Shaw Mountain Of Cascadia

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Drain tube check in 2 weeks, if output is less than 10 ml for two consecutive days call IR to schedule check sooner. Flush with 5 ml once daily, start date 3/22/25, discontinue date 3/24/25. a. On 1/30/25 at 5:03 PM, the DON stated, Resident #4's TAR had two conflicting orders, one to flush the drains with 10 ml of sterile saline, and one to flush the drains with 5 ml of sterile saline. She stated, the order to flush with 10 ml should have been discontinued on 3/21/25 when new orders were received. b. On 1/30/25 at 5:04 PM, the DON stated Resident #4 received new orders for his drain tubes on 3/14/25 and 3/21/25, and those orders were not implemented on the TAR until 3/15/25 and 3/22/25 respectively.

She stated, the new orders should have been implemented the same day they were received, not the following day. c. On 1/30/25 at 5:06 PM, the DON stated Resident #4's record did not document the amount of fluid drained from his collection bags on 3/14/25, 3/16/25, and 3/17/25, and the nurses did not follow the physician order to record output.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Shaw Mountain of Cascadia

909 Reserve Street Boise, ID 83712

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Based on record review and staff interview, it was determined the facility failed to ensure sufficient staff were on-site to provide nursing services. This failure had the potential to affect all residents living in the facility and placed them at risk for harm if their call lights were not able to be answered in a timely manner or care was not provided due to not having adequate numbers of staff. Findings include:The facility Grievance Log was reviewed for July-December 2025, and documented the following:On 8/8/25, a resident reported long call light wait times. The facility completed call light audits and staff were provided education to answer call lights in a timely manner. On 8/15/25, a resident reported they were left soiled for 2 hours while their call light was on, once staff responded they seemed hurried. The facility provided one to one training to the CNA for answering call lights.On 8/22/25, a resident reported they used their call light for incontinence care, a CNA responded and turned off the call light, then said they would come help them with

a shower, then did not return for 1 hour 15 minutes. The facility provided one to one education for the CNA and the CNA would not be assigned to work with that resident in the future. On 9/19/25, a resident representative reported their loved one had been wearing the same clothes all weekend. The facility provided education to staff for providing care and activities of daily living. On 11/3/25, a resident representative reported their loved one was observed to be in their recliner in their bedroom soiled with urine and stool. The facility provided education to staff to provide incontinence care every two hours. On 11/14/25, a resident representative reported their loved ones call lights were not being responded to. The facility provided education to all staff about answering call lights. On 12/10/25, a resident reported they waited 2 hours and 30 minutes to use the restroom because no staff were available to answer their call light. The facility did not address this concern. On 1/30/25 at 5:25 PM, the DON stated, call lights are a constant problem. She stated they do call light audits and education with the staff when concerns were brought to their attention. The DON stated the administrative staff were encouraged to answer call lights when they notice them. She added, the administration was struggling to find a solution to long call light wait times.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Shaw Mountain of Cascadia

909 Reserve Street Boise, ID 83712

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm

drained and flushed every evening, draining serous-bloody drainage, 25 ml from one drain, and 15 ml from

the other.

On 3/20/25 at 11:00 PM, in a Health Status Note, Resident #4 had 2 drains to his liver that were drained in

the evening

Residents Affected - Few

On 3/21/25 at 7:07 PM, in a Health Status Note, Resident #4 had an appointment that day for a drain check, drain #2 was removed and drain #3 remained.

On 3/21/25 at 11:00 PM, in a Skilled Charting Note, Resident #4 had 2 drains to his liver, and one drain attached and patent, measured and recorded.

On 3/22/25 at 8:49 PM, in a Health Status Note, Resident #4 had 2 drains to his liver, and one drain attached and patent, measured and recorded.

On 3/23/25 at 5:09 AM, in a Health Status Note, Resident #4 had 2 drains to his liver, and one drain attached and patent, measured and recorded.

On 3/24/25 at 11:26 AM, in a Health Status Note, Resident #4 had 1 drain to his liver and was preparing to discharge home.

On 1/30/25 at 5:12 PM, the DON stated multiple progress notes documented the wrong number of drains and Resident #4's medical record documents were not accurate. She added, the nurses may have been copying and pasting their progress notes.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet