Sunny Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Nampa, Idaho.
- Location
- 2609 Sunnybrook Drive, Nampa, Idaho 83686
- CMS Provider Number
- 135102
- Inspections on file
- 20
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Sunny Ridge during CMS and state inspections, most recent first.
Surveyors found multiple expired medications on two medication carts and in a medication storage room, including glucose gel, aspirin, fexofenadine, antacids, vitamins, and zinc, while an LPN and an RN each reported not knowing who was responsible for checking expiration dates. In addition, temperature logs for specimen, vaccine, and medication refrigerators in the storage room had not been updated for several days, despite the ADON stating that cart nurses were responsible for recording refrigerator temperatures every shift. The DON stated that nursing staff should have removed the expired medications, and facility policy required contacting the dispensing pharmacy regarding discontinued or outdated drugs and biologicals.
Surveyors found multiple failures in sanitary food handling and kitchen practices affecting residents who received meals from the facility kitchen. Staff were observed in the kitchen without required hair restraints, and a cook prepared over-easy eggs with unpasteurized eggs, serving runny yolks without checking temperatures or documenting hot-holding temperatures as required. The cook used a dry cloth stored on a cutting board to wipe plate edges and then reused the same cutting board for food preparation, while cutting boards were visibly scratched with residue and a sanitizer bucket was used despite testing below required concentration. Additional findings included black residue inside the ice machine, dirty dishes stacked above clean cutting boards and routed through the clean side of the dish room, and cooking skillets with scratched, peeling interior coatings still in use.
A cognitively intact resident with multiple medical conditions, including right-sided paralysis after a heart attack, Parkinson's disease, cognitive communication deficit, depression, and anxiety, was not offered assistance or information to create an advance directive. Review of progress notes and multiple IDT care conferences over several months showed no documentation that advance directive information was provided, and the Administrator confirmed this lack of documentation.
Two residents had inaccurate MDS assessments when key clinical information was miscoded. One resident with serious mental illness had a Significant Change MDS coded as not having a Level II PASRR, even though a Level II PASRR was present in the medical record. Another resident with ESRD on dialysis had a Quarterly MDS coded to indicate an indwelling Foley catheter, but observation confirmed no catheter was in place, and the MDS coordinator acknowledged this was an error.
A resident who was dependent on staff for ADLs and had a history of stroke with hemiplegia/hemiparesis did not have toenail care addressed in the ADL care plan. During observation with the ADON, the resident’s toenails appeared possibly fungal, brittle, thick, and brownish in color. Review of the care plan confirmed that toenail condition and care were not included, and the ADON acknowledged that toenail care should have been part of the comprehensive care plan.
A resident who was dependent on staff for ADLs and had a history of stroke with hemiplegia and hemiparesis was observed on multiple occasions to have thick, brittle, discolored toenails that the ADON believed might indicate a fungal infection. Although a podiatrist visits the facility every three months, the resident had not been seen by the podiatrist and had not been referred for podiatry services, and the ADON could not explain the lack of referral while acknowledging the resident should have been referred. This resulted in a deficiency related to toenail care and assistance with ADLs.
A resident with multiple medical conditions, including diabetes, protein calorie malnutrition, and dysphagia with a G-tube, was started on Mirtazapine in the hospital for insomnia and depression after a psychiatry consult. Upon admission, the facility’s MAR listed Mirtazapine 7.5 mg via G-tube at bedtime for appetite stimulation instead of for insomnia and depression, as documented in the hospital discharge summary. During review, the DON confirmed the medication was intended for insomnia and depression, showing that the facility failed to clarify and accurately document the correct indication for this psychotropic medication in accordance with professional standards of practice.
A resident with stroke-related hemiplegia, dysphagia, and significant recent weight loss was not consistently provided with ordered nutritional interventions, including yogurt, ice cream, and health shakes, despite physician and dietitian directives. After a communication from a Speech Language Therapist restricting milk products due to diarrhea, the Dietary Manager stopped the milk-based health shake and did not secure non-dairy alternatives or notify the Administrator of their unavailability. Observations showed missing supplements on multiple meal trays, and the resident’s dietary profile lacked documented food likes and dislikes, which were not obtained from the resident’s representative when the resident could not fully communicate them.
Staff failed to follow infection prevention practices during medication administration and care of a resident with a gastrostomy tube. An LPN entered a resident's room without hand hygiene, placed an insulin pen on a bedside table without a barrier, applied a transdermal pain patch with an ungloved hand, then donned gloves without prior hand hygiene to give insulin, and later applied a nicotine patch with an ungloved hand. An RN also entered a resident's room and administered oral medications without performing hand hygiene or donning gloves. For a resident with diabetes, protein calorie malnutrition, dysphagia, and a gastrostomy tube, staff did not change and date the syringe and graduated cylinder each night as ordered; the cylinder was dated several days earlier and the syringe was undated, despite leadership confirming these items were to be changed nightly for infection control.
A resident over age 65 with systemic lupus erythematosus had a signed consent for a COVID-19 vaccine, and a progress note documented that the vaccine was not available and the pharmacy was contacted. However, the medical record contained no documentation that the vaccine was ever administered or rescheduled. During record review, the DON and a regional resource nurse confirmed there was no evidence of vaccination despite CDC guidance emphasizing the importance of the 2025–2026 COVID-19 vaccine for older adults and those in LTC settings.
Two residents did not receive multiple physician-ordered medications as prescribed, including treatments for bipolar disorder, migraines, leukemia, COPD, and infections. Medication administration records showed missed doses coded as not given, with the DON confirming the medications were not available at the time of administration.
