Bennett Hills Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gooding, Idaho.
- Location
- 1220 Montana Street, Gooding, Idaho 83330
- CMS Provider Number
- 135134
- Inspections on file
- 18
- Latest survey
- March 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bennett Hills Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility failed to document the code status in the care plans of six residents, despite physician orders indicating their resuscitation preferences. This omission involved residents with conditions like respiratory failure, diabetes, and dementia, whose care plans did not reflect their full code or DNR statuses, including specific treatment preferences. The DON confirmed the lack of documentation.
The facility did not adhere to its policy of conducting pre-employment background checks for new hires. A nursing assistant was hired without a documented background check, which was only completed six months after the hire date. This oversight had the potential to increase the risk of harm to residents.
A resident with dementia and cognitive communication deficit was verbally abused by a CNA, which was overheard by another CNA. The incident was reported, and the abusive CNA was removed from the situation. This failure to adhere to the facility's abuse prevention policy resulted in a deficiency in protecting the resident from verbal abuse.
A facility failed to document a resident's cancer diagnosis on the comprehensive MDS assessment, despite the resident's care plan indicating a potential psychosocial issue related to the diagnosis. The DON and MDS Resource Nurse confirmed the omission.
The facility failed to post accurate daily nurse staffing information as required, with blank entries found for specific dates. This lapse in maintaining complete staffing records could affect residents, their representatives, and visitors seeking to review staffing levels.
The facility failed to ensure proper labeling, dating, and storage of medications. During audits, loose pills were found in the medication carts of both the East Hall and Skilled Hall. A CMA and an LPN confirmed that the pills should not have been loose and should have been destroyed. The DON stated that the responsibility for destroying the loose pills lay with the nurses or medication aides.
The facility failed to properly store and label food products, with issues such as expired items and lack of date marking, as well as improper meal tray coverage during delivery. These deficiencies could impact all residents by increasing the risk of consuming spoiled or contaminated food.
The facility failed to maintain a safe and clean environment, with overfilled sharps containers and mold-like substances in shower rooms. The DON admitted the absence of policies for housekeeping and sharps containers, acknowledging that showers should have been cleaned after each use and sharps containers changed when full.
The facility failed to ensure the Dietary Manager had the required competencies and certification. The DM, who started in January 2024, did not have prior experience or certification and planned to begin the CDM course in August 2024. The Administrator acknowledged the DM did not meet the necessary requirements, potentially affecting the meal satisfaction of all 52 residents.
The facility failed to monitor dish machine temperatures and sanitizer concentrations, and did not label or date food in the residents' refrigerator, placing 52 residents at risk for foodborne illness. Observations revealed inadequate rinse temperatures, ineffective sanitizing solutions, and unlabeled food items. Staff were unaware of the required procedures.
The facility failed to ensure waste was properly contained, leading to potential pest infestation. Observations revealed a large dumpster with open, bent lids and regular garbage bags mixed with cardboard. Smaller garbage cans were also found with lids open or overflowing. The Maintenance Director and Administrator acknowledged the issue and the need for lid replacement.
The facility failed to ensure a safe, homelike environment, with missing floor tiles, dirty vents, and a hole in the wall observed in two shower rooms and a hallway. The Maintenance Supervisor acknowledged these issues as unsafe and not providing a clean environment.
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential negative outcomes. One resident's care plan lacked details on using a Hoyer lift for transfers, another resident's self-administration of nasal spray was not documented, a third resident's wound care interventions were missing, and a fourth resident's preference to sleep in a recliner was not included.
The facility failed to ensure controlled medications were properly tracked and secured, as evidenced by multiple blank signature lines on narcotic accountability records. An LPN and the DON confirmed that nurses should have signed the narcotic book after counting narcotics with another nurse, but this was not consistently done, creating the potential for undetected misuse and/or diversion of controlled medications.
The facility failed to maintain a medication error rate below 5%, with errors affecting two residents. One resident received an incorrect dose of Heparin instead of a saline flush, while another resident self-administered nasal spray incorrectly and received an insufficient dose of Sertraline. These errors indicate lapses in following prescribed medication regimens and facility policies.
