Cascadia of Boise: Infection Control Failure, Tracheostomy - ID
Federal inspectors visiting Cascadia of Boise on September 25, 2025 watched a respiratory therapist identified in records as RT #1 suction the endotracheal tube of a resident listed as Resident #58. An endotracheal tube is a flexible tube threaded into the windpipe to keep the airway open and support breathing. The procedure requires close physical contact with one of the most vulnerable entry points in the human body.
RT #1 had gloves on. He did not have a gown.
This would have been unremarkable at most doorways. It was not unremarkable at this one. Posted at the entrance to Resident #58's room was an Enhanced Barrier Precautions sign, placed there specifically to instruct staff on what protective equipment to wear before making high-contact physical contact with this resident. The sign listed device care, including tracheostomy care, as an activity requiring both gloves and a gown.
The sign had been there since at least September 22, three days before inspectors watched RT #1 ignore it.
When inspectors spoke with RT #1 at 11:23 that morning, four minutes after the suctioning ended, he did not dispute what had happened. He said he should have worn a gown while suctioning Resident #58's endotracheal tube. He said he did not.
Enhanced Barrier Precautions exist for a specific reason. They are applied to residents who carry or are at elevated risk of carrying organisms that spread easily through contact, the kind that move from a staff member's clothing to a wound, a tube, a breathing apparatus. Suctioning an endotracheal tube means working directly at the opening of a patient's airway. A gown is not a formality in that context. It is the barrier between whatever RT #1 had on his clothing and the inside of Resident #58's trachea.
CMS rated the violation at the minimal harm or potential for actual harm level, meaning inspectors found no documented injury to Resident #58 as a result of what they observed. The report notes that few residents were affected.
What the report does not say is whether this was the first time RT #1 had entered that room without a gown, or the tenth. Inspectors observed one instance, on one morning, during a complaint inspection. The sign on the door had been up for at least three days before that observation. The inspection report does not say who filed the complaint that triggered the visit, or whether it involved this resident or this procedure.
What it says is this: a respiratory therapist working with a patient on airway support, in a room marked with explicit protective equipment instructions, chose not to follow them, and acknowledged that choice immediately when asked.
Resident #58 needed a surgical opening in the windpipe to breathe. The precautions on that door were not placed there arbitrarily. Someone made a clinical determination that this particular resident, with this particular set of vulnerabilities, required staff to take extra steps before touching them or their equipment. RT #1 knew the requirement. The sign was on the door. He confirmed to inspectors that he understood what it said and that he had not complied with it.
The inspection was completed November 19, 2025.
Resident #58 was still at the facility when inspectors were there. The report does not say whether that has changed.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 30, 2026 · Our methodology
Cascadia of Boise in Boise, ID was cited for violations during a health inspection on November 19, 2025.
An endotracheal tube is a flexible tube threaded into the windpipe to keep the airway open and support breathing.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.