Idaho State Veterans Home - Boise
320 Collins Road, Boise, ID 83702 · Government - State · 122 certified beds · (208) 780-1600 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- it has abuse, neglect, or exploitation citations (F0600, F0605) — most recent May 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 26.1% | 15.6% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.4% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.8% | 1.2% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 5.9% | 2.0% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.1% | 15.1% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.6% | 3.0% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 26.6% | 16.1% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.6% | 16.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 91.5% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.2% | 3.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.8% | 22.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.0% | 20.1% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.15 | 1.17 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.44 | 1.66 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 122 beds and averages 75.1 residents a day — about 62% occupied, or roughly 47 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.23 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.22 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.51 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.41 hrs/resident/day on weekends vs 4.56 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 1.47 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2018-11-09 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility did not ensure residents were free from chemical restraints. There was no documented evidence a systematic process of evaluation and care planning was utilized for staff to first implement resident-specific focused non-pharmacological interventions should residents demonstrate aggressive behaviors. This resulted in harm to 1 of 6 residents (Resident #261) reviewed for psychotropic drug use. Resident #261 was harmed when he experienced increased somnolence, sedation, and a decline in ADL's as a result of multiple psychotropic medications. Findings include: A facility policy, Mood and Behavior Medication Review Committee, undated, documented the committee identified and evaluated residents use of medication for behaviors or mood and the committee would determine the appropriate interventions and ensure consents, orders, and care plans were completed. The facility's ADL Behavior Monitor flowsheets documented the following…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2018-11-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and facility policy review, it was determined the facility failed to a) attempt GDR of psychotropic medications, b) monitor behavioral symptoms, c) obtain informed consents for the medications, and d) identify resident specific behaviors on the care plan. This was true for 4 of 6 residents (#2, #30, #87, and #261) reviewed for unnecessary medications. This resulted in harm to Resident #261 when he experienced increased somnolence, sedation, and a decline in ADL's as a result of multiple psychotropic medications. This deficient practice also had the potential for harm of other residents if they receive unnecessary psychotropic medications which were not adequately monitored. Findings include: A facility policy Mood and Behavior Medication Review Committee, undated, documented the committee identified and evaluated residents use of medication for behaviors or mood and the committee would determine the appropriate interventions and ensure consents, orders, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-16 · tag F0641 — widespreadEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 7 of 11 residents (#11, #26, #28, #29, #38, #46, and #52) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The RAI, revised 10/1/2024, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR level II screening determines a resident has a serious mental illness and/or mental retardation, or related condition. 1. Resident #26 was admitted to the facility on [DATE], with a diagnoses of dementia with agitation, PTSD, and Major Depressive Disorder. Resident #26's admission MDS assessment, dated 12/11/23 and Significant Change MDS dated [DATE], documented under…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-16 · tag F0760 — failed to prevent significant medication errors — widespreadEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, medication error reports, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 15 of 39 residents (#3, #12, #15, #16, #27, #33, #37, #39, #44, #46, #52, #57, #64, #73, and #281) reviewed for medication errors. This deficient practice created the potential for harm when residents received the wrong dosage of medications or did not receive their prescribed medications. Findings include: The facilities Procedure for Medication Errors/Omissions revised December 2015, documented a medication and treatment error report will be completed upon identification of any of the following: -wrong resident -wrong medication -wrong dose -wrong frequency -wrong route -omitted medication(s) 1. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, chronic pain syndrome, and rheumatoid arthritis. Resident #3's physician's order was for Oxycodone…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-16 · tag F0839 — widespreadEmploy staff that are licensed, certified, or registered in accordance with state laws.