Cascadia of Boise: MDS Assessment Errors Found - ID
The finding came during a November 2025 complaint inspection at Cascadia of Boise, a nursing facility at 6000 W. Denton Street. The deficiency, cited under federal tag F641, concerns the accuracy of Minimum Data Set assessments, the standardized federal forms facilities must complete for every resident. Those forms drive care planning, reimbursement, and — in cases involving mental illness and intellectual disability — a separate screening process that determines whether a nursing home can even appropriately serve a given resident.
That screening process is called PASRR, the Preadmission Screening and Resident Review. A Level II PASRR determination means a state has found a resident has a serious mental illness, an intellectual disability, or a related condition serious enough to require additional review. The form asks facilities to document whether that determination has been made.
For Resident 59, it had been. A Level II PASRR dated September 12, 2025, documented that he was considered to have a severe mental illness. Twelve days later, his comprehensive MDS assessment recorded the answer as "no."
The MDS Nurse, when inspectors reviewed the discrepancy on September 24, offered an explanation: his understanding was that if box 36 on the Level II PASRR form was checked and no additional services were recommended, the resident was considered not to have undergone a Level II review at all. Then he looked at the completed MDS alongside the PASRR documentation. He acknowledged the assessment was inaccurately completed.
Inspectors identified the same category of error for at least one other resident. Resident 110, whose record inspectors also reviewed, had a diagnosed intellectual disability that was not accurately reflected in his MDS documentation. The inspection report does not describe what the MDS recorded for Resident 110, only that what it recorded was wrong.
Resident 59's diagnoses included quadriplegia, depression, and anxiety, in addition to the severe mental illness documented in his PASRR. The inspection report does not describe what care or services, if any, he received related to his mental health needs, or whether the inaccurate MDS affected his care plan.
The harm level assigned to the deficiency was "minimal harm or potential for actual harm," the lower end of CMS's harm scale. The number of residents affected was categorized as "few."
What the inspection does not resolve is how long the MDS Nurse's misunderstanding of the PASRR process had been shaping how assessments were completed, or how many other residents' records reflect the same logic applied to their cases. The inspection covered a complaint, not a full annual survey, and the report's narrative runs to ten pages, of which this finding occupies two.
The MDS is not a bureaucratic formality. It is the document on which a facility's understanding of who a resident is, and what they need, is supposed to rest. For a man who cannot move his arms or legs and who has been determined by the state to have a severe mental illness, having that determination marked "no" in the federal record is not a paperwork irregularity. It is the facility telling the federal government, in the official language of compliance, that the state's own finding does not exist.
The MDS Nurse's explanation, that a checked box and an absence of recommended services meant the Level II review hadn't really happened, has a certain internal logic. It is also wrong, and he said so himself once he looked at the two documents together.
Whether Resident 59 received appropriate mental health services during his stay at Cascadia of Boise, the inspection report does not say.
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.
The finding came during a November 2025 complaint inspection at Cascadia of Boise, a nursing facility at 6000 W.
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.