Idaho State Veterans Home - Post Falls

F 0686 Level of Harm - Actual harm Residents Affected - Few

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

submit the necessary paper works, but it was rejected by the [name of hospital] because they don't have Resident #1's information. The HIM stated they found out that Resident #1's being a veteran his care was needed to be transferred from his previous care provider to his current care provider for him to be scheduled for his wound appointment. The HIM stated Resident #1's representative needs to make this call to initiate the transfer and they were not aware of this procedure. She stated they thought Resident #1 being a veteran could go to any (name of hospital) to another (name of hospital) hospital for his treatment.

When Resident #1's representative made the call, HIM stated Resident #1 paper works was resent about three times and several phone calls were made to follow up his wound clinic appointment. The HIM stated when Resident #1's paperwork were accepted he was scheduled for 11/3/25. Resident #1 was harmed when he developed infection to his pressure wound to his right heel. He did not have a Pressure Ulcer

Record from 8/1/25 to 9/22/25. The August and September 2025 TAR documented to cleanse his right heel with wound cleanser and apply skin prep and allow to dry. There was no documentation of the status of Resident #1's wounds from 8/1/25 to 9/22/25. The Wound Nurse did not know the status of Resident #1's wounds if he needed debridement prior to her first assessment of Resident #1's wounds on 9/23/25. The current DON did not know the condition of Resident #1's wound since she only started working in the facility about three weeks ago. The Weekly Skin/Wound assessment did not document he was refusing the assessment. Referral to the Wound clinic was requested in 9/25/25. Resident #1 was seen at the Wound clinic on 11/3/25. At the Wound clinic the physician was unable to remove the unstable eschar due to Resident #1 being in considerable pain. The HIM stated they were not aware of the procedure Resident #1's care was needed to be transferred from his previous (name of hospital) to the current (name of hospital).

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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

11/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Idaho State Veterans Home - Post Falls

590 S Pleasant View Rd Post Falls, ID 83854

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 0687

Provide appropriate foot care.

Level of Harm - Minimal harm or potential for actual harm

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

observation, interviews, and record review, it was determined the facility failed to ensure resident was seen by a podiatry as ordered by the physician. This was true for 1 of 1 resident (Resident #1) reviewed for foot care. This deficient practice created the potential for Resident #1 to experience ongoing thickening of his toenails or other complications due to lack of foot care. Findings include:Resident #1 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including dementia, heart failure and diabetes.A nursing progress notes, dated 7/31/25 documented Resident #2's health care coordinator would be looking for a podiatrist for

a referral to be seen for diabetic foot care.A nursing progress note dated 8/15/25 documented Resident needs a referral from his primary care to see the selected podiatrist for nail care. Form waiting for processing and signature.A physician assistant's progress notes, dated 8/22/25 documented the physician assistant agreed for Resident #1 to be seen by a podiatrist.On 11/11/25 at 11:26 AM, the Wound nurse was observed to change the wound dressings on Resident #1's right and left heels. Resident #2's toenails were observed to be thick, yellowish in color, and misshapen or raised from the nailbeds.Resident #2's record documented he was scheduled to be seen by a Podiatry on 11/12/25. That is about 10 weeks from the date

the physician assistant agreed for him to be seen by a podiatrist.On 11/11/25 at 9:21 AM, the Wound Nurse stated Resident #1 had dysphoric (thick, oddly shaped or colored yellow or brown) toenails and it was difficult for them to cut his toenails. When asked about Resident #1's podiatry appointment, the Wound Nurse stated she believed the request was for Resident #1 to be seen by a podiatry for his toenails and consultation for a diabetic shoe. The Wound nurse stated she did not know why Resident #2's appointment took so long to be scheduled.On 11/11/25 at 9:45 AM, the HIM stated she believed she was informed of Resident #1 needing a podiatry in September 2025 and asked the Unit Clerk to submit the necessary paper works, but it was rejected by the [name of hospital] because they don't have Resident #1's information. The HIM stated they found out that Resident #1's being a veteran his care was needed to be transferred from his previous care provider to his current care provider for him to be scheduled for his podiatry appointment. The HIM stated Resident #1's representative needs to make this call to initiate the transfer. The HIM stated they were not aware of this procedure. She stated they thought Resident #1 being

a veteran could go to any (name of hospital) for his treatment. When Resident #1's representative made the call, HIM stated Resident #1 paperwork was resent about three times and several phone calls were made to follow up his podiatry appointment.When asked if Resident #1 was referred to a private medical provider, since he had another medical insurance. The HIM stated she made phone calls to a podiatry clinic and was told there was a copay to be paid. The HIM stated Resident #1's representative refused to pay the copay.

Other clinic would not accept Resident #1's insurance.On 11/11/25 at 10:05 AM, the CEO stated lots of veteran's families would like their family to be seen at a (name of hospital) and they don't want to be seen outside of the VA (Veterans Affairs) system. The CEO stated unfortunately the (name of hospital) was having a staffing crisis and they can only see so many residents in general. We were not aware of the need for the resident's care to be transferred from one (name of hospital) to another (name of hospital). I have been trying to get a podiatry contract for over a year, but no one was accepting it.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet