Payette Healthcare Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Payette, Idaho.
- Location
- 1019 Third Avenue South, Payette, Idaho 83661
- CMS Provider Number
- 135015
- Inspections on file
- 17
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Payette Healthcare Of Cascadia during CMS and state inspections, most recent first.
The facility failed to maintain a safe and clean environment, as evidenced by a resident's difficulty maneuvering a power wheelchair due to tangled privacy curtains, and another resident's unresolved maintenance issue with a bathroom fan. Observations revealed unsafe conditions, such as a hole in the dining room floor and unsanitary shower rooms with dusty vents and a stained shower chair. Despite having a maintenance system, these issues were not addressed, indicating lapses in communication and maintenance procedures.
The facility failed to adhere to infection control practices, impacting several residents. Staff did not follow hand hygiene protocols, with CNAs handling dirty items and assisting residents without washing hands. Equipment cleaning was neglected, as a Hoyer lift was not cleaned after use. Additionally, a resident on enhanced barrier precautions did not receive proper care, as an RN administered G-tube feeding without PPE, despite clear signage. These actions placed residents at risk for cross-contamination and infection.
A facility failed to assess a resident for the ability to self-administer medications, as required by their policy. The resident, with multiple diagnoses including incomplete quadriplegia and diabetes, was given calcium carbonate tablets to use as needed without a documented assessment. The DON confirmed the assessment was not completed.
A facility failed to ensure proper handling and storage of feeding formula for a resident with a feeding tube. The resident, with a history of stroke and dysphagia, had a physician's order for Jevity 1.5. Opened bottles of the formula were left at the bedside without proper labeling or refrigeration, against facility policy. A nurse admitted to this practice, and the Clinical Resource Nurse confirmed the formula should have been refrigerated.
A facility failed to provide continuous oxygen to a resident as prescribed. The resident, dependent on supplemental oxygen due to multiple diagnoses, was left without oxygen for over four minutes when a CNA removed the nasal cannula to refill the portable liquid oxygen unit. The CNA later admitted that a backup oxygen source should have been provided.
The facility failed to conduct annual performance evaluations for CNAs, as required. A review of personnel records revealed that one CNA, hired in 2020, lacked evaluations for 2022 and 2023. The DON confirmed that these evaluations were missed, potentially allowing incompetent CNAs to provide care and increasing the risk of harm to all residents.
The facility failed to secure wound care products and resident-prescribed wound care cream in a locked treatment cart, as observed in one of two treatment carts. This oversight created the potential for unauthorized access and cross-contamination. The facility's policy requires medications and biologicals to be stored securely, with unlocked carts under nurse control. An LPN acknowledged the need to lock the cart when not nearby, and the DON confirmed this requirement.
A resident admitted with multiple health issues requested a pneumococcal vaccine, but the facility failed to administer it. The resident's medical chart lacked documentation of the vaccine being given, and the DON confirmed the omission without any documented explanation.
Deficiencies in Facility Environment and Maintenance
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by several observations and resident reports. Resident #36, who uses a power wheelchair, reported difficulty maneuvering in his room due to privacy curtains that tangled with his wheelchair. Despite being the only resident in the room, staff did not allow the curtains to be adjusted, potentially compromising his safety and comfort. Additionally, Resident #33 reported a non-functioning bathroom fan, which had been an issue for several months. Despite having a maintenance management system in place, there was no record of this issue being reported or addressed, indicating a lapse in communication and maintenance procedures. The overall environment of the facility was observed to be unsafe and unsanitary. A significant hole in the dining room floor tile posed a trip hazard, and the west side shower room had multiple areas with missing or damaged tiles, creating potential fall risks. The shower rooms also had cleanliness issues, such as dusty air vents and a shower chair with an unremovable pink substance. The maintenance supervisor acknowledged the hazards but noted that repair bids had not been approved. Housekeeping staff confirmed that shower rooms should be cleaned daily, but the observed conditions suggested otherwise, highlighting a failure in maintaining a sanitary environment.
