Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Idaho State Veterans Home - Pocatello during CMS and state inspections, most recent first.
The facility did not document that residents and their representatives were informed of their right to formulate advance directives, affecting multiple residents with serious medical conditions. Although POST documents were present in the records, there was no evidence that information or assistance regarding advance directives was provided.
The facility did not consistently implement or document its bowel management protocol for several residents with conditions such as depression, Huntington’s disease, chronic kidney disease, and dementia, resulting in prolonged periods without bowel movements and lack of timely interventions as ordered by physicians. The DON confirmed that nursing staff failed to document all required steps of the protocol.
A resident with multiple medical conditions, including heart failure and obstructive uropathy, was observed with an uncovered urinary drainage bag that was visible from the open doorway. The DON confirmed that the bag should have been covered but was not.
A resident with dementia, known to be intrusive, struck another resident who was cleaning a fish tank, resulting in facial scratches and bleeding. The incident occurred in the presence of two nurses and two CNAs, despite care plan interventions and facility policy intended to prevent abuse.
A resident with multiple diagnoses, including PTSD, was not accurately assessed in the MDS, as section A1500 failed to indicate a serious mental illness despite a level II PASRR confirming the diagnosis. No correction was documented after the PASRR was received, and the DON acknowledged the oversight.
A resident with dementia and PTSD was admitted with a Level I PASRR that did not document PTSD, despite this diagnosis being present in the medical record. The facility did not request or complete a required Level II PASRR evaluation, and the DON acknowledged that an updated Level I and a Level II PASRR should have been completed.
Two residents did not receive care in accordance with their care plans: one was transferred by a CNA using a sit-to-stand device with only one staff member instead of the required two-person assist, and another had a PTSD diagnosis that was not addressed in their care plan. The DON confirmed both deficiencies.
A resident with multiple diagnoses was found with OTC medications at the bedside, including one without a physician's order, and staff did not obtain the necessary order. Additionally, a medication cart audit revealed that the narcotic accountability record was missing a required nurse signature, with both an LPN and the DON confirming that two nurses should have signed the record during cart exchanges.
Glucose test solutions were found without required open or expiration dates, and a resident's medications were left unattended at the bedside by an agency nurse unfamiliar with the resident's self-administration status. The DON confirmed the resident was not approved for self-administration, and medications should not have been left unsecured.
Staff failed to follow infection prevention protocols, including placing insulin syringes on a resident's bed instead of a protective barrier, not cleaning a blood pressure cuff between two residents, and not cleaning lift straps after use. These actions were acknowledged by the staff and confirmed by facility leadership.
A resident reported an incident of sexual abuse involving another resident, but the facility failed to notify the State Agency within the required two-hour timeframe. The Administrator, unaware of the reporting requirement, delayed the report, leaving residents at risk. The facility's policy mandates immediate reporting, but this was not followed, resulting in a deficiency.
A resident with Chronic Obstructive Sleep Apnea did not receive prescribed Norco pain medication and CPAP therapy due to a nurse's assumption that another staff member had addressed the resident's needs. Despite the resident's requests, the nurse did not administer the treatments, and the night nurse only provided the pain medication later, omitting the CPAP therapy.
The facility did not ensure alternatives to bed rails were attempted or assessed before use for two residents. Despite policies requiring a person-centered approach and documentation of alternatives, assessments lacked explanations for the continued use of bed rails. One resident with cervical fractures and a history of falls was observed with raised side rails, while another with heart disease and vertigo had side rails despite assessments indicating they were unnecessary.
Failure to Inform Residents of Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an advance directive, as required by policy. For 10 out of 54 residents reviewed, there was no documentation in the medical records that the facility informed or provided written information regarding the right to formulate an advance directive. In each case, the residents' records contained a POST (Physician Orders for Scope of Treatment) document, but lacked an advance directive and any evidence that the facility had communicated the option or provided the necessary information to the resident or their representative. The affected residents had a range of significant medical conditions, including coronary artery disease, GERD, anemia, atrial fibrillation, hypertension, malnutrition, non-traumatic brain dysfunction, hyperlipidemia, thyroid disorder, diabetes, PTSD, chronic kidney disease, epilepsy, aphasia, hemiparesis, dementia, heart failure, and muscle weakness. In one instance, a resident had previously revoked a POA for healthcare, but there was still no documentation of an advance directive or that information about advance directives had been provided. The facility administrator confirmed the absence of both advance directives and documentation of having informed the residents or their representatives about their rights in these cases.
