Terraces Of Boise, The

F 0550 Level of Harm - Minimal harm or potential for actual harm

At 12:32 PM, Resident #22 told Resident #41 I have nothing to eat and Can I get more of this, pointing at her drinking glass. Glass was observed almost empty.

At 12:36 PM CNA #1 served regular food minced and moist with mashed potatoes with gravy. Resident #22 started eating.

Residents Affected - Some At 12:44 PM, Resident #22 was served with another plate of minced and moist food which consisted of mashed potatoes and parmesan chicken pesto.

On 12/15/25 at 1:14 PM, when asked why Resident #22 was not served her food at the same time as Resident #41, [NAME] #1 stated, the cook that was in charge of making special diets like minced and moist, forgot about it and had to get it from the kitchen upstairs. When asked if Resident #22 always eats in

the [NAME] Dining Room, [NAME] #1 stated, Yes, she always eats in this dining room.

On 12/16/25 at 2:33 PM, the RD stated residents sitting at the same table should be served their meals at

the same time.

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Terraces of Boise, The

5301 E Warm Springs Ave Boise, ID 83716

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 0602

Protect each resident from the wrongful use of the resident's belongings or money.

Level of Harm - Actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Idaho State LTC Reporting Portal System, policy review, record review and staff interview, it was determined the facility failed to ensure resident's rights were protected to be free from misappropriation of residents' funds. This was true for 1 of 3 residents (Resident #39) whose record was reviewed for misappropriation. This deficient practice caused emotional and financial harm when Resident #39's personal finances were used by a facility staff member. Findings include: Resident #39 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including a left pubic fracture, dementia, and depression.

Resident #39's admission MDS assessment dated [DATE REDACTED], documented Resident #39 was cognitively intact. An I&A, dated 12/4/25, was submitted to the Idaho State LTC Reporting Portal System identifying a facility staff member had stolen $1900 from Resident #39.The report documented on 12/4/25 at 11:30 AM,

the Executive Director (ED) was contacted by the Boise Police Department regarding the status of an ongoing investigation into suspected financial exploitation involving a former short-stay rehabilitation resident, [Resident #39]. The investigating officer reported the police department had obtained documentation confirming [CNA #2] had used [Resident #39's] credit card to pay their personal rent and utility bills.The I&A further documented, the June 2025 incident, when [Resident #39s] family notified the facility of unexplained and unauthorized activity on the resident's credit card statement. At the time of the family's concern, the resident had recently completed a short-stay rehabilitation stay at the facility from 6/1/25 through 7/2/25. The family expressed concern the activity may have occurred during the resident's stay but were unsure due to complex family dynamics. The ED immediately assisted the family in contacting law enforcement and filing a formal police report.On 12/4/25, law enforcement informed the ED they had secured evidence linking the unauthorized charges, totaling $1,900, directly to [CNA #2]. The ED informed

the family of the findings and reaffirmed the facility does not tolerate any form of abuse, neglect, or exploitation. The family stated they would check with the credit card company to confirm whether fraud charges had been removed and would follow up with the ED. The Nursing Home Administrator (NHA) was alerted to the findings immediately.On 12/17/25 at 11:34 AM, the ED stated the facility was unaware any theft had happened regarding CNA #2. He stated Resident #39 had left the facility with his family prior to any police investigations.The ED continued, When the police notified the facility of the theft, we started our internal investigations, staff trainings, and resident reviews for any additional misappropriation which might have occurred. CNA #2 was found by the police, but we have no further information regarding the case. The ED also stated the facility has been in communication with the family to make reparations; however, we cannot do more until we file for the completed case report. When asked why the facility did not address the concerns when the family first notified the facility in June 2025, the ED stated he had directed the family to contact law enforcement to file a report since the family was not sure if the charges had come from the facility or their family. The facility did not conduct any internal facility investigations at the time of the original notification in June 2025.

