Lewiston Transitional Care Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewiston, Idaho.
- Location
- 3315 8th Street, Lewiston, Idaho 83501
- CMS Provider Number
- 135021
- Inspections on file
- 16
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Lewiston Transitional Care Of Cascadia during CMS and state inspections, most recent first.
Staff stored employee food and therapy ice packs with resident food, and failed to properly label and date resident food items. Additionally, pest control measures were not followed, as dumpsters were left open and surrounded by trash and debris, attracting flies. These actions did not meet professional standards for food safety and sanitation.
A resident with COPD and multiple comorbidities had a care plan that was not updated after their oxygen therapy was discontinued. The care plan continued to indicate oxygen dependence despite the physician's order for oxygen being stopped, and staff confirmed the care plan should have been revised to reflect this change.
A resident with documented allergies and cognitive impairment was given a peanut butter sandwich by staff who did not check the medical record for dietary restrictions. The allergen binder meant to inform staff of such allergies was not updated or available in the snack room, leading to the resident consuming a known allergen.
A resident with lymphedema and congestive heart failure did not receive pain medication according to physician orders, as staff administered hydrocodone-acetaminophen inconsistently with prescribed pain levels. Medication administration records and staff interviews confirmed that the nurse did not follow the specific dosing instructions based on pain assessment.
A resident with multiple chronic conditions and cognitive impairment missed numerous scheduled morning medications over an extended period due to being asleep, with no timely documentation or physician notification regarding the missed doses. The care plan required medication administration as ordered and physician notification for issues, but these steps were not followed, and the facility lacked a policy for timely physician notification.
A nurse failed to perform hand hygiene and change gloves after touching room surfaces and equipment before accessing a resident's PICC line for IV antibiotic administration. This lapse in infection control occurred during care for a resident with multiple serious diagnoses, including sepsis and osteomyelitis, and was confirmed by both observation and staff interview.
The facility was found to have expired food items in the refrigerator and a greasy stove hood, potentially affecting 69 residents. Expired yogurt and sour cream were confirmed by staff, and the stove hood had lint buildup despite claims of recent cleaning. The CM was unaware of the cleaning process and was creating a new checklist.
A facility failed to update a Level I PASARR to include a PTSD diagnosis for a resident, despite the condition being documented in their care plan and MDS assessment. The PASARR forms from 2022 and 2023 incorrectly indicated no major mental health illnesses. The Social Services staff confirmed the oversight and acknowledged the need for an update.
A resident who required substantial assistance for bathing missed several scheduled showers due to a lack of documentation and follow-up on refusals or missed showers. The facility's policy required documentation of refusals, but this was not consistently done, leading to a deficiency in personal hygiene care.
Improper Food Storage and Pest Control Deficiencies
Penalty
Summary
Staff failed to store staff food and physical therapy ice packs separately from resident food in both the A-Wing Resident Snack freezer and the El Bistro Resident refrigerator and freezer. Specifically, therapy ice packs and packages of raw beef burgers labeled for employee use were stored with resident food items, and open, undated, or incorrectly dated food items such as orange juice and ice cream were found. The Culinary Director confirmed that staff food and therapy items should not be stored with resident food and that all resident food should be properly labeled with the resident's name, open date, and use by date. The Culinary Director also acknowledged that staff needed more education on proper food labeling and dating procedures. Additionally, pest control measures were not adequately followed. Two kitchen dumpsters were observed with their lids left open, and one dumpster had multiple flies surrounding the trash inside. The other dumpster had garbage and leaves piled around it on the ground. The Maintenance Director stated that the area around the dumpster was not cleaned as scheduled and that all staff were instructed to close dumpster lids after use, which was not done in this instance. The facility's pest control company visits every two weeks, but the observed conditions did not meet the required standards for pest control and sanitation.
Failure to Update Care Plan Following Discontinuation of Oxygen Therapy
Penalty
Summary
The facility failed to update the care plan for a resident who was admitted with multiple diagnoses, including COPD, oxygen dependence, diabetes, dementia, depression, and a cognitive communication deficit. Although a physician's order for continuous oxygen therapy was discontinued, the resident's care plan continued to document oxygen dependence and did not reflect the change in treatment. This oversight was confirmed through record review and staff interview, where it was acknowledged that the care plan should have been updated when the oxygen order was discontinued.
Failure to Follow Dietary Restrictions for Resident with Documented Food Allergy
Penalty
Summary
Facility staff failed to follow a documented dietary restriction related to a food allergy for a resident with multiple diagnoses, including dementia, diabetes, high blood pressure, depression, and anxiety. The resident was not cognitively intact, as noted in the admission MDS assessment. The care plan clearly documented allergies to aspirin, peanuts, and pollen. Despite this, a staff member provided the resident with a peanut butter sandwich upon request, without checking the resident's medical record for allergies. The incident occurred because the staff did not verify the resident's dietary restrictions before providing the food item. Additionally, the allergen binder, intended to keep staff informed of resident allergies, was not updated and was not in its designated location in the snack room at the time of the incident. As a result, the resident consumed a food item containing an allergen, though no signs or symptoms of an allergic reaction were observed following the event.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to ensure effective and appropriate pain management for a resident with multiple diagnoses, including lymphedema and congestive heart failure. The resident had physician's orders for hydrocodone-acetaminophen to be administered based on specific pain levels: one tablet for pain levels 1-5 and two tablets for pain levels 6-10. However, medication administration records showed that the orders were not followed. The resident received one tablet for a pain level of 0, one tablet for a pain level of 6, and two tablets for pain levels of 4 and 5, which did not align with the prescribed protocol. Staff interviews confirmed that the physician's orders were not adhered to, and the nurse did not review the orders after assessing the resident's pain level. These actions resulted in the resident receiving pain medication inconsistently with the physician's instructions, as documented in the medication administration record and confirmed by facility leadership.
Failure to Prevent and Report Significant Medication Errors
Penalty
Summary
The facility failed to ensure that significant medication errors were prevented for one resident with multiple diagnoses, including dementia, diabetes, hypertension, depression, and anxiety. The resident was not cognitively intact and had several physician orders for medications to be administered at specific times. Review of the Medication Administration Record (MAR) from June to August showed that the resident did not receive multiple morning medications on numerous days, with the reason documented as the resident being asleep. There was also one instance of medication refusal. The resident's care plan directed staff to administer medications as ordered and to monitor and document effectiveness and side effects, including over-sedation and lethargy, and to notify the physician as indicated. Despite repeated missed doses, there was no documentation in the medical record regarding the effects of the missed medications or any notification to the physician until mid-August, when an SBAR was submitted noting the resident's preference to sleep in. The Chief Nursing Officer confirmed that there was no documentation or physician notification regarding the missed medications prior to this date. Additionally, the facility did not have a policy specifying when the physician should be notified about missed medications, but acknowledged that best practice would have been to notify the physician within 24-48 hours.
Failure to Follow Infection Control Protocol During IV Medication Administration
Penalty
Summary
A deficiency was identified when a nurse failed to follow infection prevention and control standards during the administration of intravenous (IV) medication to a resident with a peripherally inserted central catheter (PICC) line. The nurse was observed washing her hands, donning a gown and gloves, and preparing the IV medication. However, after putting on gloves, she touched the resident's divider curtain and the IV pump, then continued with the procedure without changing gloves or performing hand hygiene before accessing the resident's PICC port. This action was contrary to facility policy, CDC guidelines, and WHO recommendations, all of which require hand hygiene and the use of clean gloves before handling invasive devices or after contact with potentially contaminated surfaces. The resident involved had a history of sepsis, pneumonia, diabetes, and was being treated for osteomyelitis with IV vancomycin via a PICC line. The nurse's failure to change gloves or perform hand hygiene after touching inanimate objects in the resident's environment and before accessing the PICC port was confirmed through observation and staff interview. The nurse acknowledged the lapse in infection control practices, and the Chief Nursing Officer confirmed that proper hand hygiene and glove use are required before accessing IV sites.
Expired Food and Unclean Stove Hood Found in Facility Kitchen
Penalty
Summary
The facility failed to ensure that food was not expired and that the stove hood was cleaned, which could potentially affect the 69 residents consuming food prepared by the facility. During an observation, it was found that the walk-in refrigerator contained expired food items, including four containers of low-fat yogurt and one container of sour cream. A staff member confirmed that these food items were expired, indicating a lapse in adherence to the facility's Food and Supply Storage policy, which mandates that all food be stored to maintain safety and sanitation. Additionally, the stove hood in the kitchen was observed to be greasy with lint buildup, which was not in compliance with the 2022 FDA Food Code. Despite the Culinary Assistant's claim that the hood was cleaned the previous week, it remained dirty, and there was no documentation to confirm regular cleaning. The CM acknowledged the oversight and was in the process of creating a new cleaning checklist, but admitted that the hood had not been cleaned that week and was unaware of how it was cleaned previously.
Failure to Update PASARR for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a Level I Preadmission Screening and Resident Review (PASARR) was updated to include a diagnosis of Post-Traumatic Stress Disorder (PTSD) for a resident. This deficiency was identified during a review of the PASARR records for a resident who had been admitted and readmitted to the facility with multiple diagnoses, including PTSD and other anxiety disorders. Despite these diagnoses being documented in the resident's care plan and quarterly MDS assessment, the PASARR forms from both 2022 and 2023 incorrectly indicated that the resident did not have any major mental health illnesses, including PTSD and anxiety disorders. The Social Services staff, responsible for overseeing PASARR reviews, confirmed during an interview that the resident had a diagnosis of PTSD and acknowledged the need to update the PASARR to reflect this information. The facility's policy requires that any resident with a newly evident or possible serious mental disorder be referred to the appropriate state-designated authority for review. The failure to update the PASARR could potentially result in the resident not receiving necessary specialized services for their mental health needs.
Failure to Provide Scheduled Bathing for Resident
Penalty
Summary
The facility failed to ensure that residents were provided with bathing consistent with their needs, specifically for one resident who was reviewed for activities of daily living. The facility's policy required staff to provide a shower, tub bath, or bed bath as scheduled and to document any refusals of care. However, Resident #6, who was cognitively intact and required substantial assistance for bathing, reported missing scheduled showers. The resident's bathing/shower record confirmed missed showers on several occasions. Interviews with staff revealed that showers were typically completed during the week, and if a shower was missed, a refusal sheet was supposed to be completed and signed, with the shower made up the next day. However, there was a lack of documentation for refusals or missed showers, which prevented the system from flagging these issues for follow-up. This lack of documentation and follow-up led to the deficiency in providing adequate personal hygiene care for the resident.
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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