Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cascadia Of Boise during CMS and state inspections, most recent first.
Insufficient Nursing Staffing and Delayed Resident Care: Repeated grievances, Resident Council concerns, and staff interviews showed delayed call light response, late meds, unmet ADL care, and staff attitude issues. Weekend staffing hours were consistently lower than weekday hours despite a high census, and a resident’s representative reported finding A resident soaked in urine and shivering while wearing only an incontinence brief. Staff also reported night shift challenges and reduced nurse/CNA positions.
Failure to notify a resident's representative of a fall. A resident with Alzheimer's, dementia, anxiety, kidney disease, and DM was found face down next to the bed with a significant bump to the back of the head and a small red mark under the eye. The I&A report identified that the resident's representative was not notified, and the CNO confirmed the notification did not occur.
A resident with quadriplegia, epilepsy, and urinary retention had a physician order for every-shift measurement and recording of indwelling catheter output for hydration management. Review of the MAR/TAR showed multiple blank entries across several months, and the CNO confirmed the urinary output was not recorded.
Surveyors found that food items in a resident freezer were not labeled or dated, and a therapy ice pack wrapped in a pillowcase was stored alongside food, leading to contamination. Additionally, ice machines in the kitchen and resident area had visible dark residue, with staff unable to confirm recent cleaning. These deficiencies reflect failures in food storage, labeling, and equipment sanitation.
Three residents with documented serious mental illness or intellectual disability had inaccurate MDS assessments, as staff failed to correctly reflect PASRR findings in the MDS records. The MDS nurse acknowledged the errors after review and interview.
A resident with dementia and mobility issues experienced a fall, after which a fall mat was implemented as an intervention. Although the fall mat was in use and observed by staff, it was not added to the resident's care plan, indicating the care plan was not revised to reflect post-fall interventions.
A nurse administered Insulin Lispro to a resident with diabetes without priming the insulin pen, contrary to manufacturer instructions and professional standards. The nurse believed priming was only necessary for new pens, while facility leadership confirmed it should be done before each use.
Staff did not follow physician's orders for two residents: one with diabetes did not have a repeat blood glucose check after a low reading as required by protocol, and another with ALS and respiratory failure had a urinary catheter in place without a physician's order due to orders not being updated after readmission.
A resident with a seizure disorder and other complex conditions had two rescue seizure medications ordered with unclear and overlapping instructions for use. The orders did not specify which medication should be administered in specific situations, and the Acting DON acknowledged the lack of clarity, increasing the risk of medication errors.
A resident with end stage renal disease and a left arm fistula had a physician's order prohibiting blood pressure measurements on that arm. Despite this, records showed blood pressure was documented as being taken on the left arm multiple times. An RN stated that staff may have inaccurately recorded the site, leading to incorrect documentation in the medical record.
Staff failed to follow infection prevention protocols, including not performing hand hygiene before donning PPE, not changing gloves or performing hand hygiene between peri and wound care, and not wearing a gown during high-contact procedures, as observed during care of multiple residents with complex medical needs.
A resident with paraplegia and diabetes was diagnosed with pneumonitis, but the facility failed to update the care plan to reflect new medical orders for intravenous fluids and antibiotics. Despite the resident's cognitive intactness and a negative urinalysis for UTI, the care plan did not address the resident's fever, elevated heart rate, and cough, as confirmed by the MDS Nurse and DON.
Two residents in an LTC facility were affected by medication order errors. One resident, with a tracheostomy and gastrostomy, received Depakote sprinkles via PEG tube despite an oral order, due to a lack of clarification by an LPN. Another resident received an incorrect Vitamin D dosage due to a physician order entry error, which was not caught by the pharmacist during the monthly review. The DON later clarified the errors.
A resident with multiple diagnoses, including stroke and left hemiparesis, was found without a dressing on an open rash on the left arm, contrary to a physician's order. The order required cleansing and covering the rash with border gauze, to be changed twice a week and as needed. Staff interviews confirmed the oversight, highlighting a failure to follow the prescribed care plan.