Residents Affected - Few

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Terraces of Boise, The

5301 E Warm Springs Ave Boise, ID 83716

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 0604

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, staff interview, and record review, it was determined the facility failed to ensure position change alarms were assessed as potential restraints and a consent from the residents' representative and physician's order were obtained prior to installation of the alarms. This was true for 2 of 3 residents (#14 and #22) reviewed for potential restraints. This deficient practice had the potential for harm if the position change alarms were improperly used and if resident's experienced physical deterioration due to lack of movement. Findings include:The State Manual Appendix PP issued 7/23/25, documented if the facility staff choose to implement alarms, they should document their use aimed at assisting the staff to assess patterns and routines of the resident. Use of these devices, like any care planning intervention, must be based on assessment of the resident and monitored for efficacy on an on-going basis.The facility's Falls and Fall Risk, Managing policy revised March 2018, documented:If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.If underlying causes cannot be readily identified or corrected, staff will try various interventions based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.The use of position alarm will be monitored for efficacy and staff will respond to alarms in a timely manner. 1.Resident #14 was admitted to

the facility on [DATE REDACTED], with multiple diagnoses including Alzheimer's disease with late onset, muscle weakness and hypertension.A Risk for Fall care plan documented Resident #14 had tab alarm, chair, pressure alarm bed as fall prevention device, initiated 8/21/24.Resident #14's record did not include documentation a least restrictive devices were attempted prior to him using the position change alarm.

Also, his record did not include an assessment of him using the chair and bed alarm as a potential restraint.On 12/16/25 at 11:38 AM, 12/16/25 at 2:07 PM, and 12/17/25 at 11:14 AM Resident #14 was observed in his wheelchair with a tab alarm attached to the back of his wheelchair, clipped on the back of his shirt. 2. Resident #22 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including Alzheimer's disease, muscle weakness and hypertension.A Risk for Fall care plan documented Resident #22 had a tab alarm to her bathroom door and tag alarm to her wheelchair initiated 5/6/25.On 12/16/25 at 11:38 AM and 12/18/25 at 5:06 PM Resident #22 was observed in her wheelchair with a tab alarm attached to the back of her wheelchair and clipped on her shirt.Resident #22's record did not include documentation that least restrictive devices were attempted prior to her using the position change alarm. Her record did not include an assessment of her using the chair alarm as potential restraint.On 12/18/25 at 4:25 PM, when asked about Resident #14 and Resident #22 having a tab alarm attached on their wheelchair, the DON stated it comes with some sort of fall risk assessments, residents being impulsive, and sometimes as requested by their representatives. The least restrictive interventions were also used such as providing the resident with soft touch call light or placing them closer to the nurse's station, using the tab alarm was our last resort. When asked about the resident's assessment before placing the tab alarm, the DON stated there was no assessment, only the fall risk assessment was completed. The DON also stated they did not require a consent before placing the tab alarm on the residents.

Residents Affected - Few

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Terraces of Boise, The

5301 E Warm Springs Ave Boise, ID 83716

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 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff and resident interview, it was determined the facility failed to ensure resident's missing personal item was investigated as potential misappropriation of resident's property. This was true for 1 of 1 resident (Resident #34) reviewed for misappropriation of personal property. This failure created

the potential for Resident #34 to experience emotional distress due to the loss of a personal item with inherent value. Findings include:Resident #34 was admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED], with multiple diagnoses including Parkinson's disease (a movement disorder that affects the nervous system), diabetes and hypertension.A Quarterly MDS assessment dated [DATE REDACTED], documented Resident #34 was cognitively intact.On 12/16/25 at 9:36 AM, Resident #34 stated a ring which was given to her by her grandmother went missing. Resident #34 stated she reported it to the facility and was told they will look for it. Resident #34 stated she was told the ring had not been found yet, and they will keep looking for it.On 12/19/25 at 10:31 AM, when asked to describe her missing ring, Resident #34 stated the ring had three stones, an emerald stone in the middle and two diamonds on the side and set in gold.On 12/17/25 at 2:26 PM, the LSW stated Resident #34 asked her family member to bring the ring to the facility on her birthday at the end of July 2025, and it was reported missing two weeks after it was brought into the facility. The LSW stated they posted a picture of the ring in the facility and looked through Resident #34's room, as well as in the laundry but the ring was not found.An undated telephone text message provided by the ED documented, Also M103 [Resident #34's room] daughters in today and state they brought in a family heirloom ring (resident's grandmother's ring a diamond and emerald ring). They brought it in last Wednesday and on Friday resident told them she had lost it.On 12/17/25 at 3:40 PM the ED was asked if Resident #34's missing ring was investigated, the ED stated they put a signage of the missing ring in the facility for about a month and looked for it in her room and laundry room, but the ring was not found. When asked if CNAs who provided care to Resident #34 and other staff were interviewed, the ED stated, Yes.

