Meridian Meadows Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Meridian, Idaho.
- Location
- 2656 E Magic View Drive, Meridian, Idaho 83642
- CMS Provider Number
- 135147
- Inspections on file
- 18
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Meridian Meadows Transitional Care during CMS and state inspections, most recent first.
The facility failed to provide sufficient nursing staff, especially on weekends and during evening/night shifts, resulting in missed and delayed care. Confirmed grievances included a resident not receiving overnight incontinence care and being found wet in the morning, a resident’s catheter bag filling to 2,000 mL before being emptied, long call‑light response times, rushed CNA care, and delays in getting residents out of bed when two‑person assistance was needed. Staffing schedules showed consistently lower staffing hours on weekends despite a stable census, and residents who usually ate in an independent dining room were moved to an assisted dining room on weekends due to lack of supervision, corroborated by a posted weekend closure notice. Residents, family members, and staff all reported that low staffing on weekends and certain night‑shift hours led to longer waits for assistance and unavailability of staff when needed.
A resident with palliative care needs, CHF, and acute kidney disease had new PRN lorazepam oral concentrate orders for anxiety and terminal agitation entered without documented informed consent. Record review showed no evidence that the resident or representative was informed of the risks and benefits of lorazepam or that consent was obtained before the medication was added as an active order. A CRN confirmed that no signed consent documenting understanding of the lorazepam treatment risks and benefits was present, resulting in a deficiency related to informing residents about their care and treatments.
A resident with type 1 DM, partial left-sided paralysis, and ataxia was observed keeping and taking glucose tablets independently whenever they felt their blood sugar was low. Facility policy required an IDT assessment, documentation on a Medication Self-Administration Safety Screen, physician orders, and care plan entries before any self-administration of medications, with periodic reassessments. The only assessment on file showed the resident required supervision for medications and did not list glucose tablets as approved for independent use, and no reassessments had been completed for several years. A physician note documented the resident was taking glucose tablets when blood sugars were in the 60s, yet there were no corresponding IDT assessments, orders, or care plan documentation authorizing this self-administration.
A resident with leukemia, dementia, anxiety, and depression was observed in bed with a transfer pole on one side and a 1/4 bed rail on the other, which the facility’s Restraint Free Environment policy defined as a physical restraint. Facility policy required a comprehensive assessment and alignment with the care plan for assistive device use, but the resident’s record contained no restraint assessment or informed consent for the 1/4 bed rail. A CRN confirmed that no restraint assessments had been completed for this device, and the report notes this practice had the potential for physical and psychosocial harm if the resident were injured, trapped, or felt unnecessarily restrained.
A resident with leukemia, dementia, anxiety, and depression was observed in bed using a transfer pole and a 1/4 bed rail, but these assistive devices were not documented in the resident’s comprehensive care plan. Record review confirmed the absence of any care plan addressing the transfer pole or 1/4 bed rail, and the CRN acknowledged that a care plan for these devices should have been in place.
The facility failed to meet professional standards of practice when staff did not clarify physician orders for oral medications for a resident who was documented as NPO with dysphagia, esophageal disease, and a gastrostomy. Despite the care plan indicating nothing by mouth, orders for prednisone and magnesium glycinate specified administration by mouth, and nursing staff did not verify or correct these routes before implementation, as required by professional nursing standards.
A resident with diabetes and muscle wasting, care planned as needing partial to moderate assistance with ADLs, was observed on multiple occasions with long, thick, yellow, and dirty fingernails, despite a facility nail care policy requiring assessment and routine cleaning/inspection of nails and specifying that licensed nurses provide nail care for diabetic residents. The resident initially reported not knowing he could request nail trimming and later stated he had asked for his nails to be cut. An LPN acknowledged the nails needed care and indicated nurses perform nail care but relied on a physician order to determine frequency; record review by the LPN and ADON confirmed there was no physician order for diabetic nail care in the resident’s chart, contrary to the ADON’s expectation that such an order should have been present from admission.
A resident with type 1 DM, partial left-side paralysis, and ataxia after a stroke was observed with glucose tablets on his desk and reported taking them whenever he felt his blood sugar going low. A physician note referenced the resident taking glucose tablets when blood sugars were in the 60s, but a review of current physician orders showed no active order for glucose tablets, which was confirmed by the CRN and DON.
