Deficiencies (last 3 years)
Deficiencies (over 3 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than Idaho average
Idaho average: 7.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 11
Dec 5, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey of Cascadia of Nampa nursing home to assess compliance with regulatory requirements and evaluate resident care and facility operations.
Findings
The survey identified multiple deficiencies including failure to assess residents for safe self-administration of medications, inaccurate MDS assessments, delayed PASARR submissions, inadequate treatment and monitoring of residents with acute changes in condition, failure to provide palatable and properly temperature-controlled food, lapses in infection control practices including hand hygiene and medication preparation, improper storage and handling of linens and food, and deficiencies in antibiotic stewardship.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure residents were assessed for safety to self-administer medication, affecting 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate MDS assessments for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to coordinate assessments with PASARR program, including late submission and inaccurate completion for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders and resident preferences, resulting in Immediate Jeopardy for 1 resident due to delayed recognition and treatment of sepsis and Stevens-Johnson Syndrome. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide accurate smoking evaluations and follow care plan for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents received respiratory services consistent with physician's orders for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to serve palatable food at safe and appetizing temperatures to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to procure food from approved sources and maintain proper storage, preparation, and sanitation including ice machine cleanliness and separation of staff and resident food. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to consistently implement infection prevention and control measures including hand hygiene, medication preparation, storage of dentures, CPAP mask sanitation, and laundry handling. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a neutral and fair arbitration process with a venue convenient to both parties. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement an antibiotic stewardship program ensuring appropriate antibiotic use for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: Many
Residents affected: Many
Residents affected: 5
Residents affected: Many
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Named in medication administration and hand hygiene deficiencies | |
| RN #2 | Named in medication preparation and hand hygiene deficiencies | |
| RN #1 | Named in medication preparation, denture storage, and CPAP mask sanitation deficiencies | |
| LPN #1 | Named in smoking paraphernalia handling deficiency | |
| MDS Coordinator | Named in MDS assessment accuracy deficiency | |
| RCM | Named in multiple deficiencies including medication self-administration, respiratory care, and antibiotic stewardship | |
| CRN | Named in Immediate Jeopardy and respiratory care deficiencies | |
| Administrator | Named in Immediate Jeopardy notification and arbitration agreement deficiency | |
| Medical Director | Named in Immediate Jeopardy deficiency | |
| Kitchen Manager | Named in food service and food safety deficiencies | |
| IP | Infection Preventionist | Named in infection control and antibiotic stewardship deficiencies |
| LSW | Named in PASARR coordination deficiencies |
Inspection Report
Routine
Deficiencies: 12
Dec 5, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, infection control, medication administration, food service, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, inadequate accommodation of resident needs such as call light access, inaccurate resident assessments, delayed PASARR submissions and inaccurate PASARR screenings, failure to provide appropriate treatment leading to immediate jeopardy for one resident, inadequate smoking evaluations, failure to ensure respiratory care as ordered, serving food and drink that was not palatable or at safe temperatures, improper food storage and sanitation practices, failure to implement infection prevention and control measures including hand hygiene and laundry practices, and failure to implement an antibiotic stewardship program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure residents were assessed for safety to self-administer medication, leaving medications at bedside without proper assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to reasonably accommodate resident needs and preferences by denying access to call light system when residents were left alone. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate Minimum Data Set (MDS) assessments for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program and delayed submission of PASARR. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care according to orders, resident preferences and goals, resulting in immediate jeopardy due to failure to identify and act upon resident's physical and cognitive deterioration. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to provide accurate and quarterly smoking evaluations and did not follow the care plan for an independent smoker. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care consistent with physician's orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to serve palatable food and drink at safe and appetizing temperatures, resulting in resident dissatisfaction. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure ice machines were cleaned, resident freezers were free from contamination, and food was properly dated and stored. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a neutral and fair arbitration process with a venue convenient to both parties. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure infection control measures including hand hygiene during medication preparation and proper handling of linens were consistently implemented. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement an antibiotic stewardship program ensuring appropriate antibiotic use and clinical indications. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for self-administration assessment: 19
Residents reviewed for call light access: 19
Residents reviewed for MDS accuracy: 5
Residents reviewed for PASARR coordination: 2
Residents reviewed for PASARR screening accuracy: 2
Residents affected by immediate jeopardy: 1
Residents reviewed for smoking evaluation: 2
Residents reviewed for oxygen use: 3
Residents interviewed about food: 9
Residents reviewed for infection control: 5
Residents reviewed for antibiotic stewardship: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Named in medication administration and hand hygiene deficiencies | |
| RN #2 | Observed preparing medications without proper hand hygiene | |
| RN #1 | Observed preparing medications and handling dentures improperly | |
| CNA #1 | Confirmed call light access issues for residents #28 and #89 | |
| RCM | Provided statements regarding medication self-administration and call light issues | |
| DON | Director of Nursing | Provided statements on call light expectations, smoking assessments, and care plan accuracy |
| CRN | Involved in medication administration and immediate jeopardy case discussions | |
| LSW | Provided information on PASARR submission and screening | |
| Kitchen Manager | Confirmed food temperature, coffee quality, and food storage deficiencies | |
| IP | Infection Preventionist | Provided statements on hand hygiene and infection control deficiencies |
| Administrator | Notified of immediate jeopardy and arbitration agreement deficiency | |
| Medical Director | Stated he was not informed of resident #60's change in cognition |
Inspection Report
Annual Inspection
Deficiencies: 4
Jun 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, fall prevention, waste disposal, and vaccination policies at Cascadia of Nampa nursing home.