The facility failed to provide residents with nourishing, palatable, well-balanced meals that met their dietary needs and preferences. Several residents reported not receiving the food items or quantities they selected, leading to dissatisfaction and hunger. The Dietary Manager and Registered Dietitian acknowledged the issues, and the Administrator was aware but no corrective actions were mentioned.
The facility failed to provide nutritionally comparable and sufficient alternate meals to residents, leading to dissatisfaction and decreased meal intake. Residents expressed concerns about the limited and repetitive nature of the alternate menu options, which were primarily limited to tuna fish sandwiches or chicken patty sandwiches with chips. The Dietary Manager confirmed the lack of variety, and the Registered Dietitian stated that there should have been planned alternates for vegetables, starch, and protein, which were not provided.
The facility failed to respect and maintain the dignity of residents who required assistance with their meals. Residents needing feeding assistance were consistently served last, leading to extended waiting periods for their meals and beverages. Staff referred to these residents as 'feeders,' a term acknowledged as undignified by the DM, LPN, DON, and Administrator.
A resident reported missing money on two occasions to the Social Services Representative, who admitted to forgetting to fill out a grievance form and failing to investigate the issue. The facility's policy required prompt investigation and response to grievances, which was not followed in this case.
The facility failed to assess a seatbelt used by a resident with congestive heart failure and COPD as a potential restraint. The resident's record lacked documentation of an assessment, and the DON and PT Director confirmed this oversight.
A resident with multiple diagnoses was transferred to the ER without documented evidence that necessary information was provided to the receiving hospital, as required by facility policy. The DON claimed that various documents were sent, but there was no documentation to confirm this.
The facility failed to notify the ombudsman of a resident's transfer to the hospital. The resident, with multiple diagnoses including depression and congestive heart failure, experienced a decline in condition and was sent to the ER. The Social Services Representative was unaware of the requirement to inform the ombudsman.
The facility failed to follow professional nursing standards for three residents, leading to potential risks for wound infection, adverse outcomes from medication refusal, and unmanaged hyperglycemia. An LPN did not label a wound dressing, a resident's repeated refusal of a Nicotine Patch was not properly documented or communicated to the physician, and another resident's high blood glucose levels were not reported as required.
A resident with COPD and other diagnoses did not receive the prescribed 3 liters of oxygen continuously via nasal cannula. Instead, the oxygen concentrator was set at 2 liters, and even when checked, it was found to be set at 2 and a half liters. The DON confirmed the resident required oxygen at the specified concentration.
The facility failed to ensure medications were properly labeled and not expired. During audits, expired Top Care eye drops and Loperamide were found, along with an unlabeled Albuterol Sulfate inhaler. Staff confirmed these medications should have been removed or properly stored.
A facility failed to ensure accurate medical records for a resident with end-stage renal disease, missing documentation for 12 dialysis sessions over two and a half months. Staff interviews confirmed that the resident's refusals to attend dialysis were not recorded in the EMR, violating the facility's policy.
The facility failed to maintain proper infection control practices, including improper handling of an oxygen cannula, lack of hand hygiene before meals, and failure to use required PPE during wound care. These actions placed residents at risk for cross-contamination and infection.
The facility failed to ensure that a resident who consented to the pneumococcal vaccine received it. The resident had multiple diagnoses and had previously received the PPSV23 vaccine. Despite consenting to receive the PCV20 vaccine, there was no documentation of its administration in her record, as confirmed by the DON.
Failure to Document Code Status in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive resident-centered care plans for six residents, which placed them at risk of negative outcomes. The care plans did not include critical information regarding the residents' code status, which is essential for ensuring appropriate medical interventions. This deficiency was identified through observation, record review, and staff interviews, revealing that the care plans lacked documentation of the residents' resuscitation preferences as per their physician orders. Specifically, the care plans for residents with various medical conditions, such as respiratory failure, hypertension, sacral spina bifida with hydrocephalus, diabetes, chronic obstructive pulmonary disease, heart failure, dementia, pneumonia, and multiple sclerosis, did not reflect their documented code statuses. These statuses ranged from full code to DNR with specific treatment preferences, such as the use of IV fluids, antibiotics, and the refusal of feeding tubes and blood products. The Director of Nursing acknowledged the omission of this critical information in the care plans.
Failure to Conduct Pre-Employment Background Check
Penalty
Summary
The facility failed to implement its policy for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. This deficiency was identified during a review of personnel files, where it was found that a nursing assistant (NA #1) was hired without a documented pre-employment background check. The facility's policy, revised in December 2023, required such checks to be completed prior to hiring. However, NA #1 was hired on June 13, 2024, and the background check was only completed on December 6, 2024, six months after the hire date. The Administrator confirmed the absence of a completed background check at the time of hire, which had the potential to place residents at increased risk for physical and/or psychosocial harm.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving verbal abuse. A certified nursing assistant (CNA) overheard another CNA verbally abusing a resident who had been admitted with diagnoses including dementia and cognitive communication deficit. The incident was reported, and the abusive CNA was instructed to leave the resident's room. The facility's policy on abuse prevention and prohibition was not adhered to, resulting in a deficiency in safeguarding the resident from verbal abuse.
Failure to Document Cancer Diagnosis on MDS Assessment
Penalty
Summary
The facility failed to document a resident's diagnosed medical condition on the comprehensive Minimum Data Set (MDS) assessment, which is required by the State Operations Manual and the Resident Assessment Instrument (RAI). This deficiency was identified for one resident whose MDS assessments were reviewed. The resident, who was admitted with multiple diagnoses including renal failure, diabetes, and hyponatremia, had a care plan updated to reflect a potential psychosocial well-being problem related to a recent cancer diagnosis. However, the comprehensive MDS assessment did not document the cancer diagnosis. The Director of Nursing (DON) and MDS Resource Nurse acknowledged that the MDS should have included this diagnosis.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately posted daily for each shift, as required by the State Operation Manual, Appendix PP. This manual mandates that facilities post specific information daily, including the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides, as well as the resident census. During a review conducted on March 20, 2025, it was found that the posted nurse staff hours for October 18, 2024, and January 9, 2025, were blank. The Administrator acknowledged that all posted nursing hours should have been completed, indicating a lapse in maintaining accurate and complete staffing records. This deficiency had the potential to affect all residents residing in the facility, as well as their representatives, visitors, and others who might want to review the facility's staffing levels.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications available for residents were labeled, dated, and stored appropriately. During an audit of the East Hall medication cart, conducted with a Certified Medication Aide (CMA) present, it was observed that there were three loose pills in the bottom of the third drawer: one oval-shaped white tablet, one small round white tablet, and one large oblong white tablet. The CMA acknowledged that the pills should not have been loose in the medication cart. Similarly, an audit of the Skilled Hall medication cart, conducted with a Licensed Practical Nurse (LPN) present, revealed two small, round white pills loose in the bottom of the third drawer. The LPN confirmed that the pills should not have been loose and should have been destroyed. The Director of Nursing (DON) later stated that the nurses or medication aides should have destroyed the loose pills.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to properly store, label, and manage food products in accordance with the Idaho Food Code, which could potentially impact all residents. Observations revealed several issues: dry pasta with an open date of 10/9/24 was not disposed of by 3/9/25, barley with a use-by date of 12/24 was still present, and Ragu pasta sauce with a use-by date of 3/13/25 was not discarded. Additionally, three #10 size cans of pineapple tidbits and beans lacked a received date. A soy sauce bottle provided to a resident had no use-by date, and a container of salsa in the resident refrigerator was found with a white fuzzy substance growing inside, indicating spoilage. Furthermore, during meal delivery, it was observed that CNA #1 delivered meal trays to residents' rooms without covers on the bread or dessert, which is against the facility's protocol. The DS confirmed that food should be covered when transported down the hall. These lapses in food handling and storage practices placed residents at risk of consuming spoiled or contaminated food, potentially leading to adverse health outcomes.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, which had the potential to impact all residents by placing them at risk for injury and infections. During observations, it was noted that sharps containers in multiple locations were overfilled, with used razors protruding from the openings. Additionally, a fuzzy black mold-like substance was observed on shower tiles and near ceiling vents in the shower rooms. Interviews revealed that the facility lacked policies for housekeeping, cleaning, showers, or sharps containers. The Director of Nursing acknowledged that showers should have been cleaned after each use and sharps containers should have been changed when full, but these actions were not taken.
