Life Care Center Of Treasure Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Boise, Idaho.
- Location
- 502 North Kimball Place, Boise, Idaho 83704
- CMS Provider Number
- 135123
- Inspections on file
- 17
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Life Care Center Of Treasure Valley during CMS and state inspections, most recent first.
The facility did not accurately document PASRR Level II determinations for several residents with serious mental illnesses in their MDS assessments. Despite evaluations by mental health authorities confirming diagnoses such as bipolar disorder, depression, and anxiety, the required information was not reflected in section A1500 of the MDS for these residents, as confirmed by the MDS Coordinator and other staff.
A resident with dementia and a history of falls experienced a fall resulting in an elbow injury, and the facility did not notify the resident's representative of the incident. The DON confirmed that the family or POA was not informed after the injury.
A resident with dementia and a history of falls was transferred to the hospital following a fall that resulted in significant injuries. The facility did not send required discharge paperwork, including hospice information, with the resident during the transfer, as confirmed by the DON.
A resident with a documented diagnosis of schizophrenia per PASRR Level I and II evaluations did not have this diagnosis reflected in their medical record, MDS, or care plan. The facility's policy requires PASRR recommendations to be included in care planning, but this was not done, as confirmed by the DON.
A resident with chronic respiratory failure and hypoxia was observed receiving oxygen at a higher flow rate than what was documented in the physician's orders. Although the DON stated the physician had increased the oxygen flow, this change was not recorded in the resident's chart, resulting in care that did not align with the documented medical orders.
Licensed nurses failed to identify and document a significant skin growth on a resident with chronic heart failure and chronic kidney disease during multiple weekly skin assessments, despite facility policy requiring such assessments and timely reporting. The growth was only documented after several missed opportunities, and the DON confirmed it should have been caught and reported.
Three nurse aides worked beyond four months without obtaining CNA certification or enrollment in a state-approved training program. Personnel file reviews and staff interviews confirmed the aides had not met certification requirements, and the DON acknowledged the deficiency.
Controlled medications were not properly tracked or secured due to missing licensed nurse signatures on narcotic accountability records for two medication carts. Both the DON and an RN confirmed that two nurses should have signed the records when accepting or releasing the carts, but this was not consistently done, creating the potential for undetected misuse or diversion.
Surveyors found that a medication cart was left unlocked and unattended by a medication nurse, a controlled medication (lorazepam) was stored in a removable, non-affixed metal box in the medication refrigerator, and glucose test solutions were not labeled with an opened date as required. The DON and LPN confirmed these practices did not meet facility protocols.
Surveyors found eight cartons of expired lemon-flavored thickened water stored in the dry storage room. The Food Service Manager confirmed the items were expired and should have been discarded, which did not meet professional standards for food service safety.
A warming cabinet was found operating at 148 degrees, exceeding the manufacturer's recommended maximum of 140 degrees. The DON confirmed the equipment should not have been used at this temperature, indicating a failure to monitor and maintain safe operating conditions for patient care equipment.
Inaccurate MDS Documentation of PASRR Level II Determinations
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of five residents, specifically in relation to their Preadmission Screening and Resident Review (PASRR) Level II evaluations and determinations of serious mental illness. For each of these residents, documentation showed that they had been evaluated by a mental health authority and determined to have serious mental illnesses such as bipolar disorder, depression, anxiety, or PTSD. However, the corresponding MDS assessments did not indicate in section A1500 that these residents had been evaluated by PASRR Level II and determined to have a serious mental illness, despite clear evidence in their records and PASRR documentation. This deficiency was identified through record review and staff interviews, where the MDS Coordinator, along with the Social Services Director (SSD) and Director of Nursing (DON), confirmed that the MDS assessments for these residents should have been marked to reflect the PASRR Level II evaluations. The residents involved had complex medical and psychiatric histories, including conditions such as congestive heart failure, Guillain-Barre Syndrome, esophageal obstruction, and various mental health disorders. The failure to accurately document PASRR Level II determinations in the MDS assessments was consistent across multiple assessment dates for several residents.
Failure to Notify Resident Representative After Fall with Injury
Penalty
Summary
The facility failed to notify a resident's representative following a fall that resulted in injury. Review of the incident and accident log, as well as resident records and staff interviews, revealed that a resident with dementia and a history of falls was admitted to the facility and experienced a fall causing an elbow injury. Documentation showed that the resident's representative was not informed of the incident or the resulting injury. The Director of Nursing confirmed that the family or power of attorney was not notified after the fall with injury.
Failure to Provide Resident-Specific Discharge Paperwork During Hospital Transfer
Penalty
Summary
The facility failed to provide resident-specific discharge paperwork to the hospital during the transfer of a resident with multiple diagnoses, including dementia and a history of falls. Documentation review revealed that after the resident experienced a fall resulting in a nasal fracture, two black eyes, and a facial laceration, there was no evidence that required information, such as hospice documentation, was sent with the resident to the hospital. The Director of Nursing confirmed that the necessary resident information was not provided to the hospital at the time of transfer.