A resident receiving palliative care with multiple comorbidities, including CHF and acute kidney disease, had physician orders for specific left heel wound care that were not followed when an RN omitted the ordered normal-saline–moistened gauze and instead applied only a clean dry dressing. The same resident’s wound vac was discontinued per provider order, and prior wound care orders were stopped, but no new wound treatment was implemented for several days, with the new left heel dressing regimen not started until four days later. The ADON reported difficulty communicating with the hospice agency to clarify wound care orders and acknowledged not seeking a temporary order from the facility’s medical director.
A resident with chronic respiratory failure with hypoxia and CHF had a physician order for oxygen at 0–2 LPM via nasal cannula as needed to maintain SpO2 ≥ 88%, with pulse oximetry checks each shift. Documentation showed SpO2 readings of 90–95% and that the resident was occasionally given 3 LPM of oxygen. Surveyors observed the resident with an oxygen concentrator running at 2.5 LPM while not wearing the nasal cannula, and later with oxygen in use while the concentrator was set at 3 LPM. The DON reviewed the record and confirmed the order was for 0–2 LPM and that the concentrator should have been set within that range, demonstrating that oxygen therapy was not consistently provided per the physician’s order.
The facility did not ensure that an RN was on duty for at least 8 consecutive hours per day as required. Review of nursing schedules over a three-week period showed multiple days without 8 consecutive hours of RN coverage. During an interview, the staffing coordinator reported being unaware that RN coverage hours had to be consecutive, resulting in noncompliance with RN staffing requirements that could affect all residents needing higher-level nursing assessment or intervention.
Surveyors found that the facility did not prevent duplicate medication orders or ensure monitoring for medication side effects for two residents. One resident on palliative care with CHF and acute kidney disease had two PRN orders for lorazepam oral concentrate written for the same dose and frequency, one for anxiety and one for terminal agitation, with no documented monitoring for sedation, respiratory status, cognitive changes, or other adverse effects despite FDA guidance. Another resident with diabetes, CHF, and mild cognitive impairment had two overlapping PRN orders for bisacodyl suppositories, which the CRN acknowledged were in error.
The facility failed to ensure medications were securely stored and free of expiration. A resident with dysphagia and a gastrostomy, who required assistance to store medications securely, was observed with medication cups containing white powder residue and multiple Jevity containers on the bedside nightstand. The resident reported that nurses sometimes left medications on the nightstand and that he occasionally obtained his own medications from the hallway and kept them there until use, without being instructed to store them elsewhere. Additionally, surveyors found multiple expired Bacitracin ointment packets in a medication cart drawer; an LPN confirmed they were expired, and the DON acknowledged there was no set schedule for checking carts for expired medications, relying instead on nurses to notice during med pass.
A resident receiving hospice services, with diagnoses including leukemia, dementia, anxiety, and depression, did not have a Hospice Election form maintained in the facility’s records as required. SOM Appendix PP and the facility’s hospice services agreement required a designated interdisciplinary team member to obtain and keep specific hospice documents, including the hospice election form, for each hospice patient. Record review showed the form was missing, and the CRN acknowledged it was not on file and stated she did not believe it needed to be included in the hospice documentation kept at the facility.
The facility failed to maintain an effective QAPI performance improvement plan (PIP) for systemic staffing concerns, despite its QAPI plan requiring a data‑driven process to identify and address gaps in care systems and ensure adequate staffing. Facility staffing data showed low weekend staffing, and resident council minutes over several months documented repeated complaints about weekend short staffing, delayed medication administration, missed snacks, and closure of the independent dining hall when staffing was insufficient. A resident reported that residents stopped complaining when the facility did not respond to their concerns. The Administrator stated a staffing PIP had been opened and then closed once residents stopped complaining, and acknowledged that independent dining was closed when there were not enough staff, while also indicating no specific staffing system gaps or metrics were identified before closing the PIP.
Staff failed to follow infection prevention and control practices during medication administration and wound care. An LPN administered medications to two residents without performing hand hygiene upon entering their rooms, only cleaning hands after leaving, despite facility expectations for hand hygiene on room entry and exit. A resident with chronic wounds, MDRO risk, and orders for Enhanced Barrier Precautions received wound care from an RN who did not wear a gown, contaminated gloves by handling the bed controls and bed surfaces, placed wound-care supplies directly on the bed, used unsanitized scissors taken from a pocket, and reapplied gloves without performing hand hygiene.