Dietary Manager Lacks Required Competencies and Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) had the required competencies and skills for the position. The job description for the DM required a minimum of two years' experience in a supervisory capacity in a hospital, skilled nursing care facility, or other related medical facility. Additionally, the DM was required to be a Certified Dietary Manager (CDM), Certified Food Service Manager, or have a similar national certification. The current DM, who started in January 2024, did not have prior experience as a DM and was not certified. She planned to begin the CDM course in August 2024, which would take six to eight months to complete, meaning she would not be fully qualified until more than a year after starting her position. The Registered Dietitian (RD) confirmed that the DM was signed up for the CDM course but would not be fully qualified until its completion. The Administrator acknowledged that the DM did not meet the educational, experience, or certification requirements for the position. The DM missed the January 2024 CDM course due to being in a trial period for the position. This deficiency had the potential to affect the meal and food satisfaction of all 52 residents receiving food from the kitchen.
Failure to Monitor Dish Machine and Sanitizer Concentrations
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of the dish machine, sanitizing solutions, and labeling of food in the residents' refrigerator. During an initial tour of the kitchen, it was observed that the dish machine's rinse temperatures did not meet the manufacturer's minimum requirement of 120 degrees Fahrenheit, with recorded temperatures ranging from 36 to 90 degrees Fahrenheit. Additionally, the chemical sanitizer concentration was not measured or recorded, and the sanitizer solution for kitchen surfaces was found to be ineffective, as indicated by a test strip that did not change color. The refrigerator at the nursing station contained unlabeled and undated food items, including partially consumed McDonald's shakes and open containers of french fries and refried beans, which were not stored in closed containers to prevent contamination. During a follow-up kitchen observation, it was noted that the sanitizer solution for pot washing and kitchen surfaces was inadequately mixed, with concentrations close to zero parts per million (PPM). The cook verified the low concentration and adjusted the solution to the required level of 200 PPM. The commercial dishwasher's rinse temperature was again found to be below the required 120 degrees Fahrenheit, and the dish machine log consistently lacked records of sanitizer levels. The Dietary Manager (DM) and Maintenance Director were unaware of the need to monitor and record the sanitizer concentration and rinse temperatures, respectively. The Registered Dietitian (RD) confirmed that the rinse temperatures were too low and that the sanitizer concentration should have been monitored. The deficiencies observed placed the 52 residents receiving meals from the kitchen at risk for foodborne illness. The facility's failure to adhere to proper sanitation procedures, including monitoring dish machine temperatures and sanitizer concentrations, as well as ensuring food in the residents' refrigerator was labeled and dated, contributed to the potential health risks. Staff interviews revealed a lack of awareness and adherence to the required procedures, further exacerbating the issue.
Improper Waste Containment Leading to Potential Pest Infestation
Penalty
Summary
The facility failed to ensure that waste was properly contained with lids or otherwise covered, creating the potential for insect and pest infestation. During an observation, a large dumpster with two plastic lids was found with both lids open, exposing the contents. There were no staff in the vicinity actively disposing of garbage. Additionally, several smaller garbage cans were observed, one of which had its lid open and was empty. The DM stated that the large dumpster was designated for cardboard, but it contained four bags of regular garbage on top of the cardboard boxes. The DM acknowledged that the garbage cans might have been full, leading to the regular garbage bags being placed in the large dumpster. The lids remained open when leaving the area. In a subsequent observation, one of the two lids of the large dumpster was open, exposing the contents again. The lids were bent, preventing a complete seal even if closed. The garbage bags observed earlier remained in the dumpster with the cardboard. The DM confirmed that the large dumpster was emptied weekly, and the smaller garbage cans were serviced daily from Monday to Thursday. The DM stated that staff should have distributed the garbage evenly among the smaller cans to prevent overflow and ensure the lids could be closed. The Maintenance Director and the Administrator both acknowledged the issue with the damaged lids and the need for replacement to prevent pest access.