Failure to Incorporate PASRR Recommendations into Care Planning
Penalty
Summary
The facility failed to incorporate recommendations from the Pre-admission Screening and Resident Review (PASRR) Level II evaluation into the Minimum Data Set (MDS) assessment and care planning for one resident. Record review showed that the PASRR Level I and Level II evaluations documented a diagnosis of schizophrenia as a major mental illness (MMI) for the resident, but this diagnosis was not reflected in the resident's medical record, MDS assessments, or care plan. The facility's PASRR policy requires that recommendations from PASRR Level II determinations be included in the person-centered care plan and during transitions of care. Staff interview with the Director of Nursing (DON) confirmed that the PASRR Level I and II findings should have been identified and addressed, and that updated PASRR evaluations should have been requested. The failure to document and incorporate the resident's mental health diagnosis as identified by PASRR evaluations resulted in the resident's specialized mental health needs not being included in their care planning.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow current physician orders for oxygen administration for one resident with chronic respiratory failure and hypoxia. The resident had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula, with oxygen saturation checks every shift. The care plan also referenced following the current medical orders for oxygen settings. However, during observation, the resident's oxygen was found set at 4 liters per minute, which was not documented as an updated physician order in the resident's chart. The Director of Nursing confirmed that although the physician had reportedly increased the oxygen flow, this change was not documented as required.
Failure to Identify and Document Skin Alterations During Assessments
Penalty
Summary
Licensed nurses at the facility failed to perform skin assessments with the necessary knowledge, skills, and competencies, as required by facility policy. Specifically, for seven out of twenty-eight licensed nurses, there were deficiencies in identifying and documenting skin alterations during weekly assessments. In the case of one resident with chronic heart failure and chronic kidney disease, weekly skin assessments repeatedly documented no skin alterations, despite a physician's order for dermatology evaluation and a nurse's progress note later identifying a large growth on the resident's right cheek that had not been previously documented. The facility's policy required weekly skin assessments by nurses and prompt reporting of any changes by CNAs to the nursing staff. However, the growth on the resident's cheek was not identified or documented during multiple weekly assessments, and the physician was not notified in a timely manner. The Director of Nursing confirmed that the growth should have been detected, documented, and reported by the licensed nursing staff, but this did not occur.
Failure to Ensure Nurse Aide Certification or Enrollment in Training Program
Penalty
Summary
The facility failed to ensure that nurse aides employed for more than four months were either certified or enrolled in a state-approved nurse aide training and competency evaluation program. Review of staffing schedules, personnel files, and staff interviews revealed that three nurse aides had been working beyond the four-month period without obtaining their CNA certification or being enrolled in a CNA program. Specifically, one nurse aide hired in January had not obtained certification or enrollment by late June, another hired in August of the previous year was also uncertified by June, and a third hired in April remained uncertified as of June. The Director of Nursing confirmed that these nurse aides had not yet obtained their CNA certification as required.
Failure to Document Narcotic Accountability for Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by missing licensed nurse signatures on narcotic accountability records for two medication carts. During audits of the 300-Wing and A-Wing medication carts, it was observed that the narcotic accountability records spanning several weeks were missing six and five required nurse signatures, respectively. Both the Director of Nursing (DON) and a registered nurse confirmed that two nurses should have signed the narcotic accountability record when accepting or releasing the medication cart, but this was not consistently done. This lapse in documentation created the potential for undetected misuse or diversion of controlled medications for all residents receiving such medications.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage and labeling of drugs and biologicals. A medication cart on the 300-Wing was found unlocked and unattended by the medication nurse, which was confirmed by both the LPN and the DON as not following required procedures. Additionally, a Schedule IV controlled medication, lorazepam, was stored in a removable metal box inside the medication refrigerator that was not permanently affixed, contrary to requirements for controlled substances. Furthermore, a set of glucose test solutions was found without an opened date, and the DON confirmed that these should be dated when opened and discarded after three months per manufacturer recommendations, which was not done.
Expired Thickened Water Found in Dry Storage
Penalty
Summary
During an initial kitchen tour, surveyors observed that eight cartons of lemon-flavored thickened water with expiration dates of April 2025 were stored in the facility's dry storage room. The Food Service Manager, present during the observation, confirmed that the thickened water was expired and acknowledged that it should have been discarded. Facility policy requires that food items be stored, prepared, distributed, and served in accordance with professional standards for food service safety, which was not followed in this instance.
Failure to Monitor Warming Cabinet Temperature
Penalty
Summary
The facility failed to ensure that patient care equipment was properly monitored and maintained in a safe operating condition, as evidenced by one of three warming cabinets being observed with a temperature reading of 148 degrees, which exceeds the manufacturer's recommended maximum of 140 degrees. The Accucold PureTherm Warming Cabinet user manual specifically warns that the appliance should not exceed 140 degrees to reduce the risk of fire, electric shock, or injury. During an interview, the DON confirmed that the warming cabinet should not have been used at this temperature, in accordance with the manufacturer's guidelines. This deficiency was identified through observation, interview, and review of the user manual, and it was noted that the failure to monitor and maintain the equipment could place residents at risk for adverse outcomes.
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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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