Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Valley Of Cascadia during CMS and state inspections, most recent first.
The facility did not provide enough nursing staff to ensure timely response to resident call lights, resulting in multiple instances where residents waited 30 minutes to several hours for assistance. Call light logs and resident interviews confirmed repeated delays, with some residents experiencing discomfort and extended waits for help with basic needs, especially during shifts with fewer staff. Staff acknowledged that call lights should be answered within 10 to 15 minutes, but this standard was not consistently achieved.
A resident with significant physical disabilities was observed being transported for a shower with an uncovered urinary catheter bag placed at his feet, contrary to facility policy requiring catheter bags to be covered. Staff stated that the bag was not covered during transport, and the CNO confirmed that covers are available and should have been used.
Two residents with complex medical histories were moved to different rooms without being given a written rationale or advance explanation for the transfer, as required by facility policy. Documentation for both room changes lacked the necessary rationale, and staff confirmed the use of outdated forms that did not require this information.
A resident with a history of major depressive disorder and a recent suicide attempt did not receive a required evaluation for specialized services as recommended by the state's Level II PASARR process. The necessary Mental Illness Evaluation and Determination report was missing from the medical record, and staff confirmed the evaluation had not been completed.
A resident with a history of traumatic subdural hemorrhage and major depressive disorder, including a recent suicide attempt, was admitted without the care plan reflecting required PASARR Level II recommendations for specialized mental health services. Review and staff interview confirmed the omission of these recommendations from the care plan, despite facility policy requiring their inclusion.
Two residents with significant respiratory conditions did not receive oxygen therapy as ordered by their physicians. One resident's oxygen concentrator was set to 0 liters per minute despite an order for 2 liters, and another resident's oxygen tubing was not connected to the concentrator despite an order for 4 liters. Nursing staff confirmed these lapses in care.
A resident with end stage renal disease and cerebral palsy reported significant pain and requested pain medication late at night, but did not receive it despite using the call light. Documentation did not reflect the resident's reported pain, and the following day, the resident experienced severe pain and was unable to attend dialysis due to lack of pain relief.
Surveyors identified failures in food storage, labeling, and hygiene, including serving expired food, improper labeling of resident and kitchen food items, and a staff member preparing food without a hair restraint. Supervisory staff confirmed these practices did not meet facility policy or food safety standards.
Staff did not follow infection control protocols during wound care and equipment cleaning. An LPN failed to perform hand hygiene between glove changes and did not change gloves after wound cleansing before applying new dressings to a resident with pressure ulcers. Additionally, a Hoyer lift used for resident transfer was not cleaned between uses and was left in the hallway without disinfection, contrary to facility policy.
A resident with cerebral palsy and acute respiratory failure was found to have her touch pad call light placed out of reach, contrary to her care plan. Staff acknowledged that the call light should have been accessible but was not, and an RN indicated frequent staff checks as a reason for the inaccessibility.
A resident with multiple diagnoses and a documented ability to make decisions was not assessed for safe smoking practices, despite facility policy requiring such evaluations. The resident's medical record and care plan lacked documentation of her smoking status, and the CNO was unaware she smoked, resulting in the required assessment not being completed.
Delayed Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights for multiple residents. Review of facility grievances, call light logs, and resident interviews revealed that several residents experienced significant delays, with some waiting up to an hour or more for assistance. Call light logs over a three-month period documented 1,770 instances where response times exceeded 30 minutes and 167 instances where the wait was longer than an hour. Residents reported waiting extended periods for help with essential needs, such as toileting, and described situations where staff turned off call lights without providing immediate assistance. Specific grievances included reports from residents who had to wait up to an hour or more for their call lights to be answered, particularly during shifts with limited staff coverage. Residents described waiting so long for assistance that it affected their comfort and ability to move, with one resident stating her legs went numb while waiting for help off the commode. Interviews with staff confirmed that call lights should be answered within 10 to 15 minutes, but this standard was not consistently met, as evidenced by the documented delays and resident accounts.
