Idaho State Veterans Home - Pocatello

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF578Aug 7, 2025

  Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 10 of 54 residents (#1, #2, #4, #9, #19, #26, #27, #29, #46, and #55) whose records were reviewed for advance directives. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning. […]

• No harm, potential for more than minimal, patternF684Aug 7, 2025

  Based on the facility Bowel Management Protocol, record review and staff interview, it was determined the facility failed to follow the facility bowel care standing order of delivering specific medications when residents do not have BM within 72 hours for 5 of 16 Residents (#5, #9, #11, #26, and #35) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include:The facility Bowel Management Protocol dated 4/2018, documented a resident's bowel movement(s) will be documented in Point of Care every shift. […]

• No harm, potential for more than minimal, isolatedF550Aug 7, 2025

  Based on observations and interviews, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 1 of 4 residents (Residents #19) observed for covered urinary drainage bag. This deficient practice had the potential for residents to experience embarrassment, and low feelings of self-worth. Findings include: Resident #19 was admitted on [DATE] with readmit on 6/17/24, with multiple diagnoses including heart failure, diabetes, and obstructive uropathy (condition when urine cannot drain through the urinary tract). On 8/4/25 at 2:31 PM, Resident #19's urinary drainage bag was uncovered and visible from the open doorway of his room. On 8/4/25 at 3:26 PM, the DON stated the urinary drainage bag should have been covered and was not.

• No harm, potential for more than minimal, isolatedF600Aug 7, 2025

  Based on policy review, record review, and staff interview, it was determined the facility failed to ensure resident's rights to be free from abuse were protected. This was true for 1 of 1 resident (Resident #61) whose record was reviewed for resident-to-resident abuse. This failure placed residents at risk for potential abuse and potential physical and psychosocial harm. Findings include:The facility Freedom from Resident Abuse, Neglect, Mistreatment, and Exploitation policy dated 2024, documented each resident.has the right to be free from verbal, sexual, physical, and mental abuse.Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including dementia and history of falling. […]

• No harm, potential for more than minimal, isolatedF641Aug 7, 2025

  Based on review of the Resident Assessment Instrument (RAI), record review, and staff interview, the facility failed to ensure residents Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 16 residents (Resident #46) reviewed for accuracy of MDS assessments. This deficient practice created the potential for residents to have their mental health needs not met due to inaccurate assessments. Findings include:Chapter 3 of The Resident Assessment Instrument (RAI), revised 10/1/2024, documented if a resident is currently considered by the state level II PASRR (Preadmission Screening and Resident Review) process to have a serious mental illness, then section A1500 of the MDS should be marked yes.Chapter 5 of the RAI documented if an MDS assessment is found to have… […]