Surveyors found that the facility did not follow its own immunization policy requiring education and documentation regarding influenza and pneumococcal vaccines. Three residents with significant medical conditions, including muscle wasting, osteonecrosis, cancer, CAD, osteoarthritis, protein-calorie malnutrition, and dementia, had no documentation that they or their representatives received CDC Vaccine Information Statements, supplemental explanations, or an opportunity to accept or decline the vaccines based on education about risks and benefits. A CRN confirmed that there were no records of vaccine education or consent for these residents in their medical charts.
Surveyors determined that the facility did not follow its COVID-19 vaccination policy for two residents with multiple comorbidities, including muscle wasting, osteonecrosis, osteoarthritis, protein-calorie malnutrition, and dementia. Record review showed no documentation that these residents were educated on the risks, benefits, and potential side effects of the COVID-19 vaccine, nor that they were offered the opportunity to accept or decline vaccination, and the CRN confirmed there were no such records on file.
Three residents experienced neglect when a staff member performed a mechanical lift transfer alone, resulting in a fall and fracture for a resident with hemiplegia, and two other residents with significant medical conditions were not provided timely incontinence care during an overnight shift, as confirmed by grievance review and camera footage.
The facility did not report allegations of neglect to the State Agency within the required timeframe for two residents. One resident with significant neurological and physical impairments suffered a fall and fracture during a transfer, and the incident was reported late. Another resident's neglect allegation was not reported separately as required. The administrator confirmed these reporting failures.
A medication cart was found unlocked and unattended in the facility, creating a potential risk for unauthorized access to medications. An RN acknowledged forgetting to lock the cart, and the DON confirmed the failure to follow protocol.
The facility failed to ensure CMAs had the necessary competencies for insulin administration. All four CMAs reviewed lacked documented competency in insulin administration, despite facility policies prohibiting CMAs from calculating dosages and administering medications via parenteral routes. One CMA was observed calculating and administering insulin injections to two residents without proper training. The Administrator confirmed the absence of specific competency training for insulin administration.
Insufficient Weekend and Night Staffing Leading to Missed and Delayed Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff were available each day to meet resident needs according to their plans of care, particularly on weekends and during evening/night shifts. Review of grievances over a six‑month period documented confirmed incidents of missed or delayed care, including a resident not receiving incontinence care between 6:00 PM and 6:00 AM and being found wet the next morning, and another resident reporting that his catheter bag was allowed to fill to 2,000 mL before a CNA arrived to empty it. Additional grievances confirmed long call‑light wait times, rushed care by CNAs, and delays in getting residents out of bed when two‑person assistance was required. A three‑week staffing schedule review showed consistently lower total staffing hours on weekends compared to weekdays, while the census remained relatively stable. Residents and family members reported that staffing was low on weekends, that staff were not available when needed throughout the day, and that rooms were often unorganized and residents not ready for scheduled outings. Residents who normally ate in the independent dining room reported being required to eat in the assisted dining room on weekends due to lack of supervision, and this was corroborated by a kitchen whiteboard stating the independent dining room was closed on Saturdays and Sundays. During interviews, night‑shift licensed nurses reported that each wing had one CNA and one nurse on duty and acknowledged that between 4:00 AM and 6:00 AM residents might wait longer for assistance as more residents began calling for help. A CNA stated the facility was often low‑staffed on weekends and not always appropriately staffed from 6:00 PM to 10:00 PM, resulting in longer wait times to meet resident needs. The staffing coordinator confirmed that staffing was based on census and that the facility did not have many weekend staff. Resident council feedback further documented repeated concerns about low weekend staffing, closure of the independent dining room on weekends, and staff observed sitting at the nurses’ station charting while call lights remained unanswered.
Failure to Obtain and Document Informed Consent for Lorazepam Use
Penalty
Summary
Surveyors found that the facility failed to ensure a resident was informed in advance of care and treatment, including the risks and benefits, before initiating a new medication. One resident with multiple diagnoses, including palliative care encounter, congestive heart failure, and acute kidney disease, had physician orders for lorazepam oral concentrate 2 mg/mL, to be given 0.5 mL by mouth every 8 hours as needed for anxiety and every 8 hours as needed for terminal agitation for 180 days. Record review showed no documentation that the resident or the resident’s representative had been informed of the risks and benefits of lorazepam or had provided consent prior to lorazepam being added as an active order. In an interview, the clinical resource nurse confirmed that neither the resident nor the representative had signed a consent documenting understanding of the risks and benefits of the lorazepam treatment. This failure to obtain and document informed consent for lorazepam use for this resident, whose record was reviewed for informed consent, was identified as a deficiency related to ensuring residents are fully informed and understand their health status, care, and treatments.
Failure to Assess and Authorize Resident Self-Administration of Glucose Tablets
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy for resident self-administration of medications, specifically glucose tablets. The facility’s policy required that residents may only self-administer medications after an IDT assessment, documented on a Medication Self-Administration Safety Screen, with corresponding care plan documentation and physician orders. The policy also required periodic reassessment at least quarterly, annually, with significant change, or after a medication error. For the resident in question, the Medication Self-Administration Safety Screen on file indicated the resident required supervision to take medications and did not list glucose tablets as a medication that could be stored and taken independently. No updated self-administration assessments had been completed since 2023. The resident, who had type 1 DM, partial left-sided paralysis, and ataxia following a stroke, was observed with a bottle of glucose tablets on his desk and stated he took them whenever he felt his blood sugar going low. A physician progress note documented that the physician had seen the resident for low blood sugars and referenced that the resident was taking glucose tablets whenever his blood sugar was in the 60s. Despite this, there were no IDT assessments, physician orders, or care plan documentation authorizing or addressing self-administration of glucose tablets. The CRN and DON confirmed there were no Medication Self-Administration Safety Screen assessments related to the resident’s ability to self-administer glucose tablets, resulting in unmonitored treatment of hypoglycemia and unsafe medication practices.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure a resident was free from the use of physical restraints unless needed for medical treatment by not assessing the safety of bed rail use or obtaining informed consent prior to use. Facility policy on Use of Assistive Devices, dated 12/29/25, required that assistive devices be used based on a comprehensive assessment and in accordance with the resident’s plan of care, and the Restraint Free Environment policy, reviewed 12/31/25, defined bed rails as a type of physical restraint. Resident #18, admitted with diagnoses including leukemia, dementia, anxiety, and depression, was observed in bed with a transfer pole on the left side and a 1/4 bed rail on the right side of the bed. Review of the resident’s record showed no documentation of a restraint assessment or consent form for the 1/4 bed rail, and on 4/3/26 the CRN confirmed that no restraint assessments had been completed for this bed rail. The report states this deficient practice had the potential for physical and psychosocial harm if the resident were injured, trapped, or felt she was being restrained unnecessarily. This deficiency was cross-referenced to F656.
Care Plan Omission for Resident Assistive Bed Devices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a resident’s comprehensive, person-centered care plan accurately reflected the use of assistive devices. One resident, admitted with multiple diagnoses including leukemia, dementia, anxiety, and depression, was observed in bed with a transfer pole on the left side of the bed and a 1/4 bed rail on the right side. Review of the resident’s care plan showed no documentation of the transfer pole or the 1/4 bed rail. In a subsequent interview, the CRN confirmed that there was no care plan implemented related to the 1/4 bed rail and transfer pole and acknowledged that there should have been. This lack of documentation and care planning for the assistive devices constituted the cited failure and had the potential to result in unmet care needs and increased risk to resident safety, as noted in the survey findings.
Failure to Clarify Oral Medication Orders for NPO Resident
Penalty
Summary
The facility failed to ensure physician orders met professional standards of quality by not clarifying medication routes for a resident who was NPO and had swallowing difficulties. Record review showed that a resident readmitted with dysphagia, disease of the esophagus, and a gastrostomy had a nutritional care plan, revised 4/3/26, documenting the resident was NPO (nothing by mouth). Despite this, physician orders directed that prednisone 5 mg be given by mouth daily for renal insufficiency and magnesium glycinate 100 mg be given by mouth at bedtime for insomnia. According to the National Council of State Boards of Nursing, nurses are professionally obligated to clarify and verify any order that is incomplete, inaccurate, unclear, or contraindicated before implementing it. On 4/2/26 at 11:32 AM, the DON and CRN confirmed that the resident does not take anything by mouth and acknowledged that the provider’s orders should have been clarified prior to implementation. This failure created the potential for harm if the resident were to receive oral medications despite having difficulty swallowing.
Failure to Provide Required Fingernail Care for Dependent Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide fingernail care to a resident who was dependent on staff for assistance with activities of daily living (ADLs), as required by facility policy. The facility’s Nail Care policy, implemented in December 2024 and revised in December 2025, required assessment of residents’ nails on admission and readmission, ongoing routine cleaning and inspection of nails during ADL care, and that only licensed nurses trim or file fingernails of residents with diabetes. The resident in question was admitted with multiple diagnoses including muscle wasting/atrophy and diabetes and had an ADL care plan indicating a need for partial to moderate assistance with ADLs. Despite these needs and the policy requirements, there was no documented physician order for diabetic nail care in the resident’s record. On multiple observations over several days, the resident’s fingernails were noted to be long, thick, yellow, and dirty, and the resident stated he preferred shorter nails. Initially, the resident reported he was unaware he could ask staff to cut his fingernails, and later stated he had asked staff to cut them. An LPN, when observing the resident’s nails with the surveyor, acknowledged that the thumbnails were long, yellow, dirty, and needed to be soaked and cut, and stated that nurses perform nail care but would need to check the resident’s order to determine how often it should be done. Upon review of the record, the LPN and ADON confirmed there was no order for diabetic nail care for this resident, despite the ADON’s statement that such an order was required and should have been present from admission. This sequence of events shows that the resident did not receive nail care services in accordance with facility policy and his assessed needs.
Lack of Physician Order for Self-Administered Glucose Tablets
Penalty
Summary
The facility failed to ensure a resident had an active physician’s order for a medication the resident was self-administering. A resident who had been readmitted with multiple diagnoses, including type 1 diabetes, partial paralysis of the left side, and ataxia after a stroke, was observed with a bottle of glucose tablets on his desk and stated he took the tablets whenever he felt his blood sugar going low. A physician’s note documented that the physician had seen the resident for low blood sugars and referenced that the resident was taking glucose tablets whenever his blood sugar was in the 60s. However, a review of physician’s orders for the relevant period showed no order for glucose tablets, and the CRN and DON confirmed there were no current physician orders related to glucose tablets. This deficient practice created the potential for adverse outcomes when the resident self-administered a medication not ordered by a physician.
Failure to Follow Wound Care Orders and Delay in Implementing New Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care according to physician orders and acceptable standards of practice for a resident with multiple diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease. The resident had a physician order directing staff to cleanse the left heel with wound cleanser, apply normal-saline–moistened gauze, and cover with a dry dressing every shift. During an observation of wound care, an RN removed the soiled dressing, cleansed the wound with wound cleanser and gauze, patted the wound dry, applied skin prep, and applied a clean dry dressing, but did not apply the ordered normal-saline–moistened gauze. The RN later confirmed she performed the wrong treatment, and the ADON confirmed the wound care provided was not consistent with the physician’s order. The deficiency also includes a lapse in implementing new wound treatment orders after discontinuation of a wound vac on the resident’s left heel. The care plan documented the resident was at risk for skin impairment and pressure ulcers, and a physician order directed discontinuation of the wound vac and application of wet-to-dry dressing until further orders were received. A Nursing Progress Note documented discontinuation of prior wound care orders, including those related to the wound vac and associated procedures, but did not document that a new wound treatment was implemented at that time. The Treatment Administration Record showed that a new wound care order for the left heel—cleanse with wound cleanser, apply normal-saline–moistened gauze, and cover with a dry dressing every shift—was not implemented until four days after the wound vac was discontinued. The ADON stated the facility had difficulty communicating with the hospice agency to clarify the wound care order and acknowledged he did not think to obtain a temporary order from the facility’s medical director.
Failure to Administer Oxygen Therapy per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy according to physician orders for a resident receiving respiratory care. Facility policy required that oxygen be administered under a physician’s order except in an emergency. The resident was admitted with chronic respiratory failure with hypoxia and congestive heart failure, and the care plan documented that the resident used oxygen per physician order. A physician order dated 3/26/26 specified oxygen at 0–2 LPM via nasal cannula as needed to maintain oxygen saturation at or above 88%, with oxygen saturation checks every shift. The March and April 2026 MAR/TAR showed oxygen saturations ranging from 90–95% and documented that the resident was occasionally receiving 3 LPM of oxygen as needed. On 3/30/26 at 1:00 PM, the resident was observed in bed with the head of the bed elevated, the oxygen concentrator running and set at 2.5 LPM, but the resident was not wearing the nasal cannula and stated he used oxygen at night and when napping. On 4/3/26 at 9:26 AM, the resident was observed lying in bed with oxygen on via nasal cannula, and at 10:43 AM the same day, the DON observed the resident still in bed with oxygen via nasal cannula and identified the concentrator setting as 3 LPM. When the DON reviewed the record at 10:45 AM, she confirmed the physician order was for 0–2 LPM via nasal cannula and acknowledged that the concentrator should have been set between 0–2 LPM, indicating that the resident had been receiving oxygen at a flow rate above the ordered range.