When asked for the documentation of what was done to look for Resident #34's ring, the ED stated they did look for the ring and staff were interviewed, but he did not have documentation of what they did to look for

the missing ring. The ED stated there were no progress notes made and there should have been. He stated, We did all the right things except writing it down.

Residents Affected - Few

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Terraces of Boise, The

5301 E Warm Springs Ave Boise, ID 83716

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 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review, and staff interview, it was determined the facility failed to ensure resident's MDS assessments accurately reflected their status. This was true for 1 of 1 resident (Resident #6) whose MDS assessment was reviewed. This deficient practice had the potential for negative outcomes if Resident #6 was not assessed and/or monitored due to inaccurate assessments. Findings include:Resident #6 was admitted to the facility on [DATE REDACTED] and readmitted [DATE REDACTED] with multiple diagnoses, including heart disease, anemia, and hypertension.Resident #6's MDS assessments documented the following: admission assessment dated [DATE REDACTED], he had no impairment on his upper and lower extremities Quarterly assessment dated [DATE REDACTED], he had impairments on both sides of his upper and lower extremities.Resident #6 was observed on the following days as follows: 12/16/25 at 3:05 PM, able to move his both [NAME] while his wheelchair was being push by the staff. 12/17/25 at 10:52 AM, sitting in his wheelchair in the living room of [NAME] House during activity with other residents, with his hand supporting his chin.On 12/18/25 at 2:24 PM, when asked during telephone interview regarding Resident #6's Quarterly MDS assessment of his range of motion dated 9/15/25, the MDS nurse stated she would review the MDS and would call the surveyor back.On 12/18/25 at 4:08 PM, the MDS nurse called back and stated, Resident #6's Quarterly MDS assessment dated [DATE REDACTED] was mistakenly coded as with impairment on both sides of his upper and lower extremities. The MDS nurse stated it should have been coded as no impairment.

Residents Affected - Few

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Terraces of Boise, The

5301 E Warm Springs Ave Boise, ID 83716

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review, and staff interview it was determined the facility failed to ensure care plans were revised as needed. This was true for 1 of 13 residents (Resident #8) whose record was reviewed for care plan revision. This deficient practice created the potential for harm if the Resident #8 did not receive oxygen treatment as ordered. Findings include:Resident #8 was admitted to the facility on [DATE REDACTED], and re-admitted

on [DATE REDACTED], with multiple diagnoses including sleep apnea and chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs).A physician's order, dated 11/12/25, directed staff to provide oxygen at 2 LPM via nasal cannula, at all times for every shift.Resident #8's care plan, dated 11/12/25, directed staff to provide oxygen continuously at 2 LPM via nasal cannula and to provide oxygen monitoring and management.On 12/16/25 at 9:19 AM, Resident #8 was observed lying in bed without an oxygen nasal cannula.On 12/18/25 at 11:36 AM, Resident #8 was again observed lying in bed without an oxygen nasal cannula. When asked where her oxygen nasal cannula was, Resident #8 stated she had not been using it for some time. She did not remember the exact date.On 12/19/25 at 10:14 AM, the ADON stated Resident #8 had been receiving O2 via nasal cannula continuously; however, she had been weaned off it and was using room air with oxygen saturation vitals taken twice per day. The ADON stated the care plan and physician's order had not been updated to reflect the removal of the nasal cannula for room air.

The care plan should have been updated to reflect Resident #8's current oxygen treatment.

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Terraces of Boise, The

5301 E Warm Springs Ave Boise, ID 83716

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 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, it was determined the facility failed to ensure medications were administered according to professional standards of practice. This was true for 1 of 7 residents (Resident #42) observed during medication administrations. This failed practice created the potential for Resident #42 to experienced adverse effects when her medications were not administered according to physician's order.

