Idaho State Veterans Home - Post Falls

In the surveyor’s words

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

• Actual harm, isolatedF686Nov 11, 2025

  Based on observation, staff interview and record reviews, it was determined the facility failed to prevent the worsening of a pressure ulcer. This was true for 1 of 3 residents (Resident #1) reviewed for pressure ulcer. This deficient practice caused harm to Resident #1 when his pressure ulcer to his right heel deteriorated and became infected. Findings include:The State Operations Manual (SOM) Appendix PP stated a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including dementia, heart failure and diabetes and chronic kidney disease.Resident #1's record… […]

• Actual harm, isolatedF600Aug 1, 2025

  Based on record reviews, interviews, facility investigation, and policy review, the facility failed to ensure one of four residents (Resident (R) 4) was free from neglect when staff failed to provide timely and competent care in response to complaints of pain and decreased urinary output of 20 sample residents. As a result, R4, who had a neurogenic bladder and an indwelling catheter, experienced severe pain, and improper placement of an indwelling catheter. Findings include:Review of the facility's policy titled, Freedom From Resident Abuse, Neglect, Mistreatment & Exploitation, dated 06/24 documented, Each resident at the [Facility Name], Idaho State Veterans Homes (ISVHs) has the right to be free from verbal, sexual, physical, and mental abuse; neglect; exploitation; mistreatment… […]

• No harm, potential for more than minimal, widespreadF882Aug 1, 2025

  Based on record review and interview, the facility failed to designate one or more qualified individuals as Infection Preventionists (IPs) who are responsible for the Infection Prevention and Control Program (IPCP) and who physically work onsite at the facility at least part-time. Failure to designate one or more qualified onsite IPs to oversee the implementation and monitoring of infection prevention practices has the potential to result in the inadequate identification, prevention, and control of infections within the facility, placing all 58 residents at increased risk for the transmission of communicable diseases and healthcare-associated infections.Findings include:Review of the facility's undated [Name of Facility] Employee Listing revealed the facility did not have a designated IP… […]

• No harm, potential for more than minimal, patternF761Aug 1, 2025

  Based on observation, interviews, and policy review, the facility failed to ensure expired medications were not available for use in one of one medication room reviewed for medication storage and labeling. Failure to ensure expired medications were not available for use had the potential to result in residents receiving expired medications, which may be ineffective or harmful, leading to adverse drug reactions, diminished therapeutic outcomes, and increased risk of complications or hospitalization.Findings include:Review of the facility's policy titled, Pharmacy Services, last reviewed on 02/25, revealed that the Pharmacist shall be responsible for reviewing all medications in the facility for expiration dates. […]

• No harm, potential for more than minimal, patternF804Aug 1, 2025

  Based on observation, interview, record review, and policy review, the facility failed to ensure food temperatures were palatable for two out of 20 sample residents (Resident (R) 9 and R43) reviewed for palatability. This created the potential for meal dissatisfaction, decreased intake, and weight loss.Findings include:Review of the facility's policy titled, Dining/Meal Service, dated 2023, revealed Food will be at the proper temperature. to meet each individual's needs and desires.1. Review of R9's admission Record (Face Sheet) located under the Profile tab in the electronic medical record (EMR) revealed R9 admitted to the facility on [DATE]. […]