Idaho State Veterans Home - Boise

In the surveyor’s words

From the most serious findings on record at Idaho State Veterans Home - Boise, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 21, 2026

  Based on staff interviews, policy, and record review, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 4 of 7 residents (#84, #71, #27, and #26) reviewed for abuse and neglect. The facility failed to prevent resident to resident altercations resulting in harm between Resident #84 and #71; failed to ensure wound care needs were met for Resident #27; and failed to prevent verbal abuse and neglect for Resident #26. Findings include: The facility's Freedom for Abuse, Neglect, Mistreatment, and Exploitation policy, revised 6/24, documented: Residents of the facility have the right to be free from all forms of abuse, neglect, exploitation, involuntary seclusion, injuries of unknown origin, misappropriation of property, and any crime.1. […]

• Actual harm, isolatedF689Aug 21, 2026

  Based on observations, record review, review of incident and accidents (I&A), review of the State Agency's Long-Term Care Reporting Portal, and staff interviews, it was determined the facility failed to ensure adequate supervision and the use of required assistive devices were used to prevent accidents. This was true for 1 of 11 residents (#21) reviewed for accidents. This deficient practice resulted in actual harm to Resident #21 who sustained a fall with a significant injury requiring emergency medical transport. Findings include:1. […]

• No harm, potential for more than minimal, widespreadF641May 16, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF760May 16, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF839May 16, 2025

  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. […]