Findings include: The facility's Administering Medications policy revised April 2019 documented the individual administering the medication checks the label three times to verify the right resident, right medications, right dosage, right time, and right method (route) of administration before giving the medication.Resident 342 was admitted to the facility on [DATE REDACTED], with multiple diagnose including inflammatory neuropathy (condition that affects the peripheral nerves, leading to symptoms such as weakness, numbness, and pain), anemia and hypertension.A physician's order documented Resident #42 was to receive the following medications: gabapentin 300 mg capsule, one capsule by mouth one time a day for pain, ordered 12/13/25 gabapentin 400 mg capsule, one capsule by mouth at bedtime for pain, ordered 12/12/25On 12/18/25 at 9:21 AM LPN #1 prepared and administered Resident #42's morning medications which included gabapentin 400 mg one capsule.On 12/18/25 at 9:45 AM, LPN #1 reviewed the physician's order of Resident #42's medications. LPN #1 stated she gave the 400 mg gabapentin to Resident #42. LPN #1 stated, I should have given the 300 mg gabapentin.

Residents Affected - Few

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Terraces of Boise, The

5301 E Warm Springs Ave Boise, ID 83716

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 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review, and staff interview it was determined the facility failed to provide respiratory services. This was true for 1 of 1 resident's (Resident #8) who was reviewed for oxygen and respiratory services. This deficient practice had the potential for Resident #8 to experience shortness of breath when her physician's order was not followed. Findings include:Resident #8 was admitted to the facility on [DATE REDACTED], and re-admitted on [DATE REDACTED], with multiple diagnoses including sleep apnea and chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs).A physician's order, dated 11/12/25, directed staff to provide Oxygen at 2 LPM via nasal cannula, at all times for every shift. On 12/16/25 at 9:19 AM, and on 12/18/25 at 11:36 AM, Resident #8 was observed lying in bed without oxygen via nasal cannula. Resident #8 stated she had not been using her oxygen for some time and did not know the exact date it stopped. On 12/19/25 at 10:14 AM, the ADON confirmed the facility was not currently providing 2 LPM of oxygen via nasal cannula at all times as per physician's orders.

Residents Affected - Few

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Terraces of Boise, The

5301 E Warm Springs Ave Boise, ID 83716

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review, staff interview, and policy review, it was determined the facility failed to ensure medications were secured when they were unattended by staff and to ensure pharmacy labels matched the physician's order. This was true for 1 of 1 resident (Resident #30) whose medication administration was observed. This failed practice created the potential for harm if medications were taken by another resident and should Resident #30's Oxycodone (opioid pain medication) be administered at the wrong dose.

Findings include: Resident #30 was admitted to the facility on [DATE REDACTED], with multiple diagnoses including stage 4 pressure ulcers of left and right heels, and hypertension (high blood pressure).1.On 12/18/25 at 12:05PM, LPN #2 entered Resident #30's room with her medications on hand. Upon entering Resident #30's room, she stated she needed to use the restroom, LPN #2 requested help from CNA to assist Resident #30 to the restroom. LPN #2 exited room with medications in hand along with dirty dishes. Upon exiting Resident #30's room, LPN #2 was observed leaving a cup containing a white powder on top of the medication cart. LPN #2 brought dirty dishes to the kitchen and returned to the medication cart. LPN #2 then took the cup with the white powder into the kitchen and mixed it with water, LPN #2 walked back to the medication cart, placing the cup containing the white powder mixed with water on top of the medication cart when a male resident asked her what soup was being served for lunch. LPN #2 was observed leaving the cup containing the white powder mixed with water on top of the medication cart and returned to the kitchen to check the menu for the male resident.On 12/18/25 at 12:15 PM when asked about the cup containing the white powder mixed with water left on top of the medication cart when she went to the kitchen to check the menu, LPN #2 stated, no Miralax (laxative used to treat occasional constipation). When asked if nursing staff was supposed to leave Miralax on top of the medication cart, LPN #2 states, No.On 12/19/25 at 10:55 AM, when asked if nurses were to leave medications unattended on top of the medication cart, the DON stated, No. 2. The facility's Labeling of Medication Containers Policy revised April 2019, documented any medication packaging inadequately or improperly labeled are returned to the issuing pharmacy. A physician's order documented Resident #30 was to receive the following: Oxycodone HCl 5 mg tablet: 0.5 tablet by mouth twice daily [6 AM and 12 PM] Oxycodone HCl 5 mg tablet: 0.5 tablet by mouth twice daily as neededOn 12/18/25 at 12:20 PM, LPN #2 prepared and administered Resident #30's medication which included the Oxycodone. The Oxycodone IR pharmacy label documented Give 0.5 tablet by mouth four times daily as needed.On 12/18/25 at 12:35 PM, when asked about the physician's order for Resident #30's Oxycodone, LPN #2 stated Resident #30 had scheduled and as needed orders for Oxycodone. When asked if the order was the same on the pharmacy's label LPN #2 stated, No. When asked what the policy was for labeling when orders change, LPN #2 stated, put an order change sticker on it. No order change sticker was observed on the medication card.On 12/19/25 at 10:55 AM, when the DON was asked if physician orders and pharmacy card labels were to match, the DON stated, Yes it should, when a provider changes the order, the pharmacy should send a new card to match. The DON stated, if nursing staff finds a pharmacy label does not match the MAR the nurse is to call the pharmacy to get a new card dispensed.

