Arbor Valley of Cascadia

Inspectors wroteBased on policy review, facility grievances, review of call light logs, and resident interviews, it was determined the facility failed to ensure enough staff were available to answer call lights in a timely manner. This was true for 7 of 27 residents (#12, #24, #50, #64, #76, #97, and #116) reviewed for staffing concerns. This deficient practice created the potential for physical and psychosocial harm if residents did not receive appropriate care or received a delay in care.

Inspectors wroteBased on observation, policy review, and interviews it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 1 of 10 residents (Resident #21) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished sense of worth.

Inspectors wroteBased on observation, record review, policy review, and interviews, it was determined the facility failed to ensure residents received prior written rationale regarding room changes. This was true for 2 of 27 residents (#38 and #97) whose records were reviewed. This deficient practice placed residents at risk of embarrassment and diminished sense of worth.

Inspectors wroteBased on observation, policy review, record review, and interviews, it was determined the facility failed to assess residents for safe smoking practices. This was true for 1 of 3 residents (Resident #97) whose medical records were reviewed. This deficient practice placed residents at risk for harm when proper smoking assessment or supervision was not provided.

Inspectors wroteBased on review of the State Operations Manual, Appendix PP, policy review, record review, and staff interview, it was determined the facility failed to ensure 1 of 5 residents (Resident #123), received recommended specialized services, identified by the state's Level II PASARR process. This deficient practice had the potential to cause significant harm if the resident's mental health needs were not adequately met.

Inspectors wroteBased on review of the State Operations Manual, Appendix PP, policy review, record review, and staff interview, it was determined the facility failed to ensure 1 of 5 resident's (Resident #123), plan of care included recommended specialized services, identified by the state's Level II PASARR process. This deficient practice had the potential to cause significant harm if the resident's mental health needs were not adequately met.

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 2 of 8 residents (#2 and #18) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels.

Inspectors wroteBased on policy review, observation, record review, and interviews, it was determined the facility failed to provide adequate pain management. This was true for 1 of 27 residents (Resident #61) whose medical records were reviewed. This failure created the potential for residents to experience continual pain and distress.

Inspectors wroteBased on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to ensure food items were dated and labeled, sanitary, and hygiene practices followed. These deficient practices had the potential to impact all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination, use of spoiled foods, and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not perform proper hand hygiene during wound care, did not follow proper wound care protocol, and did not clean equipment between resident use. This was true for 1 of 1 resident (Resident #2) reviewed for wound care and resident transfers using the Hoyer lift. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on observation, policy review and interviews, it was determined the facility failed to ensure all call light buttons or pads were easily accessible to residents. This was true for 1 of 27 residents (Resident #2) whose rooms were observed for call light device locations. This failure had the potential for harm if residents were not able to summon staff for assistance.

Inspectors wroteBased on resident group interview, review of resident council meeting minutes, and staff interview, it was determined the facility failed to ensure resident concerns were addressed. This deficient practice placed residents at risk for their needs going unmet, diminished quality of life, and decreased sense of self-worth.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a safe, clean, homelike environment. This was true for 5 of 8 residents (#23, #35, #45, #81 and #350) observed or interviewed for their environment and had the potential for all 106 residents who resided in the facility to be affected, whose common area environment was observed. This deficient practice created the potential for harm if: a) residents were embarrassed by dirty equipment and/or felt the lack of cleanliness in the facility was unacceptable, disrespectful, or undignified, and b) cross-contamination from spread of microorganisms.

Inspectors wrote2. During resident interviews conducted on 4/1/24 and 4/2/24, residents stated their food was not palatable. On 4/1/24 at 4:10 PM, Resident #6 stated, The food is so and so, sometimes it is delicious, sometimes a pig would not eat it. On 4/2/24 at 11:04 AM, Resident #350's lunch menu documented lunch was to be crusted chicken, rice pilaf, sauteed zucchini, and vanilla pudding. Resident 350's meal ticket documented she was on a regular diet. Resident 350's lunch meal was a roll, a small bowl of a light brown, thick liquid substance, and a square dessert bar. Resident #350 tasted the smooth substance in the bowl and was unable to determine what it was. On 4/4/24 at 2:53 PM, the Dietary Manager stated he was not sure what food was served to Resident #350 for her lunch on 4/2/24. He stated crusted chicken was not on the lunch menu that day. [...]

Inspectors wroteBased on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to report potential neglect to the State Survey Agency within 5 days of the alleged occurrence. This was true for 1 of 7 residents (Resident # 81) reviewed for neglect reporting and investigation. This failure created the potential for residents to be subjected to ongoing neglect without detection and protective measures implemented by the facility.

Inspectors wroteBased on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure an allegation of neglect was thoroughly investigated. This was true for 1 of 7 residents (Resident # 81) reviewed for abuse and neglect. This failure created the potential for residents to be subjected to ongoing neglect without detection and protective measures implemented by the facility.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to to ensure professional standards of practice were followed for 1 of 6 residents (Resident #30) reviewed for bowel and bladder incontinence and 1 of 5 residents (Resident #47) whose medication administration was observed. These failed practices created the potential for harm should residents experience constipation and adverse outcomes when their medications were not administered according to the physician's order.

Inspectors wroteBased on observation, record review, and resident and staff interview, it was determined the facility failed to ensure residents received treatment and assistive devices to maintain their vision. This was true for 1 of 1 resident (Resident #6) reviewed for activities of daily living. This failed placed Resident #6 at risk for decreased quality of life and psychosocial distress related to his inability to see effectively.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure residents received proper treatment and care to maintain foot health. This was true for 1 of 1 resident (Resident #79) reviewed for foot care. This failed practice created the potential for harm should residents experience complications from their medical condition related to the lack of foot care.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents were given treatment and services to maintain or improve their ability to carry out activities of daily living. This was true for 1 of 4 residents (Resident #30) reviewed for restorative nursing services. This failure placed Resident #30 at risk for decreased range of motion, functional ability, and decreased quality of life.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents received rehabilitative services as ordered by a physician. This was true for 1 of 5 residents (Resident #147) reviewed for rehabilitative services. This failure created the potential for residents to experience decline in their physical functioning when rehabilitative services were not provided.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 2 of 8 residents (#10 and #350) observed for infection control. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on observation, policy review, and staff interviews, it was determined the facility failed to ensure outdated food items were discarded. This had the potential to affect 75 residents residing in the facility who consumed food prepared by the facility at risk for adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 2 of 5 residents (#2 and #41) reviewed for quality of care. Specifically: - Resident #2 was at risk of increased contractures when her splints were not put on as ordered. - Resident #41 was at risk for hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar), when her insulin was not administered as ordered.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents who were offered and consented to the pneumococcal vaccine, received the vaccine. This was true for 1 of 5 residents (Resident #64) reviewed for pneumococcal vaccinations. This failure placed Resident #64 at increased risk of pneumococcal (bacterial) pneumonia and the potential for serious illness or death.