Infection Control and Prevention Failures
Penalty
Summary
The facility failed to adhere to infection control and prevention practices, impacting several residents. Observations revealed that staff did not follow proper hand hygiene protocols. For instance, a CNA handled dirty washcloths without gloves and then assisted a resident with hand and face washing without performing hand hygiene. Additionally, CNAs did not offer hand hygiene assistance to residents eating in their rooms, and there was a misunderstanding among staff about who was responsible for this task. The DON confirmed that staff should encourage residents to wash their hands before meals. The facility also failed to properly clean equipment and follow protocols during tube feeding. A CNA was observed returning a Hoyer lift to storage without cleaning it after use, which the DON acknowledged as incorrect. Furthermore, a resident with a PEG tube, who was on enhanced barrier precautions, did not receive care in accordance with these precautions. An RN administered G-tube feeding without donning the required PPE, despite clear signage indicating the need for gloves and a gown during high-contact care activities. The RN admitted to not following the protocol.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was initially assessed to determine if they were safe to self-administer medications. This deficiency was identified for one of two residents, specifically Resident #36, who was admitted with multiple diagnoses including incomplete quadriplegia, diabetes with diabetic polyneuropathy, and gastro-esophageal reflux. On a specific date, Resident #36 reported being given calcium carbonate oral chewable tablets at bedside to use as needed, without a documented self-administration medication assessment in his medical records. The Director of Nursing (DON) confirmed that the assessment had not been completed for this resident, which was a requirement according to the facility's policy on self-administration of medications.
Improper Handling of Feeding Formula for Resident with Feeding Tube
Penalty
Summary
The facility failed to provide adequate care and treatment for a resident with a feeding tube, specifically regarding the handling and storage of feeding formula. The resident, who was admitted with diagnoses including stroke and dysphagia, had a physician's order for Jevity 1.5 to be administered via PEG tube every four hours. On multiple occasions, opened bottles of the feeding formula were observed left at the resident's bedside without proper labeling or refrigeration, contrary to the facility's policy. A nurse admitted to leaving the formula at the bedside until it was used, and the Clinical Resource Nurse later confirmed that the formula should have been refrigerated after opening. This oversight created the potential for harm if complications arose from improper tube feeding practices.
Failure to Provide Continuous Oxygen to Resident
Penalty
Summary
The facility failed to ensure that a resident received continuous oxygen as prescribed by the physician. The resident, who was admitted with multiple diagnoses including stroke, dysphagia, and dependence on supplemental oxygen, had an order for oxygen at 2 liters per minute via nasal cannula continuously. On one occasion, a CNA removed the resident from the portable liquid oxygen to refill the unit, leaving the resident without oxygen for over four minutes. The CNA later acknowledged that she should not have removed the resident from the oxygen without first providing a backup source.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that each Certified Nursing Assistant's (CNA) performance was evaluated at least once every 12 months, as required. This deficiency was identified during a review of personnel records for five CNAs, where it was found that one CNA, hired on May 1, 2020, did not have documented annual evaluations for the years 2022 and 2023. The Director of Nursing (DON) confirmed that the evaluations should be conducted annually and acknowledged that some evaluations, including that of the identified CNA, had been missed. This oversight created the potential for incompetent CNAs to provide care, thereby increasing the risk of harm to all 44 residents living in the facility.
Failure to Secure Wound Care Products in Locked Cart
Penalty
Summary
The facility failed to ensure that wound care products and resident-prescribed wound care cream were secured in a locked treatment cart. This was observed in one of two treatment carts, creating the potential for residents to access prescribed wound care cream intended for other residents and presenting a risk for cross-contamination of wound care products stored in the cart. The facility's Medication Management policy, revised on 10/15/22, requires medications and biologicals to be stored appropriately to prevent unauthorized access, with unlocked medication/treatment carts under nurse control at all times. On 8/4/24 at 11:03 AM, the west hall wound care treatment cart was observed to be unlocked when the nurse was not present. At 11:13 AM, an LPN stated she thought the cart needed to be closed and locked when she was not near it. On 8/8/24 at 10:10 AM, the DON confirmed that treatment carts should be locked when a nurse is not present.
Failure to Administer Requested Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide a pneumococcal vaccine to a resident who requested it upon admission. The resident, admitted with multiple diagnoses including metabolic encephalopathy, chronic fatigue, and repeated falls, requested the vaccine on admission. However, a review of the resident's medical chart revealed no documentation that the vaccine had been administered. The Director of Nursing confirmed that the vaccine had not been given and there was no explanation documented in the resident's chart for this omission.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