A resident with paraplegia and cerebral palsy did not receive a Comprehensive Metabolic Panel (CMP) due to a sample collection error. The facility failed to follow up on the missing test results, despite having a process to track pending laboratory results.
The facility failed to maintain accurate clinical records for two residents, leading to potential communication issues. One resident's record lacked documentation for the discontinuation of an antibiotic, while another resident's record inaccurately noted a dressing change that was not performed. The DON and an LPN acknowledged these documentation errors.
A resident with a stage 4 pressure ulcer was at risk of infection due to improper wound cleaning by an LPN, who deviated from infection control guidelines by patting the wound in a random pattern. The facility's standards required cleaning from the center outward, which was not followed, as confirmed by the DON and SDC/IP.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available each day to meet resident needs according to their plans of care and to have a licensed nurse in charge on each shift. Review of grievances from 10/3/25 through 5/4/26 showed repeated resident and family complaints about delayed call light response, untimely medication administration, unmet ADL needs, staff attitude concerns, and delayed care. The facility’s investigations confirmed most of these allegations, including residents not being changed timely, medications not being given on time, and call lights not being answered promptly. Resident Council minutes from October 2025 through February 2026 also showed repeated concerns about call light wait times and staff attitude, including concerns about evening and night shift response times. The three-week staffing schedule from 4/19/26 through 5/9/26 showed consistently lower staffing hours on weekends than on weekdays, with weekend staffing hours notably below weekday levels despite census remaining in the low 90s to high 90s. On 5/12/26, the CEO stated the skilled census was the highest it had ever been and that grievances had increased. During interviews on 5/13/26, the resident’s representative stated weekends were "kind of dead" and described finding Resident #25 soaked in urine, shivering, and wearing only an incontinence brief, stating there were not enough staff. CNA #1 stated night shift had been a challenge and that staff had been working multiple shifts until additional staff could be trained and hired. RN #1 stated staffing could be better and reported recent Medicaid cuts had resulted in the facility reducing one nurse position and some CNA positions, with positions being slowly reinstated due to workload needs. The CEO stated staffing was based on resident needs and acuity and noted that on weekends there was one unit manager.
Failure to Notify Resident Representative of Fall
Penalty
Summary
The facility failed to notify a resident's representative of an accident involving Resident #20. The facility's Fall Response & Management policy, revised 8/21/25, stated that the facility will notify the provider and resident representative if a resident sustains a fall. Resident #20 was readmitted with multiple diagnoses including Alzheimer's, dementia, anxiety, kidney disease, and diabetes. On 12/16/25, the resident was found face down on the floor next to her bed, and upon examination had a significant bump to the back of the right side of her head and a small red mark under her right eye. The I&A report dated 12/16/25 identified that the resident's representative was not notified, and on 5/12/26 at 5:03 PM the CNO confirmed the representative had not been notified of the fall and should have been.
Failure to Document Urinary Output for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to follow a physician’s order to monitor urinary output for Resident #4, who was admitted with multiple diagnoses including quadriplegia, epilepsy, and urinary retention. A physician’s order initiated on 4/24/25 and revised on 1/20/26 directed staff to measure and record output from the resident’s indwelling urinary catheter every shift for hydration management. Review of the MAR and TAR for October 2025 through April 2026 showed multiple missed documentation opportunities, including blank entries in October, November, December, February, March, and April. On 5/12/26 at 4:25 PM, the CNO confirmed that urinary output was not recorded.
Improper Food Storage and Ice Machine Sanitation
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of food items in a resident freezer, as well as the cleanliness of ice machines. In the Alpine Resident freezer, undated lemon ices, a frozen yogurt, and a frozen entrée meal were found without resident names or dates. Additionally, a therapy ice pack wrapped in a pillowcase was stored on the top shelf of the freezer, which staff acknowledged should not have been present and resulted in contamination of the food items. The Certified Dietary Manager (CDM) was unaware that non-food items were being stored in the resident freezer, despite a policy in place regarding food storage. Further observations revealed that ice machines in both the kitchen and the Alpine ice room had a dark residue on the interior portion of the white plastic ice separator. Both the Registered Dietitian (RD) and a Registered Nurse (RN) confirmed the presence of the residue and stated that the machines are supposed to be cleaned regularly, but were unsure of the last cleaning date. These findings indicate lapses in food safety practices, including improper food labeling, storage of non-food items with food, and inadequate cleaning of food-contact equipment.
