Cascadia of Boise

In the surveyor’s words

From the most serious findings on record at Cascadia of Boise, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 22, 2023

  Based on policy review, I&A review, record review, and staff interview, it was determined the facility failed to ensure adequate supervision for residents to prevent falls. This was true for 1 of 3 residents, (Resident #21) whose records were reviewed for falls. This resulted in harm to Resident #21. Findings include: The facility's Accidents and Supervision to Prevent Accidents policy, revised on 10/15/22, stated facilities were obligated to provide adequate supervision to prevent accidents. Adequate supervision was determined by assessing the appropriate level of care and number of staff required, the competency of the staff, and the frequency of supervision needed. […]

• Actual harm, isolatedF684Jun 11, 2021

  Based on observation, staff interview, policy review, and record review, it was determined the facility failed to ensure professional standards of practice were met related to management of wounds, medication administration, failure to notify the physician of a change in condition, and failure to apply skin protection to prevent skin breakdown. This was true for 4 of 13 residents (#1, #4, #11 and #13) reviewed for treatment and care. Specifically: * Resident #4 was harmed when the facility did not assess, monitor and treat her abdominal wound according to professional standards of practice which resulted in hospitalization . […]

• Actual harm, isolatedF697Jun 11, 2021

  Based on record review, staff interview, and policy review, it was determined the facility failed to ensure residents end-of-life pain management needs and preferences were effectively assessed, treated, and integrated into the residents' individualized care plans. This was true for 1 of 12 residents (Resident #2) reviewed for pain management. Resident #2's pain related to his terminal cancer was not effectively managed to maintain his comfort the days prior to, and during, the final hours of his life, resulting in excruciating breakthrough pain. Findings include: The facility's Palliative Care policy, dated 11/20/17, documented palliative care is primarily directed at providing relief to a terminally ill person through symptom management. […]

• Actual harm, isolatedF684Apr 2, 2021

  Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident was sufficiently assessed after a fall and failure to notify the physician after a medication error occurred for 2 of 8 residents (Residents #3 and #5) whose records were reviewed. This resulted in the potential for residents to experience adverse effects from a neurological injury and medications. Findings include: 1. The facility's Care Plan policy, revised 11/28/19, stated staff were to implement immediate interventions to prevent falls, determine whether the resident experienced head trauma requiring further diagnostic evaluation to rule out a subdural hematoma, perform neurologic assessments, investigate the fall, revise the plan of care, and document the post-fall… […]

• No harm, potential for more than minimal, patternF725May 13, 2026

  Based on resident interviews, representative interviews, staff interviews, observations, review of grievances, and review of the three-week nursing schedule, it was determined the facility failed to ensure sufficient staffing was available to meet resident needs according to their plan of care. This failure had the potential to affect all residents residing in the facility if staff were not available to ensure resident needs and safety measures were provided. Findings include: The National Academies of Sciences, Engineering, and Medicine (NASEM) website accessed on 5/13/26, article titled The National Imperative to Improve Nursing Home Quality (2022) documents, inadequate staffing contributes to delayed care, missed care tasks, and reduced resident safety. […]