Failure to Provide Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure residents were provided with a safe, homelike environment. This was observed in two of the three shower rooms in the facility. Specifically, the skilled hall shower room had 8 missing floor tiles, a dry, light gray substance in the air vent slats, and a black substance around the vent on the ceiling. Additionally, the skilled hall hallway outside a room had a hole in the wall approximately 4 inches by 2 inches. The east hall shower room had a white, fuzzy film on the ceiling vent. The Maintenance Supervisor acknowledged that the missing tiles in the shower room were unsafe and that the room should not be used for showering residents. He also stated that the hole in the wall and the dirty ceiling vents did not provide a clean, homelike environment.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive resident-centered care plans for four residents, leading to potential negative outcomes. Resident #17, who was dependent on staff for transfers due to an amputation and spina bifida, did not have her care plan updated to include the use of a Hoyer lift for transfers. This omission was confirmed by the DON, who acknowledged that the care plan should have specified the type of lift, the number of staff needed, and the type and size of the transfer sling. Similarly, Resident #24, who was cognitively intact and had a physician's order to self-administer Fluticasone Furoate nasal spray, did not have this self-administration documented in her care plan. An LPN was also unaware if this was care planned, despite the resident regularly self-administering the medication. Resident #31, who required specific wound care for a subdural hemorrhage and diabetes, did not have these wound care interventions documented in the care plan, as confirmed by the DON. Lastly, Resident #198, who preferred to sleep in a recliner due to spina bifida and kidney disease, did not have this preference documented in his care plan, even though he was observed sleeping in the recliner and had been educated on the importance of sleeping in bed due to his wounds. The DON confirmed that this preference should have been included in the care plan.
Failure to Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure controlled medications were properly tracked and secured, as evidenced by multiple blank signature lines on narcotic accountability records. During a medication cart audit, it was observed that the narcotic accountability record for one medication cart had missing signatures for several days. Specifically, from 4/28/24 to 5/8/24, 7 out of 34 days lacked signatures from licensed nurses for each shift, and from 5/9/24 to 5/15/24, 8 out of 20 days had missing signatures. This indicates that the required reconciliation of controlled medications by two licensed nurses at each shift change was not consistently performed or documented, as per the facility's policy revised in December 2023. An LPN confirmed that nurses should have signed the narcotic book after counting narcotics with another nurse. The Director of Nursing (DON) also stated that the reconciliation sheets are located at the back of the narcotic book and should be signed by both the off-duty and on-duty nurses during each shift change, even if the shift is split between nurses. The failure to adhere to this protocol created the potential for undetected misuse and/or diversion of controlled medications, affecting all residents who received such medications in the facility.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, as evidenced by a 6.67% error rate observed during the survey. Resident #17, who has multiple diagnoses including amputation and spina bifida, was supposed to receive a normal saline flush solution intravenously as per the SASH protocol. However, LPN #3 administered 5 ml of Heparin 100 mg/ml instead. The Director of Nursing (DON) and a Registered Nurse (RN) were unsure about the correct dose of Heparin and had to consult the pharmacy for clarification, indicating a lack of adherence to the facility's medication administration policy and protocol knowledge among staff members. Resident #24, diagnosed with heart failure and chronic obstructive pulmonary disease (COPD), was observed self-administering Fluticasone Furoate nasal spray incorrectly by using only 1 spray in each nostril instead of the prescribed 2 sprays. Additionally, LPN #3 administered only 150 mg of Sertraline HCl instead of the prescribed 200 mg. The LPN acknowledged the errors, confirming that the resident should have received the correct dosages as per the physician's orders. These medication administration errors highlight significant lapses in following prescribed medication regimens and the facility's policies, putting residents at risk of not receiving their proper medication or dosage.
