Idaho State Veterans Home - Boise

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteIdaho 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.