Life Care Center of Treasure Valley

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected resident's status. This was true for 5 of 19 residents (#4, #30, #34, #45, and #52) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments.

Inspectors wroteBased on incident and accident log review, record review and interviews, it was determined the facility failed to ensure resident representatives were notified following resident fall with injury. This was true to 1 of 4 residents (Resident #211) whose records were reviewed. This deficient practice created the potential for harm or adverse outcomes if the residents' representatives were not notified of resident injuries.

Inspectors wroteBased on incident and accident log review, record review and interviews, it was determined the facility failed to ensure resident specific discharge paperwork was provided to the hospital during transfer to the hospital. This was true for 1 of 2 residents (Resident #211) whose records were reviewed. This deficient practice had the potential for harm if resident required health information was not provided to the hospital.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to incorporate PASRR recommendations in MDS assessment and care planning. This was true for 1 of 19 residents (Resident #32) reviewed for Level I and II PASRR evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not incorporated in their care.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to follow current physician oxygen orders. This was true for 1 of 19 residents (Resident #26) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services had been provided that were not ordered by the physician.

Inspectors wroteBased on observation, record review, and staff interviews, it was determined the facility failed to ensure licensed nurses performed tasks which they had the knowledge, skills, and competencies. This was true for 7 of 28 licensed nurses. This had the potential for adverse effects to all residents when skin related issues were missed during assessments.

Inspectors wroteBased on review of the staffing schedules, personnel files, and staff interviews, it was determined the facility failed to ensure full-time employees working as an NA were either in a State approved training and competency evaluation program or had recently and successfully completed such a program. This was true for 3 of 12 NAs (NA #1, #2, and #3) whose personnel files were reviewed. This failure had the potential to result in negative outcomes for all residents living in the facility.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts audited. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on observations, review of the State Operations Manual, and staff interviews it was determined the facility failed to ensure medications were stored and kept secure, and biologicals were labeled when opened. This was true for the facility. These deficient practices created the potential for theft and/or diversion and use of expired biologicals.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to appropriately store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to put residents who consume thickened liquids at risk for potential contamination and adverse health outcomes including contracting food-borne illnesses.

Inspectors wroteBased on observation, interview, and users manual review, the facility failed to ensure patient care equipment was monitored to ensure it was in a safe operating condition. This was true for 1 of 3 warming cabinets. This failed practice: 1) placed residents residing in the facility, at risk for adverse outcomes including skin burns 2) placed facility at risk for adverse outcomes in the event of malfunctioning equipment.

Inspectors wroteBased on record review, resident and staff interview, review of investigations and grievances, and policy review, it was determined the facility failed to ensure a resident's pain was effectively managed and treated in a respectful manner. This was true for 1 of 6 residents (Resident #40) reviewed for pain management. Resident #40 was harmed when she felt publicly degraded when denied narcotic pain medication necessary to effectively manage her pain.

Inspectors wroteBased on observation, resident and staff interview, policy review, and record review, it was determined the facility failed to ensure a) residents' personal information was communicated in a way that protected the confidentiality of the information and the dignity of the residents, and b) residents' physical privacy was maintained during care and services. This was true for 3 of 28 residents (#7, #27, and #52) reviewed for privacy and confidentiality. These deficient practices placed residents at risk psychosocial harm due to embarrassment and loss of control over their personal information and physical privacy.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices related to hand hygiene, PPE, and ensuring urinary catheter bags were not placed on the floor were followed. This was true for 4 of 28 staff (CNAs #1, #2, #3, and #4) observed during resident care, and 1 of 6 residents (Resident #56) reviewed for urinary catheter use. These deficient practices placed residents at risk of infection and cross-contamination.

Inspectors wroteBased on observation, resident and staff interview, policy review, and record review, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 2 of 28 residents (#7 and #56), reviewed for respect and dignity. This deficient practice placed residents at risk of skin breakdown, diminished sense of self-worth, and lack of sleep.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure a bed-hold notice was provided to a resident or their representative when they were transferred to the hospital. This was true for 1 of 2 residents (Resident #34) reviewed for transfers. This deficient practice created the potential for harm if the resident or his representative was not informed of the right to return to his former bed/room at the facility within a specified time.

Inspectors wroteBased on observation, record review, policy review, I&A reports, and staff interview, it was determined the facility failed to ensure a resident's care plan was reviewed and revised to reflect the use of a regular pressure-reducing mattress. This was true for 1 of 26 residents (Resident #26) reviewed for care plan revisions. This created the potential for harm if care was not provided or decisions were made based on inaccurate care plan information.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to follow physician orders for 1 of 1 resident (Resident #168) reviewed for topical medication administration. This resulted in the potential for harm if residents did not receive medications as ordered.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to follow physician orders for the maintenance of supplemental oxygen for 1 of 1 resident (Resident #2) reviewed for supplemental oxygen use. This placed Resident #2 at risk for respiratory infections when the supplemental oxygen tubing and humidifier bottle were not changed.

Inspectors wrote4. Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (low oxygen levels). Resident #56's quarterly MDS assessment, dated 10/4/18, documented severe cognitive impairment. Resident #56's November 2018 physician orders documented a POST with a code status of DNR was ordered on 6/14/18. Resident #56's current care plan documented she had an Advance Directive with a code status of DNR and directed staff to honor her wishes per her POST. On 11/6/18 at 8:37 AM, Resident #56's clinical record documented a letter of guardianship/ conservatorship. There was no documentation of an Advance Directive, Living Will, or Power of Attorney. A Care Plan Conference Record, dated 9/27/18, did not document the Advance Directive status was addressed with Resident #56 or her representative. [...]

Inspectors wroteBased on observation, facility policy review, and resident and staff interviews, it was determined the facility failed to ensure an environment was maintained that enhanced a resident's dignity and respect when staff placed a clothing protector on a resident without the resident's permission. This was true for 1 of 8 residents (#21) observed in the Ponderosa dining room. This failed practice created the potential for psychosocial harm if a resident experienced embarrassment or a lack of self-esteem due to being observed wearing a clothing protector.

Inspectors wroteBased on staff interview, facility policy review, and record review, it was determined the facility failed to ensure completed transfer information was provided to the receiving hospital for emergent transfers. This was true for 1 of 2 residents (Resident #17) reviewed for transfers. This deficient practice had the potential to cause harm if the resident was not treated appropriately or in a timely manner due to a lack of information.

Inspectors wroteBased on a resident's family member interview and staff interview, facility policy review, and record review, it was determined the facility failed to ensure transfer notices were provided in writing to a resident and the local ombudsman. This was true for 2 of 2 residents (#11 and #17) reviewed for transfers and had the potential for harm if residents were not made aware of or able to exercise their rights related to transfers.

Inspectors wroteBased on record review, staff interview, and policy review, it was determined the facility failed to ensure written notification of the facility's bed-hold agreements were provided to residents. This was true for 2 of 2 residents (#11 and #17) reviewed for transfers. The deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time.

Inspectors wroteBased on observation, record review, policy review, and staff and resident interviews, it was determined the facility failed to: a) provide supervision of medication administration to ensure a resident's medications were taken as ordered by the physician, b) ensure Prevalon boots (boots to protect skin) were in place as ordered by the physician, and c) ensure a dressing was in place as ordered by the physician. This was true for 2 of 19 residents (Residents #11 and #53) reviewed. This deficient practice had the potential for harm if residents did not receive medications ordered by the physician and if residents experienced a decline in skin condition due to lack of wearing Prevalon boots (a boot to protect skin) and protective dressings.

Inspectors wroteBased on observation, staff interview, facility policy review, and record review, it was determined the facility failed to ensure residents received proper treatment and care to maintain good foot health. This was true for 1 of 7 residents (#53) 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 proper foot care.

Inspectors wroteBased on observation, staff interview, and review of clinical records and facility policy, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 2 residents (Resident #38) reviewed for feeding tubes. This failure created the potential for harm if complications developed from improper feeding tube practices.

Inspectors wroteBased on observation, record review, facility policy review, and staff interviews, it was determined the facility failed to ensure staff changed residents' oxygen cannulas (tubing that delivers oxygen) and humidifier per physician orders and facility policy. This was true for 3 of 6 sample residents (#14, #17, and #38) reviewed for oxygen therapy. This failure created the potential for harm from respiratory infections due to the growth of pathogens (organisms that cause illness) in oxygen cannulas and humidifiers.

Inspectors wroteBased on observation, review of the facility's policy and staff interview, it was determined the facility failed to ensure expired medications were removed from medication storage room and medication carts and not available for administration to residents. This was true for 1 of 2 medication refrigerators and 1 of 3 medication carts checked for expired medications This failed practice created the potential for residents to receive expired medications with decreased efficacy.

Inspectors wroteBased on observation, policy review, medical record review and staff interview, it was determined the facility failed to ensure the glucometer used to test capillary blood glucose levels was properly cleansed between testing. This was true for 2 of 5 residents (#8 and #16) observed for the testing of capillary glucose levels. This deficient practice created the potential for harm by exposing residents to the risk of infection and cross contamination.