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of staff schedules, policy review, license review, and staff interview, it was determined the facility failed to ensure nursing staff possessed a license within the state where they provided care. This was true for 3 of 28 CNAs (CNA #4, CNA #5, CNA #6) and 2 of 22 Licensed nurses (LPN #1, and LPN #2) whose certifications and licenses reviewed. This deficient practice had the potential to affect all 77 residents in the facility. This failure created the potential for harm if residents received inappropriate care due to a staff lacking the required credentials to provide nursing care. Findings include: The facility's policy for Licensed Nurse Credentialing and License Verification, dated [DATE], documented the following: - Credentials and license are evaluated annually for performance appraisal for each licensed nurse. - Reverification of license is required at the intervals set by the Board of Nursing of this State. Licensed nurses are required to renew their license prior to the expiration of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-16 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, policy review, I&A report review, review of Quality Assurance Performance Improvement (QAPI) meeting minutes, and staff interview, it was determined the facility failed to ensure a QAPI plan was developed and implemented. This failure impacted 15 of 39 residents (#3, #12, #15, #16, #27, #33, #37, #39, #44, #46, #52, #57, #64, #73, and #281) whose records were reviewed for medication errors and had the potential to affect the other 38 residents residing in the facility. This created the potential for harm if residents received substandard quality of care from lack of identification and correction to quality deficiencies such as medication errors, staff training, and staff certification and licensure. Findings include: The facility's QAPI Plan, undated, documented: -Use quality assurance and performance improvement to make decisions to guide day-to-day operations. -Improve the quality of care and quality of life of residents with the outcome of QAPI. -QAPI includes all employees, all departments, and all services provided. -QAPI focuses on systems…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-05-16 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview it was determined the facility failed to ensure appropriate infection control measures were maintained. This was true when CNA #7 failed to remove personal protective equipment after coming in contact with a resident on enhanced barrier precautions, and RN#1 failed to perform hand hygiene prior to application of a clean dressing. This failed practice created the potential for adverse outcomes including infection due to cross contamination. Findings include: 1. The CDC website's article titled Consideration For Use Of Enhanced Barrier Precautions accessed on 5/23/25, documented effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care. On 5/13/25 at 9:34 AM, during a resident to staff interaction observation CNA #7 was observed leaving the shower room to take a resident back to his room while wearing a gown and a mask. CNA #7 took the resident to his room and removed her gown in his room before exiting. She then…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-05-16 · tag F0940 — failed to train staff — widespreadDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel record review and staff interview it was determined the facility failed to ensure an effective training program was maintained. This was true for 3 of 5 personnel records reviewed for training requirements. This failure created the potential for adverse outcomes including harm when staff were not educated on abuse protocols and did not have the minimum required training to provide direct care to residents in the facility. Findings include: 1. On 5/15/25 at 1:17 PM, during a personnel record review CNA #8's training record documented a total of 11.80 hours was completed out of the minimum annual 12-hour requirement. 2. On 5/15/25 at 1:21 PM, during a personnel record review CNA #9's training record documented a total of 1 hour was completed out of the minimum annual 12-hour requirement. CNA #9's record did not include training for abuse and neglect, dementia care, resident rights, and effective communication. On 5/16/25 at 10:01 AM, the Staff Development Coordinator stated CNA #8 and CNA #9 did not complete the training required and should have. 3. On 5/16/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, record review, review of the State Agency's Long-Term Care Reporting Portal, review of I&As, and staff interview, it was determined the facility failed to ensure a resident was free from abuse. This was true for 1 of 5 residents (Resident #56) reviewed for abuse. This failure created the potential for residents to experience ongoing abuse and potential harm. Findings include: The facility's Freedom from Abuse, Neglect and Exploitation policy, revised February 2020, documented each resident has the right to be free from exploitation, verbal, sexual, physical and mental abuse, serious bodily injury, corporal punishment, and involuntary seclusion. A review of the State Agency's Long-Term Care Reporting Portal, documented Resident #56 experienced abuse from the staff as follows: 1. A facility investigation report, received on 11/26/24, documented that on 11/19/24 at 10:15 PM, CNA #1 was observed standing in front of Resident #56 with his hands on Resident #56's upper arms and pushed him forcefully back down into the recliner and yelled Sit down. The facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-16 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on State Operation Manual Appendix PP, record review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a new major mental illness. This was true for 1 of 11 residents (Resident #46) reviewed for PASRR level II evaluations. This deficient practice had the potential to cause harm if the residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority to provide coordinated care. Findings include: The State Operation Manual Appendix PP revised on 8/8/24, documented if a PASRR level I identified a major mental illness, an in-depth evaluation, known as a PASRR level II evaluation is completed by the state-designated authority, which must be completed prior to admission to a nursing facility. Resident #46 was readmitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, PTSD, anxiety, and Major Depressive Disorder. Resident #46's PASRR level I,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 2 of 18 residents (#17 and #52) whose care plans were reviewed. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The CMS SOM, Appendix PP, dated 8/8/24 documented a resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. 1. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including dementia, anxiety, and PTSD. Resident #52's physician's orders documented: -Quetiapine (antipsychotic) was discontinued on 2/24/25. -Trazodone (antidepressant used as a sleep aid) was discontinued on 2/24/25. Resident #52's care plan, initiated on 8/29/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined the facility failed to ensure professional standards of practice were followed for 2 of 2 residents (Resident #38, #43) reviewed for bowel management. This failure created the potential for adverse outcome when standards of practice were not followed for bowel management. The CDC website's article titled, Guidelines on Bowel Care, accessed on 5/21/25 recommended that long-term care facilities prioritize bowel care and implement practices to prevent and manage constipation and other bowel-related issues, especially in residents at risk. This includes proactive strategies for residents with bowel incontinence or constipation. 1. Resident #38 was readmitted to the facility on [DATE], with multiple diagnoses including mild cognitive impairment and hemorrhoids. Resident #38's care plan, revised 11/25/19, directed staff to offer bowel interventions and encourage Resident #38 to sit on the toilet to promote bowel movements. Resident #38's MAR, dated 3/1/25 -…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2025-05-16 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, and staff interview, it was identified the facility failed to ensure residents were properly monitored for pain management. This was true for 3 of 4 residents (Resident #8, #43, and #46) whose records were reviewed for pain management. This failure had the potential to create harm when residents were not monitored adequately for pain. Findings include: 1. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including chronic pain syndrome and non-pressure related chronic ulcers of bilateral legs. Resident #8's quarterly MDS assessment, dated 2/25/25, documented he was cognitively intact. A pain interview for MDS, dated [DATE], documented Resident #8 had moderate pain almost constantly during the past 5 days. The interview also documented Resident #8's day-to-day activities were limited because of pain. Resident #8's care plan, revised on 6/10/24, documented the following interventions for pain: - Position for comfort - Assist with loose,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-16 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure pneumococcal immunizations were administered consistent with the current CDC recommendations. This was true for 2 of 5 residents (#39 and #72) reviewed for pneumococcal immunizations. This failure increased residents' risk for contracting pneumonia with potential negative outcome. Findings include: The CDC website's article titled Pneumococcal Vaccine Recommendations, dated 10/26/24, and accessed on 5/19/25, documented for routine vaccination, administer PCV 15, PCV 20, or PCV 21 for all adults 50 years or older: - Who have never received any pneumococcal conjugate vaccine. - Whose previous vaccination history was unknown. If PCV 15 was used, administer a dose of PPSV 23 one year later. If PCV 20 or PCV 21 was used, a dose of PPSV 23 is not indicated. Regardless of which vaccine was used (PCV 20 or PCV 21), their pneumococcal vaccination were complete. 1. Resident #39 was admitted to the facility on [DATE], with multiple…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-12-03 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Idaho Vets - Boise F 657 - Revised Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents' care plans were reviewed and updated as care needs changed. This was true for 1 of 16 residents (Resident #68) whose care plans were reviewed for smoking interventions. This deficient practice placed Resident #68 at risk of injury when his care plan was not updated to reflect his most recent smoking assessment. Findings include: The facility's Care Plan Development policy, dated 8/2018, documented when a resident's comprehensive assessment identified a change in a resident's physical or mental functioning not identified in the care plan, the care plan would be updated. This policy was not followed. Resident #68 was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body), stroke, dementia, and changes in his mental status. Resident #68's smoking care plan, dated 8/3/21, documented he had a potential for injury…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review, I&A report review, and staff interview, it was determined the facility failed to ensure residents received the level of supervision necessary to ensure tresidents with diminished cognitive ability did not elope from the facility and to ensure safe smoking practices. This was true for 2 of 17 residents (#45 and #68) reviewed for supervision. The facility's failure to implement and maintain supervision measures to prevent elopement placed Resident #45 at risk of physical harm when he eloped undetected from the facility and was found outside after dark in the rain sitting in his wheelchair which was stuck in a gutter.The facility's failure to proide supervision and care plan intervientions placed Resident #68 at risk for physical harm if he should burn himself related to unsafe smoking practices. Findings include: Findings include: 1. The facility's Elopement Risk Assessment policy documented the following: * A quarterly elopement risk assessment was completed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-12-03 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observation, and staff interview, it was determined the facility failed to ensure one medication cart and one medication storage room were locked. This deficient