Inaccurate MDS Assessments Related to PASRR Documentation
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, as determined through record review and staff interviews. For one resident with chronic respiratory failure, anxiety, panic disorder, and depression, both PASRR Level I and II assessments documented serious mental illness, but the Annual MDS assessment incorrectly indicated that the resident was not considered to have a serious mental illness or intellectual disability. The MDS nurse acknowledged the assessment was inaccurate after reviewing the documentation. Another resident with spastic quadriplegic cerebral palsy, chronic respiratory failure, and epilepsy had a PASRR Level I indicating an intellectual disability, but the Admissions MDS assessment incorrectly answered 'no' to the presence of a serious mental illness or intellectual disability. Similarly, a third resident with quadriplegia, depression, and anxiety had a PASRR Level II documenting severe mental illness, but the comprehensive MDS assessment did not reflect this. In each case, the MDS nurse confirmed the assessments were completed inaccurately due to misunderstanding of PASRR documentation requirements.
Care Plan Not Updated After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect post-fall needs. A resident with multiple diagnoses, including a broken leg, muscle weakness, and dementia, experienced an unwitnessed fall from bed. Following the incident, a fall assessment and interdisciplinary review were completed, and interventions such as a fall mat and keeping the bed in the lowest position were implemented. However, although the fall mat was observed in use and was identified as an intervention in the fall assessment, it was not documented in the resident's care plan. Staff interviews confirmed that the fall mat, while present in the resident's room, was not included in the care plan as required. The care plan did include other fall risk precautions, such as keeping the door open, locking bed brakes, and ensuring the resident was out of the room when in a wheelchair, but failed to reflect the addition of the fall mat. This omission indicated that the care plan was not properly updated to address the resident's post-fall needs.
Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A deficiency was identified when a registered nurse failed to prime an insulin pen prior to administering Insulin Lispro to a resident with diabetes, as observed during medication administration. The resident had a physician's order for Insulin Lispro 100 unit/ml, with instructions to inject two units subcutaneously before meals. During the observed administration, the nurse replaced the needle and sanitized the pen but did not prime it, stating that priming was only necessary for new pens. The Acting Director of Nursing later clarified that the insulin pen should be primed before each use. According to the Insulin Lispro manufacturer’s instructions, priming is required before every injection to ensure accurate dosing.
Failure to Follow Physician's Orders for Blood Glucose Monitoring and Catheter Use
Penalty
Summary
The facility failed to follow professional standards of practice by not adhering to physician's orders for three residents. For one resident with diabetes, there was a physician's order to check blood glucose levels for hypoglycemic or hyperglycemic symptoms and to follow a specific hypoglycemic protocol if blood glucose was less than 70 mg/dL. The resident's medical record showed a blood glucose reading of 50 mg/dL, but staff did not retake the blood glucose 15 minutes later as required by the protocol. A staff member confirmed that the hypoglycemic protocol was not followed in this instance. Another resident with multiple diagnoses, including amyotrophic lateral sclerosis and respiratory failure, was observed to have a urinary catheter on several occasions. However, a review of the resident's physician's orders did not show any order for a urinary catheter. The Acting DON stated that the physician's orders were not updated upon the resident's readmission due to multiple admissions and unforeseen circumstances, resulting in the resident having a catheter without a corresponding physician's order.