Failure to Provide Required Consecutive RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered professional nurse (RN) for at least 8 consecutive hours per day as required. Review of the three-week nursing schedule dated 3/8/26 through 3/28/26 showed that on 3/14/26, 3/15/26, and 3/28/26, the facility did not provide 8 consecutive hours of RN coverage. This deficiency was identified through record review of the posted nursing schedules and confirmed during an interview on 4/2/26 at 9:47 AM, when the Staffing Coordinator stated she was unaware that the required RN hours must be consecutive. The report notes that this failure had the potential to affect all residents in the facility who may require a higher level of nursing assessment or intervention, but does not provide specific resident examples or clinical details.
Failure to Prevent Duplicate Medication Orders and Monitor PRN Sedative Side Effects
Penalty
Summary
The facility failed to ensure residents were free from unnecessary drugs by allowing duplicate medication orders and not implementing monitoring for medication side effects. For one resident with diagnoses including palliative care encounter, congestive heart failure, and acute kidney disease, the medical record contained two separate PRN orders for lorazepam oral concentrate 2 mg/mL, each directing administration of 0.5 mL by mouth every 8 hours as needed, one for anxiety and one for terminal agitation. Despite FDA prescribing information indicating the need to monitor for adverse effects such as respiratory depression, cognitive impairment, paradoxical reactions, and dependence or withdrawal symptoms, the resident’s care plan and physician orders did not include any documented monitoring parameters for lorazepam use, including monitoring for sedation, respiratory status, or cognitive changes. The DON confirmed that the record lacked monitoring interventions for lorazepam. Another resident, admitted with multiple diagnoses including diabetes, congestive heart failure, and mild cognitive impairment, had duplicate PRN orders for bisacodyl suppositories. One order directed insertion of a 10 mg bisacodyl suppository rectally as needed for constipation if there were no results within 24 hours from a bisacodyl tablet, and a second order directed insertion of a 10 mg bisacodyl rectal suppository every 24 hours as needed for no bowel movement after the prior bowel protocol regimen. On interview, the CRN acknowledged that the resident had two bisacodyl suppository orders in error. These findings showed the facility did not prevent duplicate medication orders or ensure appropriate monitoring for medication side effects for the residents reviewed.
Expired and Unsecured Medications on Unit and in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to follow its Medication Storage policy requiring all drugs and biologicals to be stored in locked compartments. One resident, readmitted with dysphagia, disease of the esophagus, and a gastrostomy, had a care plan indicating supervision for self-administration of nutrition and an assessment stating he required assistance to store medications in a secure location. Surveyors observed two cups with white powdered residue, including one labeled for a specific administration time, on his nightstand along with six containers of Jevity nutritional supplement. The resident reported that nurses sometimes brought his medications to his room and left them on the nightstand for him to take when he was ready, and that he sometimes went into the hallway early in the morning to obtain his medications for the day, which he then kept on his nightstand. He also stated he self-administered his nutritional supplements and that staff provided him with a case of Jevity to self-administer. The CRN later stated she had not been informed that medications were being left on this resident’s bedside table. The deficiency also includes the presence of expired medications on a medication cart. During inspection of a medication cart on one wing, surveyors found 19 packets of Bacitracin ointment in a clear plastic cup in the bottom drawer, all bearing an expiration date that had passed. When questioned, an LPN confirmed the Bacitracin ointment was expired and stated that expired medications should be disposed of. When asked about the process for checking medication carts for expired medications, the DON reported there was no designated schedule for such checks and indicated that nurses were expected to watch for expired medications during medication pass.
Failure to Maintain Required Hospice Election Documentation
Penalty
Summary
The facility failed to maintain complete hospice records for a resident receiving hospice services, specifically by not having a Hospice Election form on file. SOM Appendix PP requires that when a LTC facility arranges hospice care under a written agreement, a designated interdisciplinary team member with a clinical background must obtain specific hospice documentation, including the hospice election form, physician certifications, plan of care, and related information. The facility’s Hospice Services Facility Agreement, dated 12/2/25, also documented that the facility would arrange hospice services and that the designated facility member would obtain hospice coordination of care information and physician certification, including but not limited to the Hospice Election Form. Resident #18 was admitted with multiple diagnoses including leukemia, dementia, anxiety, and depression and was receiving hospice services. A review of this resident’s medical record and hospice documentation showed that the Hospice Election form was not included in the records maintained at the facility. On 4/2/26 at 11:46 AM, the Clinical Registered Nurse (CRN) confirmed that Resident #18’s Hospice Election form was not on record at the facility prior to requesting a copy from the hospice company that morning. On 4/6/26 at 2:15 PM, the CRN further clarified via email that she did not believe the election form needed to be included in the hospice documentation kept at the facility level.
