Orchard View Post Acute

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

residents. Resident R32 only received minor bruising and did not exhibit signs or symptoms of psychosocial distress.During an interview on 08/13/25 at 2:17 PM, the Director of Nursing (DON) stated on 03/09/25, Resident R23 began choking RN2 without any warning. She stated Resident R32 attempted to intervene when Resident R23 turned his attention to Resident R32 and grabbed his arm. The DON stated this incident of resident-to-resident abuse was substantiated because the incident was witnessed and Resident R23 assaulted Resident R32. The DON stated the police department was contacted in this situation, but no citations were made and Resident R23 was sent to the emergency room for psychiatric evaluation.2. a. Review of Resident R61's admission Record located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE REDACTED] and had diagnoses including weakness and limitation of activities due to disability, subdural hemorrhage, and depression.Review of Resident R61's quarterly MDS with an ARD of 05/18/25 and located under the MDS tab of the EMR, revealed a BIMS score of 12 out of 15 which indicated Resident R61 was moderately cognitively impaired. He exhibited minor mood symptoms and no behavioral symptoms. b. Review of Resident R32's admission Record located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE REDACTED] and had diagnoses including intracerebral hemorrhage and depression.Review of Resident R32's quarterly MDS with an ARD of 05/15/25 and located under

the MDS tab of the EMR, revealed a BIMS score of nine out of 15 which indicated Resident R32 was moderately cognitively impaired. He exhibited moderate mood symptoms but did not exhibit behavioral symptoms.Review of Resident R61's Alert Charting, dated 05/09/25 and located under the Progress Notes tab of the EMR, revealed At 1020 this LN heard yelling coming from down the hallway, I went into room.and observed [Resident R32] standing up over roommate [Resident R61] who was sitting on his bed. [Resident R32] was yelling at roommate with his hands up making fists. I asked what was going on and [Resident R32] swung and hits [sic] roommate with his Rt [right] hand on [Resident R61] Lt [left] side of his face.Review of the facility's investigation packet for the above incident, dated 05/16/25 and provided on paper, revealed the incident occurred on 05/09/25 at 10:10 AM.

RN4 observed Resident R32 standing over Resident R61, who was sitting on his bed. Resident R32 was yelling and making fists, and

he swung and hit Resident R61 on the face. Police were contacted and Resident R32 was cited with battery. Interview with RN4 confirmed Resident R32 punched Resident R61 in the face. Interview with Resident R32 revealed he admitted to hitting Resident R61 and stated Resident R61 had kicked him in the shin. Interview with Resident R61 revealed he was hit in the face by Resident R32 and denied kicking Resident R32. Resident R32 had redness to his shin. Resident R61 received minor redness and swelling and did not exhibit signs or symptoms of psychosocial distress.During an interview on 08/13/25 at 2:17 PM, the DON stated on 05/09/25, an altercation occurred between Resident R32 and Resident R61, who were roommates. She stated Resident R32 reported Resident R61 kicked him in the leg; however, Resident R61 denied this. Resident R32 was witnessed to punch Resident R61 in the face and Resident R32 denied kicking Resident R61. The DON stated the police were called and only Resident R32 was issued a citation, as Resident R61 denied kicking Resident R32. However, Resident R32's shin had redness upon assessment. The DON stated this was a substantiated case of resident-to-resident abuse.

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

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard View Post Acute

1014 Burrell Avenue Lewiston, ID 83501

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

recall who told her that a grievance form should be filled out instead of an abuse report. 2. Review of Resident R69's Profile tab of the EMR revealed she was admitted to the facility on [DATE REDACTED] with diagnosis that include type II diabetes, overactive bladder, schizophrenia disorder, anxiety, bi-polar disorder, and cognitive communication deficit. Resident R69 expired in the facility on [DATE REDACTED].Review of Resident R69's quarterly MDS with an ARD of [DATE REDACTED] and located in the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated Resident R69 was cognitively intact.A review of a Facility Reported Incident (FRI), dated [DATE REDACTED] and provided by the facility, revealed Resident R69 reported an allegation of sexual abuse when she awoke to a Certified Nursing Assistant (CNA) checking her brief. Resident R69 became upset and asked the CNA to get the supervisor on duty. Resident R69 reported she felt she was being sexually assaulted when the CNA was checking her brief. The supervisor reassured Resident R69 that the CNA was checking her brief and calmed her down. The report indicated that the incident occurred at 1:05 AM and was not reported to the DON until 8:05 AM. A full investigation was then initiated by the DON and reported to the appropriate agencies. During an interview on [DATE REDACTED] at 1:37 PM the DON stated that she was notified of the incident when she was getting to work by the nurse on duty. The DON was aware the nurse should have immediately contacted her and in-serviced the nurse on reporting appropriately. The DON stated she immediately reported the incident and did a full investigation.