Failure to Follow Bowel Management Protocol and Physician Orders
Penalty
Summary
The facility failed to follow its established bowel management protocol for five residents whose records were reviewed for bowel and bladder care. According to the protocol, if a resident does not have a bowel movement within 48-72 hours, a series of progressive interventions, including administration of Bisacodyl tablets, suppositories, and enemas, should be implemented and documented. However, documentation revealed that for several residents, there were significant gaps between bowel movements—ranging from 120 to 144 hours—without evidence that the bowel management protocol was initiated or followed as ordered. Medication Administration Records (MARs) and CNA Task Bowel Activity logs showed that the required interventions were either not started in a timely manner or not documented as completed, despite the absence of bowel movements for extended periods. Specific examples include a resident with a history of femur fracture and depression who went five days without a bowel movement and did not have the protocol initiated, and another resident with Huntington’s disease and anxiety who experienced a prolonged period without a bowel movement despite multiple steps of the protocol being initiated without documented results. Additional residents with chronic kidney disease, PTSD, and dementia also experienced similar lapses, with the protocol either not started or not fully documented. The Director of Nursing confirmed that nursing staff did not document following all steps of the bowel protocol as required.
Failure to Maintain Resident Dignity by Not Covering Urinary Drainage Bag
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring the resident's urinary drainage bag was covered. The resident, who had multiple diagnoses including heart failure, diabetes, and obstructive uropathy, was observed with an uncovered urinary drainage bag that was visible from the open doorway of his room. This observation was confirmed by the Director of Nursing, who acknowledged that the urinary drainage bag should have been covered but was not at the time of the surveyor's visit.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. One resident, with a history of dementia and being intrusive into others' space, approached another resident who was cleaning a fish tank and began yelling. The situation escalated, resulting in the first resident striking the second resident across the face, causing three open scratches that drew blood. The care plan for the resident with dementia included interventions such as redirection and removal from the environment as needed, as well as observation and reporting of behaviors that could pose danger to self or others. At the time of the incident, two nurses and two CNAs were present and witnessed the altercation. The facility's policy stated that each resident has the right to be free from verbal, sexual, physical, and mental abuse. Despite the presence of staff and existing care plan interventions, the incident occurred, indicating a failure to implement measures to prevent resident-to-resident abuse as outlined in the facility's policy.
Failure to Accurately Complete MDS Assessment for Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident with multiple diagnoses, including hypertension, diabetes, and PTSD, a serious mental illness. The resident's MDS assessment did not indicate the presence of a serious mental illness in section A1500, despite a state level II PASRR documenting a diagnosis of PTSD. The medical record did not show that a correction was made to the MDS after the PASRR was received. The Director of Nursing confirmed that section A1500 should have been corrected following the receipt of the PASRR documentation.
Failure to Refer Resident for PASRR Level II Evaluation for Major Mental Illness
Penalty
Summary
The facility failed to refer a resident for further evaluation when the resident was diagnosed with a major mental illness. Specifically, one resident was admitted with multiple diagnoses, including dementia and PTSD. The Level I PASRR completed in Arizona did not document the PTSD diagnosis, even though it was present in the resident's medical record. As a result, a Level II PASRR was not requested or completed as required in Idaho. The Director of Nursing confirmed that an updated Level I PASRR should have been created to document PTSD and a Level II PASRR should have been requested, but this was not done.
Failure to Follow and Complete Resident Care Plans
Penalty
Summary
The facility failed to follow the comprehensive person-centered care plans for two residents. For one resident with diabetes, heart failure, and a history of CVA with left side hemiplegia and weakness, a CNA was observed transferring the resident from a wheelchair to bed using a sit-to-stand device with only one staff member, despite the care plan and physician orders requiring a two-person assist for transfers. For another resident with dementia and PTSD, the care plan did not include any interventions addressing the PTSD diagnosis. The Director of Nursing confirmed that the transfer was not performed according to the care plan and that the PTSD diagnosis should have been included in the care plan.
Failure to Ensure Proper Management and Documentation of Medications
Penalty
Summary
The facility failed to ensure proper management of over-the-counter (OTC) and controlled medications for its residents. One resident, admitted with multiple diagnoses including epilepsy and aphasia, was observed with a bottle of Tylenol and Nyquil at the bedside; while there was a physician's order for Tylenol, there was no order for Nyquil. The Director of Nursing (DON) confirmed that residents often bring in OTC medications without notifying nursing staff, and in this case, staff did not obtain a physician's order for the Nyquil as required. Additionally, during a medication cart audit, it was found that the narcotic accountability record was missing a required licensed nurse signature, and both an LPN and the DON confirmed that two nurses should have signed the record when accepting or releasing the medication cart.