Failure to Maintain Resident Dignity by Leaving Catheter Bag Uncovered
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as required by its Quality of Life policy, which specifies that staff must refrain from demeaning practices such as leaving urinary catheter bags uncovered. During an observation, a resident with Myotonic Muscular Dystrophy and functional quadriplegia was transferred via Hoyer lift for a shower, and after being covered with blankets, a CNA placed the resident's uncovered urinary catheter bag at his feet. The CNA stated that catheter bags are normally covered when the resident is in a wheelchair, but did not cover it during transport to the shower room. The CNO confirmed that catheter bags have covers and was unsure why the cover was not used in this instance, acknowledging that it should have been covered.
Failure to Provide Written Rationale for Room Transfers
Penalty
Summary
The facility failed to provide residents with prior written rationale regarding room changes, as required by its own Room to Room Transfer policy. The policy specifies that the facility must discuss transfers with residents and their families in advance, explain the rationale and rights, offer an opportunity to tour the new room, and introduce new roommates prior to the move. However, for two residents, these procedures were not followed. One resident, with a history of diabetes and a left leg amputation, was informed of his room transfer while outside and was not given a reason for the move. Documentation in his medical record did not include a rationale for the transfer, and he was not introduced to his new roommate beforehand. Additionally, after the move, he was unable to locate his prosthetic leg, which was later found in an inaccessible location. Another resident, with diagnoses including a cutaneous abscess and bipolar disorder, was also transferred to a different room without being provided a rationale. The room transfer notification in her medical record lacked any explanation for the move. Facility staff confirmed that an outdated room transfer document was used, which did not require documentation of the rationale for the transfer, resulting in the absence of required information for both residents.
Failure to Complete Required PASARR Specialized Services Evaluation
Penalty
Summary
The facility failed to ensure that a resident received specialized services as recommended by the state's Level II PASARR process. The resident was admitted with multiple diagnoses, including traumatic subdural hemorrhage and major depressive disorder, and had a documented history of depressive disorder and a recent suicide attempt. The PASARR Level I screening indicated the need for further evaluation, and the Level II screening required an individualized evaluation for specialized services by a Professional Independent Evaluator and the state's Mental Health Authority (MHA). Upon review of the resident's medical record, there was no documentation that the evaluation for specialized services by the state's MHA had been completed. Interviews with the Chief Nursing Officer (CNO) confirmed that the Mental Illness Evaluation and Determination report was not present in the resident's medical record, despite it being required. This lack of documentation and follow-through resulted in the resident not receiving the recommended specialized services.
Failure to Incorporate PASARR Recommendations into Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan included recommended specialized services identified by the state's Level II PASARR process. The facility's policies require the interdisciplinary team to use PASARR recommendations when developing care plans, especially for residents with mental disorders. Despite these policies, a review of the care plan for a resident with diagnoses including traumatic subdural hemorrhage and major depressive disorder revealed that the care plan did not document the resident's mental health diagnosis or the recommendations from the PASARR Level II evaluation. The PASARR Level II had identified a depressive disorder, a recent suicide attempt, and the need for further individualized evaluation for specialized services. Staff interview confirmed that the care plan was missing the required PASARR recommendations. The facility's policies on trauma-informed care and care planning both emphasize the importance of addressing mental health needs and specialized services as identified by PASARR, but these were not reflected in the resident's care plan at the time of review.
Failure to Provide Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory services as ordered by the physician for two residents. One resident with cerebral palsy and acute respiratory failure was observed sleeping in bed with a nasal cannula in place, but the oxygen concentrator was set at 0 liters per minute, despite a physician's order and care plan specifying oxygen at 2 liters per minute via nasal cannula while in bed. Both a registered nurse and the chief nursing officer confirmed that the oxygen concentrator should have been set to 2 liters per minute but was not. Another resident with chronic heart failure and chronic respiratory failure with hypercapnia was observed sleeping in bed with an oxygen cannula in place, but the oxygen tubing was not connected to the oxygen concentrator. The physician's order required oxygen at 4 liters per minute via nasal cannula, and the care plan documented oxygen therapy as ordered. A registered nurse stated that the CNAs had put the resident to bed and must have forgotten to connect the tubing, and the charge nurse confirmed that the CNAs should have ensured the cannula was connected after moving the resident.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide adequate pain management for a resident with end stage renal disease and cerebral palsy. The resident, who was cognitively intact, reported experiencing pain late in the evening and used the call light to request pain medication between 11:30 pm and midnight. Although the call light was answered, the resident stated that the requested pain medication was not administered, resulting in her falling asleep without relief. Documentation in the medical record for that night indicated a pain level of 0 out of 10, despite the resident's report of pain. The following day, the resident reported a pain level of 10 out of 10 and stated she had to refuse dialysis due to unresolved pain from the previous night. The Resident Care Manager confirmed that the resident reported being in pain while waiting for pain medication that was never provided. The facility's policy requires appropriate treatment and services to maintain or improve residents' abilities, but in this instance, the resident's pain was not addressed as required.
