Aspen Transitional Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Meridian, Idaho.
- Location
- 2867 East Copper Point Drive, Meridian, Idaho 83642
- CMS Provider Number
- 135130
- Inspections on file
- 20
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Aspen Transitional Rehabilitation during CMS and state inspections, most recent first.
A resident with significant mobility limitations and a care plan requiring two-person assistance for transfers was transferred by a CNA alone, contrary to documented protocols. This resulted in the resident falling and sustaining a fracture that required hospitalization and surgery.
The facility did not ensure an RN was present for at least 8 consecutive hours each day, with several days lacking consecutive RN coverage or any RN coverage at all. The DON was unaware of the requirement for consecutive hours and confirmed the absence of an RN on one of the days in question.
A resident with multiple medical conditions, including CHF and diabetes, was care planned for two-person or mechanical lift transfers. Despite this, a CNA performed a solo transfer, resulting in the resident falling and sustaining a knee fracture that required surgery.
Nurses failed to administer pain medications according to provider orders for three residents with fractures and pain management needs. Pain medications were given outside the prescribed pain level ranges, and the DON confirmed that provider orders were not followed, despite resident preferences.
Surveyors found that an LPN left a medication cart unlocked and unattended, stored refused medications in the cart for later use, and left prepared medications unsupervised on the cart. In the medication storage room, the refrigerator for narcotics was unlocked and a box containing Lorazepam was not permanently affixed, contrary to facility expectations for secure storage.
An LPN was observed preparing and administering insulin to a resident without performing hand hygiene prior to donning gloves or before the injection, instead only performing hand hygiene after glove removal. The LPN acknowledged the lapse, and facility leadership confirmed that the expected practice is to perform hand hygiene and don fresh gloves before administering injections.
The facility failed to maintain a clean kitchen environment, with undated food items and improper storage near a flaking water heater pipe. The freezer had issues with ice build-up and improperly closed ice cream containers, acknowledged by the NSD as due to a faulty door.
A resident with multiple diagnoses, including a fracture and Parkinson's disease, reported an incident where aides told her to urinate in her pad instead of assisting her to the bathroom. Despite reporting this to an LPN, the grievance was not documented in the facility's log, violating the grievance policy. The LPN educated one aide but did not take further action, potentially causing psychological harm to the resident.
An LPN in a facility failed to prime insulin pens before administering doses to two residents with diabetes, leading to medication errors. The lack of priming, which is necessary to ensure the correct insulin dose, was acknowledged by the LPN after the incidents.
The facility failed to implement consistent infection control measures for two residents. A CNA did not assist a resident with dementia in performing hand hygiene after using the toilet. An LPN did not wear a gown or perform hand hygiene between glove changes while changing a PEG tube dressing for a resident under enhanced barrier precautions.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect during a transfer, resulting in a fall with injury. The resident, who had multiple diagnoses including congestive heart failure, bilateral lower leg lymphedema, and diabetes, was care planned and assessed as requiring a two-person assist or use of a Hoyer mechanical lift for transfers. Documentation in the resident's care plan and physical therapy reports indicated that extensive two-person assistance was necessary for all transfers, and these requirements were communicated to the interdisciplinary team. Despite these documented needs, a CNA assisted the resident alone during a transfer from a chair to standing, contrary to the care plan and physical therapy recommendations. During this transfer, the resident's knee buckled, resulting in a fall that caused a fracture requiring hospitalization and surgical repair. The CNA was aware of the resident's transfer status but chose to proceed without the required assistance, leading to the incident.
Failure to Provide 8 Consecutive Hours of RN Coverage Daily
Penalty
Summary
The facility failed to ensure the presence of a registered professional nurse (RN) for at least 8 consecutive hours per day, as required by regulations. Review of the nursing schedule from 11/23/25 through 12/13/25 showed that on multiple dates, including 11/23/25, 11/29/25, 11/30/25, 12/6/25, 12/7/25, and 12/13/25, there were either no consecutive RN hours or no RN coverage at all. Specifically, on 12/7/25, there was no RN on duty. During an interview, the DON stated she was unaware that the required 8 hours of RN coverage must be consecutive and confirmed the absence of an RN on 12/7/25. This deficiency had the potential to affect all residents in the facility who may require a higher level of nursing assessment or intervention, as there was not consistent RN coverage as mandated.
Failure to Follow Resident Transfer Care Plan Results in Injury
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was developed and implemented to meet the needs and preferences of a resident with multiple diagnoses, including congestive heart failure, bilateral lower leg lymphedema, and diabetes. The resident's care plan specified that transfers should be performed using a Hoyer mechanical lift or with the assistance of two staff members, as directed by Physical Therapy and documented in the care plan. However, on the date of the incident, a CNA assisted the resident from her chair to standing without the required second staff member, contrary to the care plan instructions. During this transfer, the resident's knee buckled, resulting in a fall and subsequent injury. The resident was sent to the emergency room and diagnosed with a fracture of the right distal knee, which required surgical repair. Staff interviews confirmed that the CNA was aware of the resident's two-person transfer status but chose to proceed alone, leading to the incident.