Failure to Clarify Rescue Seizure Medication Orders
Penalty
Summary
The facility failed to ensure that medication orders were properly clarified for a resident with multiple complex diagnoses, including spastic quadriplegic cerebral palsy, seizure disorder, and congenital hydrocephalus. Record review revealed that the resident had two physician orders for rescue seizure medications—Nayzilam (midazolam) and Valtoco (diazepam)—with overlapping but not clearly differentiated instructions regarding when each should be administered. The orders did not specify which medication to use under specific seizure circumstances, leading to unclear direction for staff. During staff interview, the Acting DON confirmed that the directions for administering these medications were not clear and required clarification to prevent medication errors or overmedication.
Inaccurate Documentation of Blood Pressure Site for Dialysis Patient
Penalty
Summary
The facility failed to ensure that a resident's medical records contained accurate documentation regarding vital signs. Specifically, a resident with multiple diagnoses, including high blood pressure and end stage renal disease requiring dialysis, had a physician's order stating that blood pressure should not be taken on the left arm, which had a fistula. Despite this order, documentation showed that blood pressure was recorded as being taken on the left arm on multiple occasions. During an interview, a registered nurse acknowledged that while nurses are aware not to take blood pressure from a fistula arm, they may have inaccurately documented the site, recording the left arm when they actually used the right arm. This resulted in inaccurate documentation in the resident's medical record.
Failure to Implement Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices as observed during care provided to multiple residents. In one instance, a respiratory therapist entered a resident's room, donned personal protective equipment (PPE) without performing hand hygiene beforehand, and then proceeded to provide care involving cleaning and suctioning. The therapist acknowledged afterward that hand hygiene should have been performed prior to donning PPE. In another case, a licensed nurse performed peri care and then transitioned to wound care for a resident without changing gloves or performing hand hygiene between the two tasks. The nurse later confirmed that gloves should have been changed and hand hygiene performed when moving between different body sites and after peri care. Additionally, a respiratory therapist was observed providing endotracheal suctioning to a resident under Enhanced Barrier Precautions without wearing a gown, despite signage indicating that both gloves and a gown were required for such high-contact activities. The therapist admitted that a gown should have been worn during the procedure. These lapses in infection control practices were identified through direct observation and staff interviews, and were not in accordance with CDC guidance for hand hygiene and use of PPE.
Failure to Update Care Plan for Resident with Pneumonitis
Penalty
Summary
The facility failed to develop a comprehensive resident-centered care plan for a resident diagnosed with pneumonitis. The resident, who was admitted with multiple diagnoses including paraplegia and diabetes mellitus, was cognitively intact according to a quarterly MDS assessment. On a specific date, a physician's assistant noted a diagnosis of pneumonitis versus urinary tract infection, and the resident's urinalysis result was negative for a urinary tract infection. Despite these findings, the resident's care plan did not reflect the new orders for intravenous fluids and Rocephin, an antibiotic, which were documented in the nursing progress notes. Interviews with the MDS Nurse and the Director of Nursing confirmed that the care plan should have been updated to reflect the resident's change in condition, which included fever, elevated heart rate, and cough. The absence of an updated care plan placed the resident at risk of unmet care needs, as the care plan did not address the resident's current medical condition and treatment requirements.
Medication Order Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medication orders were written accurately per current standards of practice, affecting two residents. Resident #71, who had multiple diagnoses including tracheostomy, dementia, and gastrostomy, was ordered to receive Depakote sprinkles orally, despite being NPO and requiring medications to be administered via a PEG tube. The LPN administering the medication did not clarify the route with the physician, and the RCM acknowledged the error upon review. The DON confirmed that the nurse should have verified the order before administration. Resident #52, with diagnoses including fibromyalgia and dysphasia, was affected by an incorrect medication order for Vitamin D. The order incorrectly stated a dosage of 2,000 mg instead of the correct 50 mcg/2,000 IU. The LPN administered the incorrect dosage based on the erroneous order, and the DON later clarified the mistake. Additionally, the pharmacist failed to identify the error during the monthly medication regimen review, and the expired order for Vitamin D was not discontinued as it should have been.