practice placed residents at risk if they accessed other residents' medications, alcoholic beverages, or cigarettes stored in these areas. Findings include: The facility's Medication Administration and Medication Orders policy, revised 12/2015, documented medication carts were locked when not in use. It also documented multi-use medical supplies, prescribed alcoholic drinks, and cigarettes were kept in the locked medication room. 1. On 12/1/21 at 9:01 AM, the medication cart on 2 [NAME] was observed. The drawers on the cart were opened easily with no key. The drawers contained multiple medications for residents and there was a locked narcotic box, a package of cigarettes, and a lighter. Staff were not present at the nurses' station where the medication cart was located. Resident #73 was present at the nurses' station feeding himself. On 12/1/21 at 9:06 AM, RN #1 returned to the nurses' station,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2018-11-09 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents receiving psychoactive medication had consents in place prior to initiation of the medications. This was true for 5 of 6 residents (#2, #30, #87, #100, and #261) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving psychotropic medications without knowledge of the risks and benefits associated with each medication, alternative treatment options, and the right to refuse the medications. Findings include: A facility policy Mood and Behavior Medication Review Committee, undated, documented the committee identified and evaluated residents' use of medication for behaviors or mood and the committee ensured consents were completed. a. Resident #261 was admitted to the facility on [DATE], with diagnoses including dementia with Lewy bodies (abnormal protein deposits in the brain) and behavioral disturbances, depression, and sleep disorder. A significant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2018-11-09 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, it was determined the facility failed to develop resident-specific care plans. This was true for 3 of 6 residents (#30, #87, and #261) reviewed for psychotropic medications. The residents' care plans did not include resident specific behaviors related to the use of psychotropic medicatons and/or did not include behaviors for which the psychotropic medications were administered. This failure created the potential for residents to receive inappropriate or inadequate care with a subsequent decline in health. Findings include: 1. Resident #261 was admitted to the facility on [DATE], with diagnoses including dementia with Lewy bodies and behavioral disturbances, depression, and REM sleep disorder. Resident #261 passed away at the facility on 6/14/18. A significant change MDS assessment, dated 6/7/18, documented Resident #261 was severely cognitively impaired and he was totally dependent or required extensive assistance from one to two staff members with cares.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2018-11-09 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility grievances, resident records, and facility policies, and resident, resident family, and staff interview, it was determined the facility failed to ensure there were sufficient numbers of staff to meet the supervision, restorative, and ADL needs of residents. This was true for 8 of 22 residents (#27, #30, #41, #67, #77, #93, #100, and #261) reviewed for staffing concerns, and had the potential to affect all residents residing in the facility. This deficient practice created the potential for physical and psychosocial harm if residents did not receive appropriate care or received a delay of care. Findings include: a. Residents did not receive baths/showers consistent with their needs and bathing schedules. The facility's Bathing policy and procedure, dated 10/2015, documented staff were to provide residents with bathing services at least once weekly or per resident preference. i. On 11/6/18 at 11:17 AM, Resident #93 said he did not receive showers as he should. Resident #93 stated it was due to the facility being short staffed. Resident #93 stated it irks…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2018-11-09 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, observation, and staff interview, it was determined the facility failed to ensure staff performed effective hand hygiene and implemented effective infection prevention measures related to urinary catheters. This was true for 9 of 22 residents (#2, #10, #15, #20, #28, #35, #95, #101, #103) reviewed for infection control. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include: a. The facility's Daily Catheter/Peri-Care Competency, undated, documented staff were to wash hands, put on gloves, perform peri-care, remove gloves after performing peri-care, use hand gel sanitizer and apply gloves, provide a clean brief, and then remove gloves and perform hand hygiene. This policy was not followed. On 11/5/18 beginning at 2:58 PM, CNA #16 and CNA #20 were observed assisting Resident #35 on One East of the main room of the Secured Care Unit. Resident #35 was assisted from his recliner to his wheelchair, then from his wheelchair to his bed to perform peri-care. After cares he was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-11-09 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, policy review, and record review, it was determined the facility failed to ensure a) written notice was provided to residents and/or their representatives prior to room and/or roommate changes, and b) residents were allowed to share a room with a roommate of their choice when practicable. This was true for 3 of 23 residents (#1, #30, and #89) reviewed for a room change and created the potential for harm should the residents experience a diminished sense of self-worth due to lack of control over their environment. Findings include: The facility's Change of Room or Roommate Policy/Procedure, dated 2/14/18, documented the resident would be provided with advanced written notice of a room transfer or