Ashton Memorial Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ashton, Idaho.
- Location
- 700 North Second Street, Ashton, Idaho 83420
- CMS Provider Number
- 135097
- Inspections on file
- 15
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Ashton Memorial Living Center during CMS and state inspections, most recent first.
The facility was found to have improperly stored food items in the walk-in refrigerator, with several items lacking proper date marking as required by the FDA 2022 Food Code. Loose tomatoes and open containers of dressings were not dated, posing a risk of food contamination. The Food Service Manager confirmed the oversight.
The facility failed to provide the required 12 hours of in-service education for three CNAs and did not complete annual performance reviews for three CNAs. The HR Director and DNS acknowledged that these requirements were not met since COVID-19 in 2020.
The facility failed to maintain infection control practices by not encouraging hand hygiene before meals and not cleaning glucometers after use. CNAs did not prompt residents to perform hand hygiene before eating, and an RN did not disinfect a glucometer after use, believing it was unnecessary for personal devices. The DNS confirmed these practices were not in line with facility policies.
The facility did not provide Advance Beneficiary Notices (ABNs) to three residents, failing to inform them of their potential financial liability when Medicare Part A benefits ended. A resident with chronic kidney disease and sepsis, another with dementia and hypertension, and a third with Parkinson's disease and a lumbar fracture were affected. The DNS confirmed the absence of ABNs, highlighting a compliance issue with beneficiary protection notifications.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in recorded heights and missing documentation of a PASARR Level II evaluation. These inaccuracies were confirmed by the DNS and could potentially result in negative outcomes if residents are not properly assessed or monitored.
A facility failed to refer a resident with developmental delay for a PASARR Level II evaluation, as required by their admission criteria policy. Despite the resident's multiple diagnoses, including heart failure and hypertension, the necessary evaluation was not completed, as confirmed by the DNS.
A facility failed to follow its wound care protocol by not dating and initialing wound dressings for a resident, as required by their policy. This oversight was confirmed by the DNS and posed a risk for infection and skin breakdown.
The facility did not post a completed daily staffing sheet as required. Observations on a specific morning showed the sheet was blank at 8:00 AM and remained so by 9:25 AM, despite the DNS stating it should be completed by the start of the shift at 6:00 AM.
A resident with chronic respiratory failure and hypoxia was using an oxygen concentrator without a physician's order. The resident's care plan indicated the need for oxygen to maintain saturation levels, but the medical record lacked a formal order. The DNS confirmed the absence of a physician's order since admission.
The facility failed to store medications appropriately, as the emergency narcotic kit containing Ativan was found in an unlocked refrigerator, contrary to the policy requiring double locking. An LPN and the DNS confirmed the requirement for double locking controlled substances.
Improper Food Storage and Date Marking
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, as observed during an inspection of the kitchen. In the walk-in refrigerator, several items were found without proper date marking, which is required by the FDA 2022 Food Code. Loose tomatoes were on the shelf without received or use-by dates, and an open container of Ranch dressing lacked an open or use-by date. Additionally, a container of Italian dressing had an open date of 7/23/24 but no use-by date, and a container of Caesar dressing had an open date of 9/24/24 with no use-by date. The Food Service Manager acknowledged that the tomatoes should have been in a container and dated, and the open dressings should have been dated.
Deficiency in CNA In-Service Education and Performance Reviews
Penalty
Summary
The facility failed to provide the required minimum of 12 hours of in-service education per year for three Certified Nursing Assistants (CNAs) whose personnel records were reviewed. Specifically, CNA #4 and CNA #5 had no documented in-service hours for 2023 or 2024, while CNA #7 had only 1.25 hours documented for the same period. This lack of in-service education was acknowledged by the HR Director, who confirmed that the CNAs should have completed the 12 hours of annual in-service education. Additionally, the facility did not complete annual performance reviews for three CNAs as required. CNA #2 had no documented annual evaluation since her hire date in 2020, CNA #4's last evaluation was in 2020, and CNA #5 had no evaluation since her hire in 2019. The HR Director and the Director of Nursing Services (DNS) both stated that staff evaluations had not been performed since the onset of COVID-19 in 2020, although they acknowledged that these evaluations should have been conducted.
Infection Control and Prevention Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices, as observed during meal delivery and medical equipment cleaning. Specifically, staff members did not encourage or offer hand hygiene to residents before meals served in their rooms. On multiple occasions, CNAs did not prompt residents to perform hand hygiene before eating, and they acknowledged this oversight during interviews. The Director of Nursing Services (DNS) confirmed that CNAs should have offered hand hygiene to residents receiving meals in their rooms. Additionally, the facility did not adhere to its policy regarding the cleaning of glucometers. An RN used a glucometer to check a resident's blood sugar and returned it to the storage box without disinfecting it. The RN believed that since the glucometer was the resident's personal device, it did not require cleaning after each use. However, the DNS stated that glucometers should be cleaned after every use, indicating a failure to follow established cleaning protocols.