Failure to Follow Provider Orders for Pain Medication Administration
Penalty
Summary
Nurses at the facility failed to follow provider orders for pain medication administration, as evidenced by medication administration records (MARs) and staff interviews. For three residents with multiple diagnoses including fractures and a history of falls, pain medications were given outside the prescribed pain level ranges. Specifically, one resident received oxycodone for pain levels below the ordered threshold on multiple occasions, while another was given ibuprofen and oxycodone for pain levels not matching the provider's specified range. A third resident was administered oxycodone for pain levels above the ordered range on two consecutive occasions. The Director of Nursing (DON) confirmed that nurses did not follow provider orders and acknowledged that resident preference does not supersede provider orders. These actions were identified through record review and staff interviews, demonstrating a failure to ensure that nursing services met professional standards of quality as required.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and handling practices. One medication cart was found unlocked and unattended for several minutes, contrary to facility expectations that carts remain locked when not in the nurse's sight. An LPN admitted to leaving the cart unsecured and also reported a routine practice of storing refused, prepared medications in the cart for later administration, instead of disposing of them as required. Additionally, the LPN was seen leaving a prepared liquid medication unattended on top of the medication cart while retrieving another medication from a separate room, leaving the medication unsupervised. Further deficiencies were identified in the medication storage room, where the refrigerator used for narcotic storage was found unlocked and unmonitored. Inside the refrigerator, a black metal box containing Lorazepam was not permanently affixed, as required for controlled substances. The DON and CNM confirmed these practices, with the DON stating that the expectation was for all controlled substances to be securely stored and for medications to never be left unattended or stored improperly.
Failure to Maintain Hand Hygiene During Insulin Administration
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during medication preparation and administration. Specifically, an LPN was observed preparing a resident's insulin at the medication cart, donning gloves, and then touching the resident's insulin pens and the resident's door with gloved hands without performing hand hygiene prior to donning gloves or before administering the insulin injections. Hand hygiene was only performed after glove removal and prior to leaving the resident's room. During an interview, the LPN acknowledged that hand hygiene should have been performed prior to donning gloves after entering the resident's room and before administering the injections. The DON, with the CNM present, confirmed that the expectation is for nurses to perform hand hygiene and don fresh gloves after entering a resident's room and prior to administering injections.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during inspections. In the dry food pantry, baking trays, pots, and pans were stored on shelves adjacent to a water heater pipe with flaking insulation, resulting in debris on the shelves and floor. Additionally, several food items, including a box of cornmeal, refrigerated green onions, frozen bread loaves, and veggie sausage patties, were found undated, contrary to the facility's Food Storage policy. The policy requires date marking on all high-risk foods to ensure they are consumed, sold, or discarded by the appropriate date. Further inspection revealed issues with the freezer, where ice cream containers had lids that were not fully closed, and ice droplets were noted on the ceiling above them. A large amount of ice was also found inside a plastic bin containing wrapped frozen bread, with ice droplets on the ceiling above the bin and a cardboard box on the top shelves of the freezer. The Nutritional Services Director acknowledged that the freezer door did not close well, leading to ice build-up and melting incidents. The storage shelves affected by pipe insulation particles contained unused pots, pans, and baking containers that should have been stored elsewhere.
Failure to Document and Address Resident Grievance
Penalty
Summary
The facility failed to properly document and address a grievance reported by a resident, which is a violation of the resident's rights to voice grievances without discrimination or reprisal. The grievance policy of the facility, updated on September 28, 2022, requires that grievances be promptly investigated and resolved, with documentation of the date received, steps taken to investigate, and corrective actions. However, in the case of Resident #135, who was admitted with multiple diagnoses including a fracture of the left thigh and Parkinson's disease, this process was not followed. The resident reported an incident where she was told by two aides to urinate in her pad instead of being assisted to the bathroom, which she found distressing. Despite reporting the incident to an LPN, the grievance was not documented in the facility's grievance log for September 2024. The LPN acknowledged being informed of the incident and stated that one of the aides was educated on appropriate language and behavior, but did not believe further action was necessary. This lack of documentation and inadequate response to the grievance had the potential to cause psychological harm to the resident, as her concerns were not formally acknowledged or addressed according to the facility's policy.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure residents were free from medication errors, specifically in the administration of insulin. This deficiency was observed in two residents with diabetes, who were administered insulin without the proper priming of the insulin pens. Priming is necessary to remove air from the needle and cartridge, ensuring the correct dose is delivered. The American Diabetes Association and the Insulin Lispro Kwikpen guidelines both recommend priming before each injection to ensure full dose administration. In the observed incidents, an LPN administered insulin to two residents without priming the insulin pens. For one resident, the LPN replaced the needle and dialed the pen to the prescribed units for both Insulin Lispro and Lantus but did not prime the pens before injection. Similarly, for the second resident, the LPN followed the same procedure without priming the pens. When questioned, the LPN admitted to not priming the pens and acknowledged that priming should have been done before administering the insulin doses.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to consistently implement infection control measures, as observed in the care of two residents. Resident #85, who was admitted with multiple diagnoses including dementia, was assisted by a CNA to the bathroom. After using the toilet, the CNA did not assist the resident in performing hand hygiene, despite acknowledging that it should have been done. This oversight was a direct violation of the facility's hand hygiene policy, which mandates handwashing after personal use of the toilet. In another instance, Resident #83, who had a feeding tube and was under enhanced barrier precautions, did not receive proper infection control measures during a dressing change. An LPN was observed changing the dressing on the resident's PEG tube site without wearing a gown, as required by the signage on the resident's door. Additionally, the LPN did not perform hand hygiene between glove changes during the procedure, stating that her hands were clean and only the gloves were dirty. The Infection Preventionist later confirmed that a gown should have been worn and hand hygiene should have been performed between glove changes.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