roommate change, and the notice would include the reason for the recommended move. Prior to the room transfer, the resident, his/her roommate, and the resident's representative would be provided with information regarding the decision for the room transfer. The policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-11-09 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and policy review, it was determined the facility failed to ensure all allegations of potential abuse were thoroughly investigated. This was true for 1 of 3 residents (#76) who were reviewed for potential abuse and neglect. The failure created the potential for harm when suspected abuse was not immediately reported to the Administrator or designee, a resident was not protected, and an investigation of potential abuse for Resident #76 was not investigated. Findings include: An undated facility policy titled, Freedom from Abuse, Neglect and Exploitation, documented a person who had knowledge of potential acts of abuse, neglect, exploitation or misappropriation of resident property would report the information to an immediate supervisor or the charge nurse. The policy documented the charge nurse would report the incident to the Administrator. The policy documented all alleged violation would be thoroughly investigated by the facility. The policy documented all suspected…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-11-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and policy review, it was determined the facility failed to ensure all allegations of a potential abuse or neglect were reported to the Administrator and State Survey Agency within 2-24 hours. This was true for 1 of 3 residents (#76) reviewed for abuse/neglect and had the potential to adversely affect any resident experiencing a potential incident of abuse or neglect. The deficient practice created the potential for harm if potential abuse was not reported and investigated completely. Findings include: An undated facility policy titled, Freedom from Abuse, Neglect and Exploitation, documented a person who had knowledge of potential acts of abuse, neglect, exploitation or misappropriation of resident property would report the information to an immediate supervisor or the charge nurse. The policy documented the charge nurse would report the incident to the Administrator. The policy documented all suspected cases of abuse would be investigated following the guidelines set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-11-09 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, observation, and record review, it was determined the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were complete and accurate for 2 of 3 residents (#64 and #84) reviewed for PASARRs. The deficient practice had the potential to cause harm if residents required, but did not receive, specialized services for mental health needs while residing in the facility. Findings include: 1. Resident #64 was readmitted to the facility on [DATE], with diagnoses which included quadriplegia, major depressive disorder, bipolar disorder, anxiety disorder, and alcohol dependence in remission. An admission MDS assessment, dated [DATE], documented Resident #64 was cognitively intact and he had minimal signs and symptoms of depression. The MDS documented Resident #76 had no signs of delirium, psychosis, behaviors, rejection of care or wandering. The MDS documented a level 2 PASARR evaluation was not completed despite qualifying diagnoses. On [DATE] at 2:42 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-11-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, and policy review, it was determined the facility failed to ensure residents were provided with bathing care consistent with their needs. This was true for 2 of 5 (#30 and #41) residents reviewed for bathing. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, skin impairment, and compromised physical and psychosocial well-being. Findings include: The facility's Bathing policy and procedure, dated 10/2015, documented staff were to provide residents with bathing services at least once weekly or per resident preference. a. Resident #41 was admitted to the facility on [DATE], with diagnoses including scoliosis, arthritis, and intervertebral disc disorder. Intervertebral disc disorder is a common condition characterized by the breakdown (degeneration) of one or more of the discs that separate the bones of the spine. An admission MDS assessment, dated 8/22/18, documented Resident #41 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-11-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, policy review, and record review, it was determined the facility failed to ensure residents received treatment and services to prevent further decrease in range of motion (ROM). This was true for 3 of 5 residents (#27, #30, and #41) reviewed for treatment and services related to ROM. This deficient practice placed residents at increased risk of experiencing a decrease in mobility and function due to lack of active ROM (AROM) or passive ROM (PROM) services. Findings include: The facility's undated, Restorative policy and procedure documented staff were to provide restorative services to prevent contractures, restore normal movement, maintain function and prevent further deterioration of joints and muscles, and develop and retrain muscles. a. Resident #27 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including obesity, spinal cord injury, paraplegia, and subluxation of the distal radioulnar joint of the left wrist (partial dislocation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DIVISION OF VETERANS SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 01/01/2006 |
| HOLLOWAY, RICKY | Individual | W-2 MANAGING EMPLOYEE | — | since 06/09/2016 |
CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in ID
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Idaho Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 135131. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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