Below 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 - Post Falls during CMS and state inspections, most recent first.
A resident with multiple chronic conditions developed worsening pressure ulcers, including a right heel ulcer that progressed to Stage IV with infection, due to lapses in wound assessment, missing documentation, and delays in specialist wound care. Staff changes and administrative confusion further contributed to the lack of timely intervention and oversight.
A resident with diabetes and other chronic conditions was not seen by a podiatrist as ordered, resulting in a prolonged delay before a podiatry appointment was scheduled. The resident's toenails became thick, yellow, and misshapen during this period, and staff reported difficulty providing nail care. The delay was due to administrative confusion regarding VA care transfers, incomplete paperwork, and insurance or copay issues.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have a qualified Infection Preventionist (IP) working onsite at least part-time, as required. The current IP worked remotely and did not visit the facility, and the previous IP and DON, who had overseen infection control, had both resigned. The facility was left without a certified or qualified onsite IP, and recruitment for a replacement was ongoing.
Expired urinary pain relief tablets, fleet laxative enemas, and hydrogen peroxide were found available for use in a medication storage room. Staff interviews revealed confusion about responsibility for monitoring and removing expired medications, with the RN, pharmacist, and DON each providing different accounts of the process. Facility policy requires regular review and removal of expired medications, but this was not consistently followed.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency related to meal quality standards.
A resident was subjected to physical restraints without a documented medical need, in violation of requirements that mandate restraints only be used for medical treatment.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
A resident did not receive the necessary care and services to maintain or improve ROM and mobility, resulting in a decline that was not attributed to a medical reason.
Surveyors found that an area was not free from accident hazards and lacked adequate supervision to prevent accidents, resulting in a deficiency for failing to maintain a safe environment.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility failed to implement an effective antibiotic stewardship program, lacking protocols for the duration and prophylactic use of antibiotics. A resident admitted with a UTI was prescribed Cephalexin without an end date, and the required Infection Report was not completed. The DNS, acting as the Infection Preventionist, confirmed the absence of evaluation for the resident's antibiotic use. Despite consistent prophylactic antibiotic use among residents, no issues were identified in trending reports, and the facility lacked criteria for comparing usage rates.
A facility failed to provide a resident with the necessary SNF ABN and NOMNC forms when skilled therapy services were discontinued. Due to miscommunication about the last covered day, the Health Information Specialist did not issue the notices, leaving the resident and their representative uninformed about potential costs and appeal rights.
Two residents experienced abuse from another resident with a history of aggression. The first incident involved a resident with vascular dementia who was accused of theft and physically harmed. A month later, another resident with cognitive and physical impairments was grabbed and caused pain. Both incidents were witnessed by staff, but the facility's abuse prevention policy was not effectively implemented, allowing the aggressive resident to harm others.
A facility failed to notify the Ombudsman about a resident's discharge to the hospital due to a lack of policy guidance and staff awareness. The resident, who had severe cognitive impairment, was transferred to the emergency department, but the Ombudsman was not informed as required. Interviews revealed that the Social Worker was unaware of the notification requirement, and the Administrator confirmed the policy did not address this need.
A resident with dementia and other medical conditions was found with dried feces on his body, indicating neglect in incontinence care. Despite facility policy requiring two staff members for care, discrepancies in staff reports revealed that the resident was not properly attended to during the night shift. The Abuse Response Team confirmed neglect, as the resident's condition suggested he had not been cleaned for several hours.
A resident with type two diabetes mellitus experienced hypoglycemia incidents, but the facility failed to follow its protocol. On two occasions, the resident's low blood glucose levels were not rechecked or documented, and the physician was not notified as required. Nursing staff did not adhere to the hypoglycemia treatment guidelines, leading to a deficiency in care.
A resident with cerebral infarction and hemiparesis was left without access to her call light, which was placed in a dresser drawer by a CNA. The resident, who required assistance for transfers and ambulation, was found by RN2 calling for help after the CNA informed RN2 of the oversight. The facility's policy requires call lights to be within reach, and staff confirmed this was a safety issue.
Failure to Prevent Worsening and Infection of Pressure Ulcer Due to Lapses in Assessment and Documentation
Penalty
Summary
The facility failed to prevent the worsening of a pressure ulcer for a resident with multiple comorbidities, including dementia, heart failure, diabetes, and chronic kidney disease. The resident developed pressure ulcers on multiple sites, most notably the right heel, which deteriorated from an unstageable deep tissue injury to a Stage IV ulcer with infection. Documentation shows that the wound increased in size, developed slough and eschar, and became infected, as evidenced by foul odor, drainage, and a positive wound culture for Streptococcus agalactiae. The resident experienced pain during wound care, and antibiotics were started after infection was confirmed. There were significant lapses in wound assessment and documentation. Weekly Pressure Ulcer Records were missing for extended periods, specifically from early August to late September, and there was no documentation of wound status or refusal of care during this time. The Treatment Administration Record indicated that wound care was being provided, but there was no corresponding assessment or progress documentation. Staff interviews revealed that there was no dedicated Wound Nurse during a critical period, and nurse managers were responsible for wound care without clear oversight or knowledge of the resident's wound status. The current CNO and Nurse Manager were not present during the period in question and could not provide information about the care provided. Delays in obtaining specialist wound care further contributed to the deficiency. A referral to a wound clinic was made in late September, but due to administrative confusion regarding the resident's veteran status and required transfer of care, the appointment was not scheduled until early November. During this time, the resident's wounds continued to deteriorate, and the wound clinic physician was unable to perform debridement due to the resident's pain. The lack of timely assessment, documentation, and specialist intervention resulted in the resident suffering harm from a worsening, infected pressure ulcer.
Failure to Ensure Timely Podiatry Care for Diabetic Resident
Penalty
Summary
A resident with multiple diagnoses, including dementia, heart failure, and diabetes, was not seen by a podiatrist as ordered by the physician. Nursing progress notes indicated that a referral for diabetic foot care was initiated, and the physician assistant agreed to the podiatry consult. However, there was a significant delay of approximately 10 weeks before the resident was scheduled to be seen by a podiatrist. During this period, observations showed the resident's toenails were thick, yellowish, and misshapen, and the wound nurse reported difficulty in providing nail care due to the condition of the toenails. The delay in scheduling the podiatry appointment was attributed to administrative and procedural issues, including confusion regarding the transfer of care for a veteran patient, incomplete paperwork, and insurance or copay barriers. Staff interviews revealed a lack of awareness about the need to transfer care between VA facilities and challenges in securing an appointment due to staffing shortages at the VA hospital. Attempts to refer the resident to private providers were unsuccessful due to insurance limitations and refusal to pay copays.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Designate Qualified Onsite Infection Preventionist
Penalty
Summary
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 least part-time. Review of the facility's employee listing showed there was no designated IP working onsite. An interview with the current IP revealed that she worked remotely and did not spend any time onsite, although she had been assisting the facility since April. She also stated that the facility had hired an IP, but that individual had quit a few weeks prior, and no one currently at the facility was certified or qualified as an IP. Further interviews with the Administrator confirmed that the previous IP, a registered nurse, had started in August but was still in the process of completing the required training before resigning in July. The previous Director of Nursing (PDON), who had overseen the IPCP, also resigned in May. The Administrator provided a training certificate for the PDON and indicated that the previous IP had completed infection prevention modules through the CDC, but no completion certificate was available. The facility had been actively recruiting for a new IP since the last resignation.
