denominator 76 |
| Transfer of health information to patient | 97.37% |
96.28%
1.1 pts better
|
Numerator 37 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 40.3% |
25.2%
15.1 pts better
|
Numerator 27 · Denominator 67 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.1
1.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 3.5 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.6
0.8 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.0 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
96.8%
1.2 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 98.1% · Q3 97.9% · Q4 100.0% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.7% |
96.2%
3.5 pts worse
|
95.5%
2.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
2.7%
0.7 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.8% · Q3 0.0% · Q4 2.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.3% |
13.6%
4.3 pts better
|
11.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 6.1% · Q3 6.4% · Q4 10.6% · 4Q avg 9.3% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
5.4%
3.7 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 4.7% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.7% |
16.2%
12.5 pts worse
|
19.6%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.8% · Q2 32.7% · Q3 24.4% · Q4 17.8% · 4Q avg 28.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
20.5%
9.3 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 12.5% · Q3 10.3% · Q4 8.1% · 4Q avg 11.2% · 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 | 15.5% |
17.9%
2.4 pts better
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.0% · Q3 4.7% · Q4 29.8% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
16.7%
3.6 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 20.4% · Q3 4.5% · Q4 42.2% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.5%
1.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.9%
0.7 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.0% · Q3 2.1% · Q4 2.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.8% |
22.6%
1.8 pts better
|
19.8%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 25.7% · Q3 13.7% · Q4 18.1% · 4Q avg 20.8% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
3.4%
4.1 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 4.9% · Q3 6.8% · Q4 7.9% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
90.2%
3.8 pts better
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.7% · Q2 94.7% · Q3 97.0% · Q4 93.5% · 4Q avg 94.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
11.6%
1.5 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 13.2% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.2% · Q3 2.2% · Q4 2.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
86.5%
8.3 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
17.5%
0.4 pts worse
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 17.4% · Expected 23.2% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Assessment and Care Planning (1 deficiency)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Resident Assessment and Care Planning (2 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-10-04
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-04
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-04
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-10-04
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-10-04
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 2022-10-04
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-04
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-04
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2018-03-02
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-03-02
Fire Safety
Meet other general requirements.
Corrected 2018-03-02
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2018-03-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-03-02
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2018-03-02
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2018-03-02
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2018-03-02
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2018-03-02
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2018-03-02
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-03-02
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-03-02
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2018-03-02
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2018-03-02
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2018-03-02
Inspection history
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-09-12
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 2025-09-12
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 2025-09-12
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-24
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 2025-01-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-24
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-24
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-24
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-24
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 2025-01-24
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-24
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-24
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-01-24
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-01-24
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2025-01-24
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 2025-01-24
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-24
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-01-24
Health
Post nurse staffing information every day.
Corrected 2025-01-24
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 2025-01-24
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 2025-01-24
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-01-24
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 2022-09-02
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 2019-02-18
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 2019-02-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-02-18
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 2019-02-18
Health
Provide and implement an infection prevention and control program.
Corrected 2019-02-18
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 2019-02-18
Penalties and ownership
Fine · fine $25,604
Fine
Fine · fine $10,586
Fine
Fine · fine $7,409
Fine
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Security Interest · Organization
5% Or Greater Security Interest · Organization
Nearby options
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
Ammon, ID
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Idaho Falls, ID
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
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