Federal inspectors discovered the oversight in November during a complaint investigation at the 6000 West Denton Street facility. Resident #33, who has Alzheimer's disease and muscle weakness, had been falling repeatedly since her admission earlier this year.
The 83-year-old woman broke her right leg before arriving at Cascadia and struggled with difficulty walking. Her family knew she was a restless sleeper who had been moved to a new mattress.
On August 21, staff found Resident #33 on the floor within one foot of her bed during an unwitnessed fall. She was lying on her right side and appeared distressed. The incident report noted she was wearing gripper socks and had a fall mat by her bed when the fall occurred.
A post-fall evaluation completed the same day recommended continuing the floor mat intervention. An interdisciplinary team review on August 22 determined she had no injuries from the fall and added a new precaution: Resident #33 would stay out of her room when using her wheelchair.
Her daughter noticed the safety measures during a September 22 visit. "My mom had fallen out of bed a few times as she is a restless sleeper and was on a new mattress," the family member told inspectors. She saw that fall precautions were in place, including the floor pad and keeping her mother's bed in the lowest position.
From September 22 through September 25, inspectors observed the fall mat on the floor near Resident #33's bed. When she was in bed, staff kept it in the lowest position. When she was up, they wheeled her to the main dining room and kept her door open except during personal care.
But the written care plan told a different story.
Resident #33's official care plan included keeping her door open, locking bed brakes, maintaining the bed in a safe transfer position, and keeping her out of the room when in her wheelchair. The floor mat that staff had been using for over a month appeared nowhere in the document.
The charge nurse confirmed the disconnect on September 25. "The fall mat was not in Resident #33's care plan," she told inspectors. "If the fall mat is in Resident #33's room, it should be on her care plan."
Federal regulations require nursing homes to develop complete care plans within seven days of comprehensive assessments and revise them when residents' needs change. The care plan serves as the roadmap for all staff providing care, ensuring everyone knows what interventions a resident requires.
Cascadia's failure meant that while direct care staff were implementing the fall mat intervention daily, the official care plan provided no guidance about this safety measure. New staff members or those unfamiliar with Resident #33's specific situation would have no documentation indicating she needed the floor mat.
The facility's care plan did document other fall prevention measures implemented at different times. Door positioning and bed brake protocols started July 25. The wheelchair room restriction began August 22, the day after her documented fall.
Resident #33's case illustrates how documentation gaps can undermine resident safety even when staff are providing appropriate interventions. The charge nurse's admission that the fall mat "should be on her care plan" acknowledged that the facility's own protocols weren't being followed.
For a resident with Alzheimer's disease, muscle weakness, and a history of multiple falls, accurate care planning becomes critical. Each shift change brings new staff members who rely on written care plans to understand a resident's specific needs and safety requirements.
The inspection found that one of 22 residents reviewed had care plan revision failures, suggesting the problem may be isolated rather than systemic. However, for Resident #33, the documentation gap meant her fall prevention strategy existed in practice but not on paper.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. The finding represents a failure in the facility's care planning process rather than a complete absence of fall prevention efforts.
Resident #33 continues to receive the floor mat intervention that staff determined she needs. Whether Cascadia has since updated her care plan to reflect the safety measure remains unclear from the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cascadia of Boise from 2025-11-19 including all violations, facility responses, and corrective action plans.