Findings
The facility was found deficient in honoring residents' rights to self-determination regarding TV use during meals, implementing fall prevention interventions after a resident fall, properly containing waste to prevent pest infestation, and ensuring eligible residents were offered pneumococcal vaccinations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure residents' rights for self-determination were honored regarding TV use during meals for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a fall prevention intervention was implemented following a fall for Resident #10. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure waste was properly contained with lids or otherwise covered, creating potential for pest infestation affecting all residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents eligible for pneumococcal vaccine were offered the vaccine, affecting 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 90
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Observed turning off TV during meals against resident preference | |
| LPN #1 | Educated CNA #3 about leaving TV on if residents requested | |
| Administrator | Stated TV could be left on during meals as residents' choice | |
| DON | Stated floor mat was to be placed next to Resident #10's bed to reduce injury risk | |
| Dietary Manager | Stated dumpster should be closed and not left open | |
| Infection Preventionist | Stated facility lacked process for shared decision-making on PCV20 vaccination |
Inspection Report
Routine
Deficiencies: 4
Jun 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, fall prevention, waste disposal, and vaccination policies at Cascadia of Nampa nursing home.
Findings
The facility was found deficient in honoring residents' rights to self-determination regarding TV use during meals, implementing fall prevention interventions after a resident fall, properly containing waste to prevent pest infestation, and ensuring eligible residents were offered pneumococcal vaccinations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure residents' rights for self-determination were honored regarding TV use during meals for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a fall prevention intervention was implemented following a fall for Resident #10. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure waste was properly contained with lids or otherwise covered, creating potential for pest infestation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were offered pneumococcal vaccine they were eligible to receive for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 90
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Observed turning off TV during meals against residents' wishes | |
| LPN #1 | Educated CNA #3 about leaving TV on if residents requested | |
| Administrator | Stated TV could be left on during meals as residents' choice | |
| Director of Nursing (DON) | Stated floor mat was to be placed next to Resident #10's bed to reduce injury risk | |
| Dietary Manager | Observed dumpster lid open and stated it should be closed | |
| Infection Preventionist | Stated facility lacked process for shared decision-making on PCV20 vaccination |
Inspection Report
Routine
Deficiencies: 20
Feb 1, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, resident council operations, advance directive documentation, notification of significant changes, care planning, bathing and hygiene assistance, fall prevention and supervision, pressure ulcer care, medication administration timeliness, respiratory care, food safety, and grievance handling.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 19
Level of Harm - Actual harm: 2
Deficiencies (20)
| Description | Severity |
|---|---|
| Facility failed to ensure residents #15 and #168 had assessments and orders for self-administration of medications prior to allowing them to self-administer. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide guidance and act promptly on Resident Council group grievances and concerns for 13 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure documentation and provision of advance directives for 6 residents, including lack of copies and failure to offer assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to notify resident #319's physician and family in a timely manner of significant change in condition. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain a homelike environment for residents #16, #24, #29, and #41 due to unrepaired wall damage. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to respond to, investigate, and resolve grievances for multiple residents, including issues with call light response times and missing personal items. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to complete required documentation for resident #318's transfer to hospital including physician order and transfer summary. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide timely written notice of transfer to resident #318 and/or her representative. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to complete a comprehensive assessment for resident #65 upon significant change when placed on hospice. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to develop and implement comprehensive care plans including code status and assistance with eating for residents #40 and #43. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure care plans were reviewed/revised and residents or representatives involved for 9 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide assistance with bathing and eating consistent with residents' needs for 5 residents (#1, #7, #15, #37, #41). | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to follow neurological assessment policy after unwitnessed falls for residents #1, #43, #54, #65, and #319. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure timely administration of medications for residents #15 and #32. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide pressure ulcer prevention and treatment for residents #1 and #318, resulting in actual harm to Resident #318. | Level of Harm - Actual harm |
| Facility failed to provide adequate supervision and fall prevention interventions for residents #1, #40, and #65, and failed to ensure bed wheel locks were applied for residents #7, #24, and #41. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure bed rails were assessed for safety risk and consent obtained for resident #54 prior to use. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain dishwasher rinse temperature at 180 degrees Fahrenheit and failed to ensure food on steam table was held at safe temperature. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure bowel care protocol was followed for resident #267, placing resident at risk for fecal impaction. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure oxygen therapy was provided with a physician's order for resident #318. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 79
Residents affected: 13
Residents affected: 6
Residents affected: 4
Residents affected: 21
Residents affected: 3
Residents affected: 5
Residents affected: 2
Residents affected: 5
Residents affected: 9
Residents affected: 1
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RCM #2 | Resident Care Manager | Named in medication self-administration and grievance findings |
| RN #3 | Registered Nurse | Named in medication delay and fall supervision findings |
| LPN #3 | Licensed Practical Nurse | Named in pressure ulcer care findings |
| DNS | Director of Nursing Services | Named in neurological assessment and fall supervision findings |
| CNA #4 | Certified Nursing Assistant | Named in bathing assistance and grievance findings |
| RCM #1 | Resident Care Manager | Named in transfer and oxygen therapy findings |
| FSE #1 | Food Service Employee | Named in dishwasher temperature findings |
| Dietary Manager | Named in dishwasher and food temperature findings | |
| Social Worker | Named in advance directive and grievance findings | |
| Administrator | Named in grievance and resident council findings | |
| Activities Director | Named in resident council findings | |
| CNA #1 | Certified Nursing Assistant | Named in pressure ulcer and fall supervision findings |
| RCM #5 | Registered Nurse | Named in pressure ulcer findings |
| LPN #6 | Licensed Practical Nurse | Named in pressure ulcer findings |
| CNA #2 | Certified Nursing Assistant | Named in fall supervision findings |
| CNA #10 | Certified Nursing Assistant | Named in restorative nursing findings |
| CNA #6 | Certified Nursing Assistant | Named in restorative nursing findings |
| PT Director | Physical Therapy Director | Named in restorative nursing findings |
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