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Terraces of Boise, The

5301 E Warm Springs Ave Boise, ID 83716

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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

they had not cleaned or sanitized the dish drying racks in some time as they were working through the refrigerator racks first. We should have cleaned and sanitized these racks long before they developed a layer of dust. On 12/18/25 at 4:58 PM, during dinner tray line observation at [NAME] House, the following was observed: At 5:15 PM, [NAME] #1 placed food containers on top of the cutting board and knife used for chopping foods for mechanical chopped diets. At 5:17 PM, [NAME] #1 removed the food containers and chopped up vegetables and cooked chicken without cleaning or sanitizing the cutting board and knife. At 5:19 PM, [NAME] #1 placed a sauce container back onto the cutting knife, on top of the cutting board to serve sauce on top of the chicken and vegetables. He then placed the sauce container back into the heating cart. [NAME] #1 did not clean or sanitize the cutting board and knife. At 5:20 PM, [NAME] #1 placed

a drinkable straw on the same cutting board as listed above, filled up the cup with liquid food, and then placed the drinkable straw into the cup which was then served to the resident. At 5:24 PM, [NAME] #1 placed the sauce container from the heating cart back on top of the flat surface of the cutting knife which was lying on the cutting board. He used the same knife to cut cooked noodles and chicken breast without sanitizing or cleaning between uses. [NAME] #1 then used the flat surface of the cutting knife to scoop up cut chicken breast and noodles onto a resident's plate, which was served. Cleaning and sanitation of the cutting board and knife was not observed for the duration of tray line which ended at 5:42 PM. On 12/18/25 at 5:45 PM, [NAME] #1 stated the containers are cleaned and sanitized prior to use. He stated the containers could have been placed elsewhere on the countertop, but he did not believe he was cross contaminating food contact surfaces since everything was cleaned and sanitized prior to use. When asked if

the cutting board and knife should have been cleaned between uses, when the containers were placed on top of them, he stated they could have been, but it is not what he normally does. On 12/19/25 at 9:51 AM,

the Kitchen Manager stated [NAME] #1 should have placed the sauce and food containers on the countertop, not on top of the cutting board and knife. He stated the cutting board, and knife should have been cleaned and sanitized after being used for holding the food and sauce containers.

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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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Terraces of Boise, The

5301 E Warm Springs Ave Boise, ID 83716

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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

medications to Resident #43, performed hand hygiene and exited the room. When asked when hand hygiene is performed, RN #1 stated, Before and after. It's difficult with a med cup and water in hand. When asked if RN #1 performed hand hygiene before entering resident #43's room RN #1 stated, I did not perform hand hygiene.

1. 3. On 12/18/25 at 8:43 AM, five capsules were observed on top of the medication cart. There was no barrier

between the five capsules and top of the medications cart, and LPN #1 was about 3-4 steps away from her medication cart talking to the ST. As soon as LPN #1 saw the surveyor, LPN #1 walked back to her cart and opened the capsule and placed them inside the pill pouch.

On 12/18/25 at 9:11 AM, when asked about the capsules on top of the medication cart, LPN #1 stated she should have put the capsules inside the medication cup.

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

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