Cycle 1
Health 2025-09-18 · Fire 2024-07-26
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Nampa, ID
Wellspring Health & Rehabilitation Of Cascadia
4-star overall rating with 3-star inspections with $30,927 in total fines with 1 recent health deficiencies
2105 12th Avenue Road, Nampa, ID
(208) 467-5721
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
120
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascadia Healthcare
Operator or chain grouping
Approved since
1983-09-09
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
0.72
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.70
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
1.29
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
0.32
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.01
CMS adjusted total nurse staffing hours
Case-mix index
1.81
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,269
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.70
Baseline 19.24% · Performance 20.18% · Measure score 2.70 · Achievement 2.70 · Improvement 0
Healthcare-associated infections
2.20
Baseline 5.63% · Performance 7.18% · Measure score 2.20 · Achievement 2.20 · Improvement 0
Total nurse turnover
3.47
Baseline 49.37% · Performance 49.49% · Measure score 3.47 · Achievement 3.47 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.13 hours · Performance 3.06 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.07% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 7.41% · Lower 95% interval 6.02% |
| Discharge to community | 60.58% |
50.57%
10 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 60.38% · Lower 95% interval 48.11% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 47 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 26.19% |
53.69%
27.5 pts worse
|
Numerator 11 · Denominator 42 |
| Discharge mobility score | 45.24% |
50.94%
5.7 pts worse
|
Numerator 19 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 47 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.18% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 6.82% · Lower 95% interval 4% |
| Staff COVID-19 vaccination coverage | 10.24% |
8.2%
2 pts better
|
Numerator 13 · Denominator 127 |
| Staff flu vaccination coverage | 35.34% |
42%
6.7 pts worse
|
Numerator 47 · Denominator 133 |
| Discharge function score | 54.76% |
56.45%
1.7 pts worse
|
Numerator 23 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 34.62% |
25.2%
9.4 pts better
|
Numerator 9 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
96.8%
2.9 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.1% |
96.2%
0.1 pts worse
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
2.7%
0.5 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 1.2% · Q4 2.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
13.6%
12.1 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 2.6% · Q4 1.4% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.4%
2.5 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 4.5% · Q3 5.3% · Q4 7.4% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
16.2%
0.9 pts worse
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 17.9% · Q3 15.6% · Q4 16.0% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
20.5%
11.1 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 8.2% · Q3 9.6% · Q4 9.1% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.1%
0.2 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.5% |
17.9%
12.4 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 6.9% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
16.7%
0.6 pts worse
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 6.0% · Q3 22.2% · Q4 26.1% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.5%
1.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.9%
1.6 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.1% |
22.6%
2.5 pts worse
|
19.8%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 19.8% · Q3 24.7% · Q4 31.9% · 4Q avg 25.1% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
3.4%
4.3 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 9.4% · Q3 5.8% · Q4 8.8% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
90.2%
0.9 pts better
|
81.7%
9.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.9% · Q2 91.6% · Q3 95.5% · Q4 94.8% · 4Q avg 91.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.6% |
11.6%
7 pts worse
|
12.0%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 20.0% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.2% |
86.5%
3.7 pts better
|
79.7%
10.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
17.5%
0.3 pts worse
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 20.0% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-26 · Fire 2019-11-15
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2019-11-15 · Fire 2019-03-01
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2019-11-15
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-10-07
F · Potential for more than minimal harm
2019-11-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-10-07
F · Potential for more than minimal harm
2019-11-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-07
F · Potential for more than minimal harm
2019-11-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-10-07
E · Potential for more than minimal harm
2019-11-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-11-15
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-11-15
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-11-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-10-07
D · Potential for more than minimal harm
2019-11-15
K924 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that anesthesia apparatus are tested after any adjustment, modification or repair.
Corrected 2019-10-07
F · Potential for more than minimal harm
2019-03-01
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-03-15
F · Potential for more than minimal harm
2019-03-01
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-03-27
F · Potential for more than minimal harm
2019-03-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-03-15
E · Potential for more than minimal harm
2019-03-01
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2019-03-15
D · Potential for more than minimal harm
2019-03-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-03-15
D · Potential for more than minimal harm
2019-03-01
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-03-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-18
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 2025-10-24
L · Immediate jeopardy
2024-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-27
G · Actual harm
2024-07-26
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 2024-08-27
E · Potential for more than minimal harm
2024-07-26
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 2024-08-27
E · Potential for more than minimal harm
2024-07-26
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-26
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-26
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 2024-08-27
D · Potential for more than minimal harm
2024-07-26
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 2024-08-27
D · Potential for more than minimal harm
2024-07-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-08-27
D · Potential for more than minimal harm
2019-11-15
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 2019-12-18
D · Potential for more than minimal harm
2019-11-15
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 2019-12-18
D · Potential for more than minimal harm
2019-11-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-12-18
D · Potential for more than minimal harm
2019-11-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-12-18
D · Potential for more than minimal harm
2019-11-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-12-18
D · Potential for more than minimal harm
2019-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-18
C · Minimal harm
2019-11-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-12-18
Penalties and ownership
What sits behind the stars
$30,927
2024-07-26
Fine
Fine · fine $30,927
Fine
Ownership
Allen, Daniel
Operational/Managerial Control · Individual
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
Hammond, Owen
Operational/Managerial Control · Individual
Hintz, Jesse
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
Nearby options
Other facilities in reach
#1
Sunny Ridge
Nampa, ID
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Meadow View Nursing And Rehabilitation
Nampa, ID
3-star overall rating with 3-star inspections with $8,018 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Orchards Of Cascadia, The
Nampa, ID
1-star overall rating with 1-star inspections with Special Focus status with $8,824 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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