Failure to Properly Label Biologicals and Secure Medications
Penalty
Summary
Surveyors observed that glucose test solutions in the facility were not labeled with the date they were opened or their expiration date, as required. Both an LPN and an RN confirmed that the glucose test solutions should have been dated when opened, but were not. Additionally, a resident with multiple diagnoses, including hypertension, diabetes, and PTSD, was found to have their morning medications left unattended in a medication cup on their bedside table without a licensed nurse present. The nurse responsible, who was an agency nurse on her first day with the resident, was unaware if the resident had a self-medication administration assessment. The DON later confirmed that the resident was not approved to self-administer medications and that the nurse should not have left the medications at the bedside.
Infection Control Lapses in Medication Administration and Equipment Cleaning
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by multiple observed incidents involving staff and residents. In one instance, a registered nurse placed insulin syringes directly on a resident's bed while preparing to administer medication, rather than using a protective barrier on the bedside table as required. Both the nurse and the infection preventionist acknowledged that this was not in accordance with facility protocol. The resident involved had a history of coronary artery disease and diabetes and was receiving insulin therapy at the time of the incident. Additional deficiencies were observed in the cleaning and disinfection of shared medical equipment. A nurse was seen using a blood pressure cuff on two different residents without cleaning it between uses, contrary to the facility's policy. Furthermore, a certified nursing assistant cleaned a sit-to-stand device after a resident transfer but failed to clean the straps, instead draping the uncleaned straps over the sanitized device. The director of nursing confirmed that the straps should have been cleaned. These lapses in infection control practices were confirmed through staff interviews and record review.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving Resident #149 to the State Agency within the required two-hour timeframe. Resident #149, who was admitted with diagnoses including post-hospitalization care for a fracture, Type 2 Diabetes, major depressive disorder, and anxiety disorder, reported that Resident #22 entered the shower room while she was bathing and later made inappropriate comments and physical contact. The incident was reported to the facility's Administrator on 1/15/24, but the Administrator advised staff they had 24 hours to report the incident and did not report it to the State Agency until 1/16/24. The facility's policy requires immediate reporting of suspected abuse, but the Administrator was unaware of the two-hour reporting requirement. This delay in reporting resulted in the allegation not being acted upon in a timely manner, leaving Resident #149 and other residents at risk. The facility's failure to adhere to the reporting guidelines outlined in their policy and federal regulations led to a deficiency in ensuring resident safety and timely investigation of abuse allegations.
Failure to Administer Pain Medication and CPAP Treatment
Penalty
Summary
The facility failed to follow physician orders for a resident's pain medication and respiratory treatment, which were crucial for managing the resident's chronic conditions. The resident, who was diagnosed with Chronic Obstructive Sleep Apnea, was supposed to receive Norco for pain management and CPAP therapy with oxygen at bedtime. However, on a specific evening, the resident did not receive the prescribed Norco medication or the CPAP treatment as documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The deficiency occurred when RN #2, the evening nurse, did not administer the required treatments, assuming another staff member had addressed the resident's needs. Despite the resident's repeated requests for his routine treatments, RN #2 failed to respond, citing being busy with another resident. The Director of Nursing (DON) confirmed that RN #2 did not provide the necessary care and that the night nurse only administered the pain medication later, neglecting the CPAP treatment entirely.
Failure to Assess and Document Alternatives to Bed Rails
Penalty
Summary
The facility failed to ensure that alternatives to bed rails were attempted or assessed before placing bed rails on residents' beds, specifically for two residents. The facility's policy, dated October 2023, mandates a person-centered approach and the use of appropriate alternatives before installing bed rails. However, the assessments for the residents did not document why alternatives failed or why bed rails continued to be used when assessments indicated they were no longer needed. Resident #34, with multiple diagnoses including cervical fractures and a history of falling, was observed with raised side rails despite an assessment recommending only 1/4 bed rails. The assessment did not explain how attempted alternatives failed. Similarly, Resident #33, with diagnoses including heart disease and vertigo, was observed with raised side rails even though assessments from July 2023 and January 2024 indicated no need for bed rails. The facility's administrator acknowledged the expectation to try all alternatives before using side rails.
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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 Pocatello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gateway Transitional Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Monte Vista Hills Healthcare Center | 2 mi | ★★★★★ | 8 | 0 |
| Quinn Meadows Rehabilitation And Care Center | 4 mi | ★★★★★ | 6 | 0 |
| Syringa Chalet Nursing Facility | 22.3 mi | ★★★★★ | 8 | 0 |
| Bingham Memorial Skilled Nursing & Rehabilitation | 22.6 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.