Failure to Provide Nourishing and Palatable Meals
Penalty
Summary
The facility failed to ensure residents were provided with nourishing, palatable, well-balanced meals that met their daily special dietary needs and specific preferences as documented on the residents' meal tickets. This issue was identified for five residents who reported not receiving the food items they selected or the quantities they requested. For instance, one resident consistently ordered three chicken sandwiches but received only two chicken patties on a bun, and another resident requested three fried eggs but was served only two. Additionally, residents reported missing items on their trays, such as zucchini and oranges, which were either not available or not provided despite being requested. The facility's policy stated that menus should be developed to meet the nutritional needs and preferences of residents, but this was not consistently followed. Resident Council meeting minutes documented ongoing concerns about missing food items and unfulfilled meal preferences. During interviews, residents expressed dissatisfaction with the meals served, indicating that they often did not receive the food they selected or the quantities they needed to feel satisfied. One resident, who was a large man, reported hoarding food because he did not receive enough to eat, while another diabetic resident was served fruit cocktail in heavy syrup instead of the fresh fruit she requested. The Dietary Manager (DM) and Registered Dietitian (RD) acknowledged the issues, stating that dietary staff did not always serve everything residents requested on their meal tickets. The DM admitted to routinely serving less food to certain residents based on her judgment of their dietary needs, rather than following the residents' selections. The RD confirmed that residents should be served what they selected and that their preferences should be accommodated. The Administrator was aware of the situation and verified that some residents might be hungry if served regular-sized portions, but no corrective actions were mentioned in the report.
Failure to Provide Sufficient Alternate Meals
Penalty
Summary
The facility failed to provide nutritionally comparable and sufficient alternate meals to residents, as observed through multiple instances and resident interviews. The facility's Food and Nutrition Menus policy required that menu alternatives aligned with individual needs and preferences should be available if the primary menu or immediate selections for a particular meal were not to the resident's liking. However, the Week Two spring/summer cycle menu and its daily menu extensions did not include planned alternative food items. Resident Council meeting minutes from 7/14/23 to 3/13/24 documented ongoing concerns about the limited and repetitive nature of the alternate menu options. Residents expressed dissatisfaction with the lack of variety and the repetitive nature of the alternate meals, which were primarily limited to tuna fish sandwiches or chicken patty sandwiches with chips. Specific resident interviews revealed that residents were often served the same limited alternatives, leading to dissatisfaction and decreased meal intake. For example, one resident was served a chicken patty on a bun instead of a casserole, which she did not like, and another resident could not get a peanut butter and jelly sandwich because it was not on the alternate menu. The Dietary Manager (DM) confirmed that the alternate menu for lunch and dinner every day for the current six-month cycle menu was either a tuna fish sandwich or a chicken patty sandwich with chips, with no alternatives for vegetables, starch, fruit, or dessert. The Registered Dietitian (RD) stated that there should have been planned alternates on the menu daily for lunch and dinner, including alternates for vegetable and starch exchanges in addition to the entree/protein, which were not provided.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to respect and maintain the dignity of residents who required assistance with their meals. Observations during breakfast and lunch revealed that residents seated at horseshoe-shaped tables, who needed feeding assistance, were consistently served last. These residents were brought to the dining room first but had to wait extended periods for their meals and beverages, while other residents in the main dining area were served promptly. This practice led to residents at the horseshoe tables sitting unassisted, not drinking their beverages, and some dozing off or with their eyes closed. Staff interviews confirmed that the residents at the horseshoe tables were referred to as 'feeders,' a term acknowledged by the Dietary Manager (DM), Licensed Practical Nurse (LPN), Director of Nursing (DON), and the Administrator as undignified. The DM and LPN stated that the residents at the horseshoe tables were served last so that staff could be available to assist them without interruption. However, this resulted in these residents waiting significantly longer for their meals and beverages compared to other residents in the dining room. One resident at the horseshoe table, who could be interviewed, expressed that she was improving and could eat with less assistance but still had to wait long periods for her meals. The DON and Registered Dietitian (RD) acknowledged that referring to residents as 'feeders' was a dignity issue and that residents needing assistance should not be brought to the dining room first if they were going to be fed last. The Administrator confirmed that the terminology used was not dignified and that residents needing assistance should not have to wait as long as they had.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure grievances were responded to and investigated, and prompt corrective action was taken to resolve them. This was evident in the case of a resident who reported missing money on two occasions. The resident, who was moderately cognitively intact and had multiple diagnoses including aftercare following surgical amputation of both legs below the knee, reported the missing money to the Social Services Representative. However, the Social Services Representative admitted to forgetting to fill out a grievance form and failing to investigate the issue. The facility's Grievances policy and procedure, revised December 2023, required the Grievance Official to evaluate and investigate concerns and take immediate action to resolve them. The policy also mandated that the Grievance Official or designee respond to the individual expressing the concern within three working days. In this case, the Social Services Representative did not follow the policy, leading to the resident's grievances being unaddressed and unresolved.