Failure to Maintain Effective QAPI PIP for Systemic Staffing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to implement and sustain a performance improvement plan (PIP) for a systemic staffing concern, despite its QAPI Facility Plan requiring a data‑driven, organized, facility‑wide program to identify and address gaps in systems and ensure adequate staffing. The facility’s own PBJ staffing data for the first quarter of 2026 documented concerns with low weekend staffing. Resident council minutes showed that residents repeatedly reported staffing problems over several months: in November 2025, residents reported the facility was often short staffed on weekends; in December 2025, they reported weekend staffing issues that delayed medication administration until 9:30–10:00 AM, with staffing concerns noted as in progress; and in January 2026, residents were told new staff had been trained and were working regularly, and residents stated short staffing had significantly improved, with the concern noted as resolved. A resident later reported that residents stopped complaining about staffing around December 2025 when the facility had failed to respond to their earlier concerns. Additional findings showed that residents continued to experience staffing‑related issues after the staffing PIP was closed. In March 2026, resident council minutes documented that residents were concerned about not receiving snacks when the facility was short staffed. During a group interview, residents voiced concerns about low weekend staffing and poor staff response time during the night shift, and independent diners reported they could not eat in the independent dining hall when there were not enough staff on weekends. The Administrator confirmed that independent dining had to be closed when staffing was insufficient so residents could dine in the dependent dining hall with available staff. The Administrator reported that a staffing PIP opened in October 2025 was closed in December 2025 when residents stopped complaining, and he did not identify any specific gaps in staffing systems or metrics used to evaluate staffing effectiveness before closing the concern, despite ongoing documented staffing‑related issues.
Failure to Maintain Hand Hygiene and Enhanced Barrier Precautions During Med Pass and Wound Care
Penalty
Summary
The deficiency involves failures in infection prevention and control practices during medication administration and wound care. During a morning medication pass, an LPN prepared and administered medications to two residents without performing hand hygiene upon entering their rooms, despite later stating that hand hygiene is performed before entering and exiting resident rooms. For one resident, the LPN prepared medications, poured water, locked the cart, entered the room, and handed the resident a medication cup and water without performing hand hygiene until exiting the room. For another resident, the LPN similarly prepared medications, entered the room, and administered medications with a spoon and applesauce without performing hand hygiene upon entry, only doing so upon exit. The DON later confirmed that staff should perform hand hygiene upon entering residents' rooms. The deficiency also includes improper infection control practices during wound care for a resident with multiple diagnoses, including palliative care encounter, congestive heart failure, acute kidney disease, chronic wounds, and a history of MDRO to the left heel. The resident’s care plan identified risk for MDRO and physician orders required Enhanced Barrier Precautions every shift, with posted signage directing hand sanitizing before entering and after leaving the room and use of gloves and gowns for high-contact care, including wound care. During observed wound care, an RN entered the room, performed hand hygiene, and applied gloves but did not wear a gown as required. The RN contaminated gloves by adjusting the bed with the same gloves used for wound care, placed the resident’s foot and wound-care supplies on the bed, used scissors taken from a pocket without sanitizing them, touched the bed footboard with gloved hands after donning clean gloves, and reapplied gloves at the end of the procedure without performing hand hygiene. The RN later confirmed that proper PPE, instrument sanitization, and hand hygiene should have been used.
Failure to Educate Residents on Risks and Benefits of Flu and Pneumonia Vaccines
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to educate residents on the risks and benefits of pneumococcal and influenza immunizations as required by facility policy and SOM Appendix PP. The facility’s written policy, last reviewed on 12/22/25, stated that prior to administration of influenza or pneumococcal vaccines, the resident or legal representative would be provided the current CDC Vaccine Information Statement, supplemented with visual or oral explanations, and that a signed consent form and documentation of education and acceptance/refusal would be maintained in the medical record. Record review and staff interview showed that this process was not followed for several residents. For one resident with muscle wasting and osteonecrosis who was readmitted to the facility, the medical record did not contain documentation that he was offered the opportunity to accept or decline the pneumococcal vaccine based on education about risks and benefits, and the Clinical RN confirmed there were no records of such education. For another resident with cancer and coronary artery disease, the record likewise lacked documentation of education or an opportunity to accept or decline the pneumococcal vaccine, which the Clinical RN also confirmed. A third resident with osteoarthritis, protein-calorie malnutrition, and dementia, and/or her representative, had no documented evidence in the record that she was offered the opportunity to accept or decline influenza and pneumococcal vaccines based on staff education regarding risks and benefits, and the Clinical RN again stated there were no records of this education. This lack of documented education and consent occurred for 3 of 5 residents reviewed for current immunizations.