Expired Medications Found in Medication Storage Room
Penalty
Summary
Expired medications, including urinary pain relief tablets, fleet laxative enemas, and bottles of hydrogen peroxide, were found available for use in the medication storage room during an observation. The facility's policies require the pharmacist to review all medications for expiration dates and remove expired or discontinued drugs at least every thirty days. However, the expired medications observed had not been removed, and staff interviews revealed uncertainty regarding who was responsible for monitoring and removing expired medications from the medication room. The RN present during the observation acknowledged the presence of expired medications and stated that the pharmacy consultant regularly checked for expired items, but could not confirm how often central supply staff performed checks. The pharmacist confirmed that she manually tracked medications with pharmacy labels, while central supply staff were responsible for other medications. The DON, in the presence of the administrator, was initially unsure who was responsible for monitoring expired medications and later stated that all nurses were responsible for checking the medication rooms.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the meals did not consistently meet standards for taste, appearance, or temperature at the time of service.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for their daily personal care and routine activities.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in ROM or mobility, except in cases where such decline was medically unavoidable. The report notes that the necessary interventions to maintain or improve the resident's physical abilities were not implemented as required.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the presence of accident hazards and insufficient supervision in the area, as directly observed by surveyors. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of protocols addressing the duration and prophylactic use of antibiotics. The policy required the Infection Preventionist to be notified when a resident was admitted with an antibiotic, and for the staff nurse to complete an Infection Report and Criteria Checklist. However, for one resident admitted with a urinary tract infection and prescribed Cephalexin for prophylaxis, there was no end date for the medication, and the required Infection Report and Criteria Checklist was not completed. The Director of Nursing Service, who was acting as the Infection Preventionist, confirmed the absence of evaluation for the resident's antibiotic use and acknowledged that the policy did not include monitoring the duration of antibiotic use. The facility's quarterly Antibiotic Stewardship meetings and monthly infection control tracking showed a consistent number of residents receiving prophylactic antibiotics without stop dates, yet no issues were identified in the trending reports. The Director of Nursing Service, who had been absent for three weeks, stated that the facility did not have goals or criteria for comparing the rate of prophylactic antibiotic use and did not view the current use as problematic. The Administrator expressed concern over the high prophylactic use of antibiotics and intended to discuss the matter with the Director of Nursing Service and the Medical Director.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a resident with the necessary Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage form and the Notice of Medicare Non-coverage (NOMNC) form when skilled therapy services were being discontinued. This oversight involved a resident who had skilled days remaining and planned to stay in the facility. The facility's policy required that these notices be delivered at least two days before the last covered day, but due to miscommunication and confusion regarding the last covered day, the forms were not issued. As a result, the resident and their representative were not informed about the potential costs of continuing care or their right to appeal the decision. The Health Information Specialist, responsible for preparing and delivering these notices, did not issue them due to conflicting information about the resident's last covered day. Initially informed that services would not end, the specialist did not prepare the forms. Later, it was confirmed that the services would indeed end on the originally planned date, but by then, it was too late to provide the required two-day notice. The specialist did not understand that the notices should have been issued even if late, resulting in the resident and their representative not receiving any notification or verbal communication about the discontinuation of services.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident abuse, as evidenced by two separate incidents involving a resident with a history of wandering and aggression. The first incident involved a resident with vascular dementia and intact cognition, who reported that another resident with severely impaired cognition entered his room, accused him of theft, and caused skin abrasions. The incident was witnessed by a CNA who intervened and reported it to the Administrator. Despite the initiation of 15-minute checks on the aggressive resident, another incident occurred a month later. The second incident involved a resident with moderate cognitive impairment and physical disabilities, who was grabbed and pulled by the same aggressive resident in the hallway, causing pain. This incident was witnessed by a CNA, and emergency services were called. The aggressive resident was discharged to the hospital following this incident. The facility's policy on abuse prevention was not effectively implemented, as the aggressive resident had a prior incident of aggression that was not adequately addressed, leading to further harm.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Ombudsman regarding the discharge of a resident, identified as R24, who was transferred to the hospital. The facility's policy on involuntary transfers and discharges, dated February 2023, did not include any information about notifying the Ombudsman when a resident is discharged to the hospital. This oversight was evident in the case of R24, who had severe cognitive impairment and was sent to the emergency department via ambulance. The review of R24's records, including the Face Sheet, Minimum Data Set, and Progress Notes, confirmed that there was no documentation of the Ombudsman being informed about the discharge. Interviews with facility staff revealed a lack of awareness and clarity regarding the notification process. The Social Worker, during her orientation, was not informed about the requirement to notify the Ombudsman, and as a result, did not do so for R24's discharge. The Administrator confirmed that the responsibility for notifying the Ombudsman lay with the Social Workers, but acknowledged that the current facility policy did not address this requirement. This lack of communication and policy oversight led to the deficiency in notifying the Ombudsman about the resident's transfer to the hospital.