Failure to Assess Seatbelt as Potential Restraint
Penalty
Summary
The facility failed to ensure that a seatbelt used for a resident was assessed as a potential restraint. This was identified for one resident who was observed sitting in her electric wheelchair with a seatbelt fastened. The facility's policy defined a physical restraint as any device that the resident cannot remove easily and restricts freedom of movement. The policy also required an accurate and thorough assessment by the IDT before applying any restraints. However, the resident's record did not include documentation of such an assessment for the seatbelt. The resident in question had multiple diagnoses, including congestive heart failure and chronic obstructive pulmonary disease. Despite these conditions, there was no documentation that the seatbelt was assessed as a potential restraint. The DON and PT Director reviewed the resident's record and confirmed the absence of such documentation. They also stated that the seatbelt came with the wheelchair and no assessment was completed regarding its use. When asked if the seatbelt should have been assessed as a potential restraint, the DON and PT Director did not provide an answer.
Failure to Provide Necessary Information During Resident Transfer
Penalty
Summary
The facility failed to ensure that necessary information was provided to the receiving hospital during the transfer of a resident. The facility's policy required that specific information, including contact information of the resident's practitioner, advance directives, special instructions, comprehensive care plan goals, and other necessary documentation, be communicated to the receiving healthcare institution. However, for the resident in question, there was no documentation in the medical record indicating that this information was provided to the hospital during the transfer. The resident, who had multiple diagnoses including depression, congestive heart failure, and dysphagia, experienced a decline in condition and was sent to the ER. Although the Director of Nursing (DON) stated that various documents were sent with the resident, there was no documentation to confirm this. This lack of documentation could potentially lead to delays in treatment and care for the resident at the receiving hospital.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure transfer notices were provided to the ombudsman for a resident transferred to the hospital. Resident #9, who had multiple diagnoses including depression, congestive heart failure, and dysphagia, was admitted to the facility on an unspecified date. On 3/10/24, the resident was reported to be in pain with a high pulse rate, and the physician and resident's representative were notified. The following day, the resident's condition declined further, and the representative requested an ER visit, which was approved by the provider. The resident was sent to the ER, but there was no documentation that the ombudsman was informed of the transfer. The Social Services Representative later confirmed that she was unaware of the requirement to notify the ombudsman of such transfers.
Failure to Follow Professional Nursing Standards
Penalty
Summary
The facility failed to follow professional standards of nursing practice for three residents, leading to potential risks for wound infection, adverse outcomes from medication refusal, and unmanaged hyperglycemia. Resident #31 had a wound dressing that was not labeled with the date, time, or initials, contrary to the Lippincott Nursing Procedures textbook guidelines. This oversight was observed when an LPN changed the dressing without labeling it, and the LPN later acknowledged the mistake. Resident #37, who was moderately cognitively intact and had a physician's order for a Nicotine Patch, refused the patch 29 times out of 41 opportunities. The facility's policy required that the physician be notified of such refusals, but there was no documentation that this was done. The DON admitted that while the provider was verbally informed, no follow-up was made to obtain further orders regarding the refusals. Resident #43, who had diabetes, had blood glucose levels greater than 400 mg/dl on two occasions. The physician's order required that the provider be notified of such high readings, but there was no documentation that this was done. The Nurse Practitioner and DON confirmed that the physician should have been notified and that the resident's condition and the notification should have been documented in the progress notes or a Change of Condition assessment.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to ensure that Resident #16 received oxygen therapy as per the physician's orders. Resident #16, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), multiple rib fractures, and pneumonia, had a physician's order dated 4/5/24 to receive 3 liters of oxygen continuously via nasal cannula. However, the nurses' daily skilled notes from 5/9/24 to 5/15/24 documented that the resident's oxygen was administered at 2 liters instead of the prescribed 3 liters. Observations on multiple occasions confirmed that the oxygen concentrator was set at 2 liters, and even when checked by LPN #1, it was found to be set at 2 and a half liters, not the prescribed 3 liters. Resident #16, who was severely cognitively impaired, expressed concerns about his health and mentioned that he did not feel good on 5/16/24. Despite his condition and the physician's clear orders, the staff failed to administer the correct oxygen concentration. The Director of Nursing (DON) confirmed that the resident required oxygen for his COPD diagnosis and acknowledged that the nurses should have administered the oxygen at the concentration specified in the physician's orders.