Failure to Provide Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide the required Advance Beneficiary Notice (ABN) to three residents, which is necessary to inform them of their potential financial liability when their Medicare Part A benefits end. Resident #7, who was admitted with chronic kidney disease and sepsis, did not receive an ABN when their Medicare A benefits ended on May 23, 2024. Similarly, Resident #19, admitted with dementia and hypertension, was not given an ABN when their benefits ended on May 28, 2024. Resident #25, with diagnoses including Parkinson's disease and a lumbar vertebra fracture, also did not receive an ABN when their benefits ended on July 21, 2024. The Director of Nursing Services (DNS) confirmed the absence of ABNs for these residents, indicating a lapse in the facility's compliance with beneficiary protection notification requirements.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status, which was identified for three residents. Resident #5's MDS assessments showed inconsistencies in recorded height, with earlier assessments documenting a height of 66 inches and a later assessment recording 69 inches. The Director of Nursing Services (DNS) acknowledged that the height should have been accurately recorded. Similarly, Resident #7's MDS assessments showed discrepancies in height measurements, with one assessment documenting 66 inches and subsequent assessments recording 60 inches. The DNS confirmed that these assessments should have been accurate. Resident #14's case involved a failure to document a PASARR Level II evaluation in the annual MDS assessment, despite having a significant change in status assessment that indicated the need for such an evaluation. The PASARR Level II was completed a year prior, but the annual MDS assessment did not reflect this. The DNS confirmed the omission of the PASARR Level II evaluation in the documentation. These inaccuracies in the MDS assessments could potentially lead to negative outcomes if residents are not properly assessed, cared for, or monitored.
Failure to Conduct PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer residents for further evaluation when diagnosed with a major mental illness, intellectual disability, or a related condition, as required by the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. This deficiency was identified during a review of records, policies, and staff interviews, specifically affecting one resident. The facility's Admission Criteria policy, dated March 2019, mandates that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders. However, a resident admitted with multiple diagnoses, including heart failure, hypertension, and developmental delay, did not receive the necessary PASARR Level II evaluation. This oversight was confirmed by the Director of Nursing Services (DNS), indicating a lapse in the facility's adherence to its own admission criteria and the PASARR process.
Non-compliance with Wound Care Protocol
Penalty
Summary
The facility failed to adhere to professional standards of practice for wound care for a resident, which was identified during a survey. The facility's wound care policy requires that all wound dressings be dated and initialed when changed. However, during an observation, it was noted that the resident's left leg had two undated bandages, indicating non-compliance with the facility's policy. The Director of Nursing Services (DNS) confirmed that it was the facility's expectation for staff to date and initial all wound bandages, which was not followed in this instance. This oversight created the potential for resident harm or adverse outcomes related to infection and skin breakdown.
Failure to Post Daily Staffing Sheet
Penalty
Summary
The facility failed to ensure that a completed daily staffing sheet was posted in the nursing facility, which is a requirement. On the morning of November 4th, it was observed at 8:00 AM that the staffing sheet was left blank. The Director of Nursing Services (DNS) confirmed that the staffing sheet should have been completed at the beginning of the shift, which started at 6:00 AM. Despite this, by 9:25 AM, the staffing sheet remained blank, indicating a failure to comply with the posting requirement.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for a resident who was admitted with multiple diagnoses, including diabetes and chronic respiratory failure with hypoxia. An oxygen concentrator was observed in the resident's room, and the resident reported using oxygen at night and while sleeping in a recliner chair. Despite this, the resident's medical record did not include a physician's order for oxygen therapy. Progress notes documented the resident using oxygen while asleep, and the care plan indicated the use of oxygen to maintain oxygen saturations above 90%. The Director of Nursing Services confirmed that no physician's order for oxygen had been obtained since the resident's admission.
Improper Storage of Controlled Substances
Penalty
Summary
The facility failed to ensure that medications were stored appropriately, as observed during an inspection of the medication storage room. The facility's emergency narcotic kit, which contained Ativan, a controlled substance, was found in a plastic box secured with a plastic zip tie inside an unlocked medication storage refrigerator. This was contrary to the facility's Control Substance policy, which required narcotics to be double locked. During the inspection, an LPN confirmed that the narcotic emergency kit should have been double locked, and the Director of Nursing Services (DNS) reiterated this requirement the following day.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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