Failure to Document COVID-19 Vaccine Education and Offer for Residents
Penalty
Summary
Surveyors found that the facility failed to follow its COVID-19 Vaccination policy requiring documentation in the medical record of education on risks, benefits, and potential side effects of the COVID-19 vaccine, as well as documentation of each dose administered or the reason for non-receipt (medical contraindication or refusal). Record review for two residents showed no documentation that they were offered the opportunity to accept or decline the COVID-19 vaccine, nor that any vaccine-related education was provided. One resident was readmitted with multiple diagnoses including muscle wasting and osteonecrosis, and another was admitted with multiple diagnoses including osteoarthritis, protein-calorie malnutrition, and dementia, yet neither record contained any entries regarding COVID-19 vaccine education or offer. In staff interview, the Clinical Resource Nurse confirmed there were no records on file related to educating or offering the COVID-19 vaccine for these residents. This deficient practice created the potential for harm when residents were not offered education related to the risks and benefits of receiving the COVID-19 vaccination.
Failure to Prevent Resident Neglect During Transfers and Incontinence Care
Penalty
Summary
The facility failed to protect residents from neglect, as evidenced by three separate incidents involving residents with significant medical needs. One resident, who had a history of cerebral infarction, hemiplegia, and major depressive disorder, required two-person transfers using a mechanical lift according to her care plan. Despite this, a staff member attempted to transfer her alone, resulting in the sling detaching and the resident falling, which caused a comminuted fracture and significant pain. Another resident, with non-dominant sided hemiplegia and dysphagia following a stroke, filed a grievance stating that incontinence care was not provided when a specific CNA was on duty. Review of camera footage confirmed that the CNA only attended to the resident once during an overnight shift, substantiating the resident's claim of neglect. The resident was subsequently assessed, and no evidence of physical or psychosocial harm was found following the incident. A third resident, diagnosed with severe vascular dementia, chronic kidney disease, and diabetes, was found soiled at the end of a shift, indicating that incontinence care had not been provided. Facility investigation and camera footage revealed that the same CNA had extended absences from the floor and provided minimal care to residents during the shift. The investigation confirmed that the CNA failed to perform required care for this resident, though no physical or psychosocial harm was identified upon assessment.
Failure to Timely Report Allegations of Neglect
Penalty
Summary
The facility failed to ensure timely reporting of allegations of neglect to the State Agency for two residents. For one resident with a history of cerebral infarction, hemiplegia, and major depressive disorder, an incident occurred during a transfer with a full mechanical lift when the sling detached, resulting in a fall and a comminuted fracture of the left arm. The incident was not reported to the State Agency until after the injury was confirmed by X-ray, which was outside the regulated reporting timeframe. The investigation later confirmed neglect due to a staff member deviating from the resident's plan of care by attempting the transfer alone. In another case, a resident with hemiplegia and dysphagia following a stroke made an allegation of neglect, which was documented in the facility's grievance log. However, this allegation was not reported to the State Agency as a separate incident and was instead included in another investigation without associating the resident's name. The administrator acknowledged that the allegation should have been reported when it was received.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the security and inaccessibility of medications to unauthorized staff and residents, as observed with one of the three medication carts. On January 6, 2025, at 10:25 AM, a medication cart located on the 200 hall was found unlocked and unattended by staff. RN #1, who was responsible for the cart, returned at 10:33 AM and acknowledged that she should have locked the cart when she stepped away. The Director of Nursing confirmed that RN #1 did not adhere to the facility's protocol for securing the medication cart before leaving it unattended. This oversight created a potential risk for harm if unauthorized individuals accessed the medications.
Inadequate CMA Competency in Insulin Administration
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) possessed the necessary competencies for medication administration, specifically for insulin. This deficiency was identified for all four CMAs reviewed. The facility's policies stated that CMAs are prohibited from administering medications via parenteral routes and from calculating medication dosages. However, CMA #1 was observed calculating insulin dosages and administering subcutaneous insulin injections to two residents, despite the facility's skills check-off sheets lacking documentation of competency in insulin administration. The facility's Administrator confirmed the absence of specific CMA competency training for insulin dosage calculation and subcutaneous injection.
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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