Medication Labeling and Expiration Deficiency
Penalty
Summary
The facility failed to ensure medications available for residents were properly labeled and had not expired. During a medication cart audit of the Skilled Hall medication cart, a bottle of Top Care eye drops with an expiration date of 3/2024 was found. An RN confirmed the eye drops were expired and should have been removed. In a separate audit of the East Hall medication cart, a package of Loperamide with an expiration date of 2/23/23 and an unlabeled Albuterol Sulfate inhaler were found. An LPN identified the inhaler as belonging to a resident based on a sharpie mark but acknowledged it should have been stored in its original box. The DON stated that discontinued and expired medications should be removed from the medication carts promptly.
Failure to Document Dialysis Refusals
Penalty
Summary
The facility failed to ensure that the medical record of a resident with end-stage renal disease, who was dependent on renal dialysis, was accurate and complete. Specifically, the resident had a physician order for hemodialysis three times a week, but the Dialysis Flow Sheets showed that 12 sessions were missing over a period of two and a half months. The missing dates were not documented in the resident's Progress Notes, Medication Administration Records (MARs), or Treatment Administration Records (TARs). This lack of documentation meant that the healthcare provider was unaware of the extent of the resident's non-compliance with dialysis treatments. Interviews with staff revealed that the resident refused dialysis at least once a week, and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the refusals should have been documented in the Electronic Medical Record (EMR). However, the refusals were not recorded, which was verified by the DON and ADON. This failure to document the resident's refusals to attend dialysis sessions was a violation of the facility's policy on the content of medical records, which requires prompt and appropriate entries by all healthcare professionals involved in the resident's care.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, which had the potential to impact all 52 residents. One incident involved an LPN who picked up a resident's oxygen cannula from the floor and placed it back in the resident's nose without cleaning it. Another incident involved CNAs who did not offer hand hygiene to residents before serving their meals and placed dirty trays on a cart with clean trays. Additionally, an LPN provided wound care to a resident without wearing the required gown, despite the resident being on Enhanced Barrier precautions due to wounds and a physician's order requiring PPE for high-contact care activities. Resident #3, who had multiple diagnoses including acute pancreatitis and respiratory failure, was subjected to improper handling of their oxygen cannula. During lunch tray delivery, residents were not offered hand hygiene, and dirty trays were mixed with clean ones. Resident #31, with diagnoses including subdural hemorrhage and diabetes, was not provided with the required Enhanced Barrier precautions during wound care, as the LPN failed to wear a gown. These actions and inactions directly violated the facility's infection control policies and placed residents at risk for cross-contamination and infection.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that residents who were offered and consented to the pneumococcal vaccine received the vaccine. This was evidenced by the case of a resident who had multiple diagnoses, including amputation of her left leg above the knee and spina bifida. The resident's record showed that she had received the PPSV23 vaccine previously and had consented to receive the PCV20 vaccine according to CDC recommendations. However, there was no documentation in her record indicating that the PCV20 vaccine was administered to her. The Director of Nursing (DON) reviewed the resident's record and confirmed the absence of documentation for the administration of the PCV20 vaccine. This failure to administer the vaccine as per the resident's consent and CDC guidelines created the potential for increased risk of pneumococcal pneumonia and severe illness or death among residents.
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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