The DON stated that the CNA was suspended during the investigation and was re-instated when the allegation was unsubstantiated but did not work with the resident again. During an interview on [DATE REDACTED] at 9:27 PM, Registered Nurse (RN) 3 stated she was called into the Resident R69's room by CNA5. RN3 stated Resident R69 was visibly upset and told her CNA5 had sexually molested her. RN3 stated she explained to Resident R69 that the CNA was checking her brief as she was assigned to do. RN3 stated that Resident R69 stated she was not fully awake and was startled by the incident. RN3 stated she assured Resident R69 that CNA5 would not come into the room and that she would be the only staff to assist her the rest of the night. RN3 stated that Resident R69 calmed down and went back to sleep. RN3 stated she did not send CNA5 home and did not immediately report the incident to the DON.

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

08/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard View Post Acute

1014 Burrell Avenue Lewiston, ID 83501

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, staff interview, and policy review, facility staff failed to protect one of nine residents (Resident (R) 69) reviewed for abuse from further abuse by not immediately removing a staff from the facility who was accused of sexual abuse of 25 sample residents. This failure decreased the facility's potential to protect the residents and ensure a safe environment during the investigation.Findings include:Review of the facility's policy titled, Abuse screening, training, identification, investigation, reporting, and protection-Idaho, dated 02/19, indicated that any staff member involved will be removed from their duties and sent home while a thorough investigation was conducted. Review of Resident R69's Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE REDACTED] with diagnosis that include type II diabetes, overactive bladder, schizophrenia disorder, anxiety, bipolar disorder, and cognitive communication deficit. Resident R69 expired

in the facility on [DATE REDACTED].Review of Resident R69's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE REDACTED] and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident R69 was cognitively intact.A review of a Facility Reported Incident (FRI), dated [DATE REDACTED] and provided by the facility, revealed Resident R69 reported an allegation of sexual abuse when she awoke to a Certified Nursing Assistant (CNA) checking her brief. Resident R69 became upset and asked the CNA to get the supervisor on duty. Resident R69 reported she felt she was being sexually assaulted when the CNA was checking her brief. The supervisor reassured Resident R69 that the CNA was checking her brief and calmed her down. The report indicated that the incident occurred at 1:05 AM and was not reported to the Director of Nursing (DON) until 8:05 AM. A full investigation was then initiated by the DON.During an interview on [DATE REDACTED] at 1:37 PM, the DON stated that she was not notified of the incident until she arrived at work by the nurse on duty. The DON stated she did a full investigation. The DON stated that the CNA was not suspended until she received the report at 8:00 AM but was re-instated when the allegation was unsubstantiated and did not work with the resident again. During an interview on [DATE REDACTED] at 9:27 PM, Registered Nurse (RN) 3 stated she was called into the Resident R69's room by CNA5. RN3 stated Resident R69 was visibly upset and told her CNA5 had sexually molested her. RN3 stated she explained to Resident R69 that the CNA5 was checking her brief as she assigned to do. RN3 stated that Resident R69 stated she was not fully awake and was startled by the incident. RN3 stated she assured Resident R69 that CNA5 would not come into the room and that she would be the only staff to assist her the rest of the night. RN3 stated that Resident R69 calmed down and went back to sleep. RN3 stated she did not send CNA5 home at the time of the incident and did not immediately report the incident to DON because she told CNA5 not to go back in the room and took over

the care of Resident R69.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited ORCHARD VIEW POST ACUTE in LEWISTON, ID for a deficiency under regulatory tag F-F0641 during a standard health inspection conducted on 2025-08-15.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure each resident receives an accurate assessment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of ORCHARD VIEW POST ACUTE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-15.

Federal health inspectors cited ORCHARD VIEW POST ACUTE in LEWISTON, ID for a deficiency under regulatory tag F-F0655 during a standard health inspection conducted on 2025-08-15.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of ORCHARD VIEW POST ACUTE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-15.

Federal health inspectors cited ORCHARD VIEW POST ACUTE in LEWISTON, ID for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-15.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of ORCHARD VIEW POST ACUTE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-15.

Federal health inspectors cited ORCHARD VIEW POST ACUTE in LEWISTON, ID for a deficiency under regulatory tag F-F0690 during a standard health inspection conducted on 2025-08-15.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of ORCHARD VIEW POST ACUTE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-15.

Federal health inspectors cited ORCHARD VIEW POST ACUTE in LEWISTON, ID for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-15.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of ORCHARD VIEW POST ACUTE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-15.