Deficient Food Storage, Labeling, and Hygiene Practices Identified
Penalty
Summary
Surveyors observed multiple failures in food storage, labeling, and hygiene practices within the facility's kitchen and resident food storage areas. Clean plastic containers were found stacked while still wet, contrary to proper drying procedures. Grape juice was served to residents despite being past its use-by date, and several food items in resident refrigerators, such as potato salad, salad greens, and frozen strawberries, were found to be expired or past their designated use-by dates. Additionally, an open box of ice cream bars lacked a use-by date, and cartons of food thickener in dry storage were observed to be past their best used-by dates. Staff interviews confirmed that these items should have been discarded according to facility policy and food safety standards. Further, a staff member was observed preparing food without wearing a required hairnet or hair restraint, which was acknowledged as a violation of facility policy by supervisory staff. These findings demonstrate a lack of adherence to professional standards and facility policies regarding food safety, labeling, and hygiene, as required by the FDA Food Code and the facility's own procedures. No information was provided regarding the medical history or condition of specific residents affected at the time of the deficiency.
Failure to Follow Infection Control Practices During Wound Care and Equipment Cleaning
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during wound care and equipment cleaning. Specifically, an LPN did not perform hand hygiene between glove changes while providing wound care to a resident with quadriplegia and pressure ulcers. The LPN removed soiled dressings, changed gloves without performing hand hygiene, and did not change gloves after cleansing the wounds before applying new dressings. The LPN later stated uncertainty regarding the facility's hand hygiene policy and acknowledged the correct procedure was not followed. Additionally, staff did not clean a Hoyer lift after use, leaving it in the hallway for over 20 minutes without disinfection between resident transfers. A nurse confirmed that the lift should have been cleaned immediately after use. These lapses were observed during care of a resident with multiple pressure ulcers and during resident transfers, contrary to the facility's established policies for hand hygiene, wound care, and equipment cleaning.
Call Light Pad Not Accessible to Resident with Complex Needs
Penalty
Summary
The facility failed to ensure that all call light buttons or pads were easily accessible to residents, as observed in the case of one resident with multiple diagnoses, including cerebral palsy and acute respiratory failure. The resident's care plan specified the use of a touch pad call light and required staff to validate its placement upon leaving the resident. During observation, the call light pad was found on the bedside table and not accessible to the resident. An RN stated that the resident did not really need the call light pad because staff checked on her often. The Chief Nursing Officer later confirmed that staff should have ensured the call light pad was accessible on the resident's bed but had not done so.
Failure to Assess Resident for Safe Smoking Practices
Penalty
Summary
The facility failed to assess a resident for safe smoking practices as required by its Smoking Campus policy, which mandates an interdisciplinary evaluation of residents who wish to smoke upon admission, quarterly, with significant changes, or as needed. One resident, who was admitted and later readmitted with diagnoses including a cutaneous abscess of the abdominal wall and bipolar disorder, was found to be cognitively intact according to her most recent MDS assessment. Despite the resident stating she was an independent smoker, there was no documentation of a smoking assessment in her medical record, nor was her smoking status included in her care plan. The Chief Nursing Officer confirmed that they were unaware the resident smoked and acknowledged that the required assessment had not been completed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boise
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timber Springs Transitional Care | 1.7 mi | — | 19 | 0 |
| Cascadia Of Boise | 1.9 mi | — | 8 | 0 |
| Life Care Center Of Treasure Valley | 2 mi | — | 0 | 0 |
| Life Care Center Of Boise | 2.1 mi | — | 0 | 0 |
| Skyline Transitional Care Center | 3 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.