Neglect in Incontinence Care for Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident, identified as R23, who was dependent on staff for activities of daily living. R23, who had diagnoses including dementia, kidney disease, neurogenic bladder, and uropathy, was found with dried feces on various parts of his body, including his hands, face, neck, and catheter tubing. The incident was reported by CNAs who discovered the condition at 6:20 AM, indicating that the resident had been left in this state for several hours. The facility's policy required two staff members to be present when providing care to R23, but this was not adhered to during the night shift. Interviews with staff revealed discrepancies in the care provided to R23. CNA4 and CNA5 were responsible for the last rounds, which began at 4:00 AM. CNA4 reported that CNA5 claimed to have provided care to R23 at 5:15 AM, including emptying the catheter bag and changing the brief. However, CNA2 and CNA3 found R23 in a state that suggested he had not been cleaned for several hours, with dried feces on his body and a full catheter bag. CNA5, when interviewed, could not recall providing care to R23 and was assigned to a different unit that night. The Director of Nursing Services (DNS) confirmed that the documentation of care was not done in real-time and that the information was recorded before the last rounds. The Abuse Response Team, consisting of the Administrator, DNS, RN Manager, and Social Workers, validated neglect related to R23's care. The team concluded that the bowel movement had occurred before 5:15 AM, as the stool was dried, indicating a failure to provide timely and appropriate care to the resident.
Failure to Follow Hypoglycemia Protocol for Insulin-Dependent Resident
Penalty
Summary
The facility failed to provide appropriate nursing care and services for a resident, identified as R16, who was using insulin and experienced hypoglycemia incidents. The facility's policy required that blood glucose (BG) levels below 70 mg/dl should be treated with 15 grams of carbohydrates, rechecked in 15 minutes, and the physician notified. However, there were instances where R16's low blood sugar levels were not rechecked or documented, and the physician was not contacted as per the protocol. This oversight was noted on two occasions, with BG levels recorded at 64 and 58, where the necessary follow-up actions were not documented or performed. R16, who had a diagnosis of type two diabetes mellitus, was receiving insulin treatment and had intact cognition. The resident reported experiencing low blood sugar incidents and recalled being given orange juice for low blood sugar. On one occasion, the resident's morning BG level was 64, and although the insulin dose was held, there was no documentation of a recheck or physician notification. Similarly, another incident recorded a BG level of 58, where the insulin was held, and snacks and juice were given, but again, there was no documentation of a physician being contacted or the BG level being rechecked. Interviews with nursing staff revealed a lack of adherence to the hypoglycemia protocol. RN6 and RN5, who were responsible for R16's care during these incidents, failed to document the rechecking of BG levels and did not notify the physician as required. The Director of Nursing Services (DNS) later identified these deficiencies and noted that the physician should have been notified for BG levels below 70. The RN Manager confirmed the protocol and emphasized the need for documentation of BG rechecks and physician contact in the medical record.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as R16, by not ensuring her call light was within reach. R16, who was admitted with diagnoses including cerebral infarction, hemiplegia, and hemiparesis, had intact cognition and was at risk for falls due to poor mobility and left-sided hemiparesis from a stroke. The care plan for R16 included the use of a call light to seek staff assistance for transfers and ambulation. However, on the night of the incident, a CNA forgot to return R16's call light, leaving it in a dresser drawer out of her reach. This oversight was discovered when RN2 received a text message from the CNA after her shift ended, prompting RN2 to check on R16, who was found maladjusted in bed and calling for help. The facility's policy, as stated in the Resident Safety Policy, mandates that call lights should be placed within easy reach of residents at all times. Interviews with staff, including the Administrator, DNS, RN2, and the Social Worker, confirmed that the call light was not within R16's reach, which was a violation of the facility's policy and a potential safety issue. The incident was investigated by the previous DON, who arrived at the facility in the early hours following the incident. The staff acknowledged the importance of keeping call lights accessible to residents to ensure their safety and uphold their rights.
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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 Post Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Post Falls | 4.3 mi | ★★★★★ | 8 | 0 |
| Spokane Valley Health And Rehabilitation Of Cascad | 8.1 mi | ★★★★★ | 26 | 0 |
| Advanced Health Care Of Coeur D'alene | 8.8 mi | ★★★★★ | 10 | 0 |
| Ironwood Rehabilitation And Care Center | 9.3 mi | ★★★★★ | 21 | 0 |
| Lakeside Rehabilitation And Care Center | 9.8 mi | ★★★★★ | 14 | 0 |
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