Failure to Follow Physician's Order for Dressing Changes
Penalty
Summary
The facility failed to follow a physician's order regarding dressing changes for a resident with a rash on the left arm. The resident, who was admitted with multiple diagnoses including stroke, acute respiratory failure with hypoxia, and left hemiparesis and hemiplegia, was documented as severely cognitively impaired. A physician's order dated August 6, 2024, required the staff to cleanse the resident's open rash with wound cleanser, cover it with border gauze, and change the dressing two times a week and as needed. However, observations on August 7, 2024, revealed that the resident did not have a dressing on the left arm at two different times during the day. Interviews with staff confirmed the deficiency. An LPN confirmed that the resident was supposed to have a dressing on the left arm, which should be changed as per the physician's order. The LPN also confirmed that if the dressing came off, it should be redressed. The Director of Nursing stated that if the dressing came off, it was to be redressed. Despite these acknowledgments, the resident was observed without a dressing, indicating a failure to adhere to the physician's order, which created the potential for infection to spread to the resident's open areas.
Failure to Obtain Physician-Ordered Laboratory Test
Penalty
Summary
The facility failed to obtain physician-ordered laboratory testing for a resident, specifically a Comprehensive Metabolic Panel (CMP). The resident, who was admitted with diagnoses including paraplegia and cerebral palsy, had physician orders for three laboratory tests: a Complete Blood Count (CBC), a Comprehensive Metabolic Panel (CMP), and a Urinalysis with Culture and Sensitivity (UA with C&S). While the results for the CBC and UA with C&S were present in the resident's record, the CMP results were missing. The deficiency was identified when the Director of Nursing (DON) was informed that the CMP results were not received. Upon investigation, it was discovered that the blood sample for the CMP was collected in the wrong type of tube, preventing the test from being conducted. The facility had a process in place to track pending laboratory results, discussed during morning clinical meetings, but failed to follow up on the missing CMP results, leading to the deficiency.
Inaccurate Clinical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, leading to potential communication failures among the interdisciplinary team. For one resident, the clinical record did not include documentation regarding the discontinuation of an antibiotic, daptomycin, which was initially prescribed for MRSA urosepsis. The Director of Nursing (DON) failed to document the infectious disease physician's order to discontinue the antibiotic after 48 hours, which was an oversight acknowledged by the DON. For another resident, the clinical record inaccurately documented that a dressing change had been completed when it had not. The resident, who was severely cognitively impaired, was observed without a dressing on his left arm, despite a progress note indicating that the dressing had been applied. The LPN responsible for the documentation admitted to not performing the dressing change and acknowledged the error. The DON emphasized the expectation for nurses to perform treatments as ordered and document them accurately after completion.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to infection control guidelines during a wound care dressing change for a resident with a stage 4 pressure ulcer. The resident, who was admitted with multiple diagnoses including acute and chronic respiratory failure, dementia, and a stage 4 pressure ulcer on the sacral region, was dependent on a gastric tube for nutrition and had a tracheostomy. The physician's order required daily cleansing and dressing of the wound on the resident's right buttock. However, during an observation, an LPN was seen cleaning the wound by patting it with gauze in a random pattern, moving from areas outside the wound to inside the wound bed, which increased the risk of contamination. The facility's competency guidelines and Lippincott's nursing standards of practice both directed that wound cleaning should be performed from the center of the wound outward in concentric circles to prevent contamination. Despite these guidelines, the LPN did not follow the correct procedure, as confirmed by their statement of uncertainty about the cleaning method used. The DON and the SDC/IP both reiterated that the correct procedure was to clean from the inside of the wound to the outer region. This deviation from established infection control practices placed the resident at an increased risk of infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boise
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timber Springs Transitional Care | 0.5 mi | ★★★★★ | 19 | 0 |
| Life Care Center Of Boise | 0.5 mi | ★★★★★ | 0 | 0 |
| Skyline Transitional Care Center | 1.1 mi | ★★★★★ | 9 | 0 |
| Arbor Valley Of Cascadia | 1.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Treasure Valley | 2 mi | ★★★★★ | 0 | 0 |
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