Cycle 1
Health 2025-06-12 · Fire 2025-06-12
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Twin Falls, ID
Twin Falls Transitional Care Of Cascadia
5-star overall rating with 4-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
674 Eastland Drive, Twin Falls, ID
(208) 734-4264
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
116
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascadia Healthcare
Operator or chain grouping
Approved since
1988-03-10
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
0.63
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.47 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.47 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
2.93
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,160
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9989
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.71
Performance 17.86% · Measure score 7.71 · Achievement 7.71 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
6.47
Baseline 6.18% · Performance 5.90% · Measure score 6.47 · Achievement 6.47 · Improvement 1.88
Total nurse turnover
2.6
Baseline 67.69% · Performance 54.41% · Measure score 2.6 · Achievement 2.27 · Improvement 2.6
Adjusted total nurse staffing
1.49
Baseline 3.93 hours · Performance 3.50 hours · Measure score 1.49 · Achievement 1.49 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.96% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 9.21% · Lower 95% interval 6.57% |
| Discharge to community | 48.84% |
50.57%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 42.65% · Lower 95% interval 37.86% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 61 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 70.21% |
53.69%
16.5 pts better
|
Numerator 33 · Denominator 47 |
| Discharge mobility score | 59.57% |
50.94%
8.6 pts better
|
Numerator 28 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 61 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.9% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 0% · Lower 95% interval 2.81% |
| Staff COVID-19 vaccination coverage | 3.64% |
8.2%
4.6 pts worse
|
Numerator 2 · Denominator 55 |
| Staff flu vaccination coverage | 46.09% |
42%
4.1 pts better
|
Numerator 59 · Denominator 128 |
| Discharge function score | 70.21% |
56.45%
13.8 pts better
|
Numerator 33 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 39 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 14.71% |
25.2%
10.5 pts worse
|
Numerator 5 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
96.8%
2.2 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 97.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.0% |
96.2%
0.2 pts worse
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
2.7%
1.7 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 1.9% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.1% |
13.6%
12.5 pts worse
|
11.4%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 20.6% · Q3 23.9% · Q4 39.6% · 4Q avg 26.1% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.4%
2.2 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.3% · Q3 4.1% · Q4 3.8% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
16.2%
9.3 pts worse
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 29.5% · Q3 26.5% · Q4 20.4% · 4Q avg 25.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.3% |
20.5%
10.8 pts worse
|
16.7%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 27.6% · Q3 32.5% · Q4 28.3% · 4Q avg 31.3% · 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 | 11.3% |
17.9%
6.6 pts better
|
16.3%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
16.7%
1.3 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 11.9% · Q3 20.0% · Q4 19.6% · 4Q avg 18.0% · 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 | 1.0% |
1.9%
0.9 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 1.9% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
22.6%
3.3 pts better
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 18.8% · Q3 23.8% · Q4 9.5% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
3.4%
1.7 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 4.9% · Q3 6.8% · Q4 2.6% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
90.2%
6.6 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.1% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.3% |
11.6%
6.3 pts better
|
12.0%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.3% · Observed 5.5% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.9% |
86.5%
4.6 pts worse
|
79.7%
2.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
17.5%
0.5 pts worse
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 20.0% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-05 · Fire 2024-07-05
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-04-01 · Fire 2019-04-01
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-17
F · Potential for more than minimal harm
2025-06-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-17
E · Potential for more than minimal harm
2025-06-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-09-17
D · Potential for more than minimal harm
2025-06-12
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 2024-09-17
F · Potential for more than minimal harm
2024-07-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-18
D · Potential for more than minimal harm
2024-07-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-12
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 2025-07-11
D · Potential for more than minimal harm
2025-06-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-12
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-12
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 2025-07-11
D · Potential for more than minimal harm
2025-06-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-12
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 2025-07-11
D · Potential for more than minimal harm
2025-06-12
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 2025-07-11
D · Potential for more than minimal harm
2025-06-12
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 2025-07-11
F · Potential for more than minimal harm
2024-07-05
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 2024-08-02
D · Potential for more than minimal harm
2024-07-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-07-05
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-07-05
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 2024-08-02
D · Potential for more than minimal harm
2024-07-05
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 2024-08-02
D · Potential for more than minimal harm
2024-07-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-07-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-02
J · Immediate jeopardy
2019-04-01
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2019-05-21
G · Actual harm
2019-04-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-05-21
G · Actual harm
2019-04-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-05-21
G · Actual harm
2019-04-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-05-21
G · Actual harm
2019-04-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-05-21
E · Potential for more than minimal harm
2019-04-01
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 2019-05-21
E · Potential for more than minimal harm
2019-04-01
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 2019-05-21
D · Potential for more than minimal harm
2019-04-01
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-04-01
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 2019-05-21
D · Potential for more than minimal harm
2019-04-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-04-01
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 2019-05-21
D · Potential for more than minimal harm
2019-04-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-04-01
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 2019-05-21
D · Potential for more than minimal harm
2019-04-01
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 2019-05-21
D · Potential for more than minimal harm
2019-04-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-21
C · Minimal harm
2019-04-01
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-05-21
Penalties and ownership
What sits behind the stars
Ownership
Cascadia Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Cascadia Services LLC
Operational/Managerial Control · Organization
Dopp, Matthew
Operational/Managerial Control · Individual
Hammond, Owen
Operational/Managerial Control · Individual
Laforte, Stephen
Operational/Managerial Control · Individual
Nelson, Timothy
Operational/Managerial Control · Individual
Timberline Ohi Tenant LLC
5% Or Greater Security Interest · Organization
White Oak Healthcare Finance LLC
5% Or Greater Security Interest · Organization
Wilcox, Sawyer
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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4-star overall rating with 3-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Oak Creek Rehabilitation Center Of Kimberly
Kimberly, ID
1-star overall rating with 2-star inspections with abuse icon flag with $13,627 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Bridgeview Estates
Twin Falls, ID
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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