A resident with Parkinson's disease and cognitive decline fell and sustained a head laceration due to inadequate supervision and failure to use a foot device during wheelchair transport. The care plan intervention was not followed, and the resident was transported without foot pedals, leading to the fall.
The facility failed to serve meals simultaneously to residents seated at the same table, affecting their dignity. In the Main Dining Room, a resident received her meal 19 minutes after others, while another waited 38 minutes due to miscommunication. In the Assisted Dining Room, a resident's meal was delayed by 15 minutes due to an unupdated dining room change. The DON and Dietary Director acknowledged the issues.
The facility failed to maintain adequate staffing levels, resulting in delayed care and resident falls. Residents reported long wait times for assistance, particularly during meal times, leading to discomfort and accidents. Incidents included residents falling while attempting to manage their needs independently due to delayed staff response. The DON acknowledged the staffing issues and lack of documentation on staff education regarding care plans and call light response times.
A LTC facility failed to ensure residents were free from significant medication errors, affecting three residents. One resident received an accidental second dose of Oxycontin, another did not receive prescribed medications due to order processing delays, and a third missed doses of Clindamycin. These errors were identified through record reviews and staff interviews, with the involved staff no longer employed at the facility.
The facility failed to maintain a clean and sanitary kitchen environment, with improper food storage and labeling practices observed. Several food items were opened and undated, and some spices were expired. Ice build-up in the freezer and dust accumulation on equipment were noted, along with inadequate sanitization of dish cloths. The facility lacked proper documentation and oversight in maintaining kitchen equipment and ensuring food safety.
A facility failed to obtain informed consent for Trazodone, prescribed for a resident with bipolar disorder. The facility's policy requires informing residents or their representatives about the right to decline treatment and the associated risks. Despite a physician's order for Trazodone, no signed consent was found in the resident's medical record, and the Clinical Resource Nurse confirmed its absence, indicating non-compliance with the policy.
A facility failed to notify the ombudsman of a resident's hospital transfers, as required. The resident, who was cognitively intact and had multiple diagnoses, experienced two unplanned hospitalizations. The facility's administrator confirmed the omission of the required notification.
The facility failed to provide bed hold notices to two residents upon their transfer to the hospital, as required by policy. One resident with acute cholecystitis and diabetes was transferred after experiencing abdominal pain, while another with end-stage renal disease and other conditions had two unplanned hospitalizations. In both cases, there was no documentation of bed hold notices being given, which was confirmed by the DON and Administrator.
A facility failed to ensure accurate MDS assessments for a resident with dementia, PTSD, and major depressive disorder. The resident's PASARR Level II was inaccurately documented in annual MDS assessments as not completed, despite having been completed previously. The MDS Coordinator noted an exemption for the PASARR Level II, leading to the documentation error.
A resident with diabetes was administered insulin by an LPN who failed to prime the insulin pen before injection, contrary to the manufacturer's instructions. This oversight could lead to improper dosing, as the LPN mistakenly believed priming was unnecessary.
A facility failed to ensure pharmacist recommendations were addressed by the attending physician, leading to potential unnecessary medication use for a resident. The resident, with multiple diagnoses including breast cancer and diabetes, was receiving haloperidol in ABHR cream for anxiety, which was deemed potentially inappropriate by the pharmacist. The Pharmacy Consultation Report lacked a physician's response, and the DON noted the recommendation should have been sent to the Hospice Physician.
A facility failed to adhere to infection control protocols when a nurse administered medication to a resident with an enteral feeding tube without wearing a protective gown, despite Enhanced Barrier Precautions signage. This oversight was acknowledged by the nurse and posed a risk of infection transmission.
A resident with multiple diagnoses, including hypertension and osteoporosis, consented to receive the influenza vaccine upon admission to the facility. Despite this consent being documented, the vaccine was not administered. The DON, also the Infection Preventionist, confirmed that vaccinations were offered upon admission but could not explain why the vaccine was not given.
Expired Medications and Incomplete Refrigerator Temperature Monitoring
Penalty
Summary
Surveyors identified a deficiency related to medication labeling and storage when they observed expired medications on two medication carts and in the medication storage room, as well as incomplete temperature monitoring of medication refrigerators. During inspection of the East Hall medication cart with an LPN present, multiple expired items were found, including glucose gel, aspirin 81 mg, fexofenadine, TUMS, vitamin D, aspirin 325 mg, and diphenhydramine, with expiration dates ranging from April to December of the prior year. The LPN stated she did not know who was responsible for ensuring medications in her cart were not expired. On another hall’s medication cart inspected with an RN present, expired zinc, aspirin 325 mg, and vitamin E were found, and the RN similarly reported being unsure who was responsible for checking expiration dates. In the facility’s medication storage room, an additional expired bottle of zinc was observed. Further inspection of the medication storage room with the ADON revealed that temperature logs for the specimen, vaccine, and medication refrigerators had not been updated since the morning shift several days earlier. The ADON confirmed that refrigerator temperatures had not been checked since that time and stated that cart nurses were responsible for checking and recording refrigerator temperatures every shift. The DON later stated that the expired medications in the medication carts and storage room should have been removed by nursing staff. The facility’s written policy on Medication Labeling and Storage required that discontinued, outdated, or deteriorated medications or biologicals be addressed by contacting the dispensing pharmacy for instructions on returning or destroying these items.
Failure to Maintain Sanitary Food Handling and Kitchen Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a clean and sanitary kitchen environment and to handle food in accordance with professional standards and the FDA Food Code for residents receiving food from the facility kitchen. During an observation, a dietary aide was seen walking through the kitchen without a hair net, and later acknowledged he should have been wearing one. On another occasion, a cook prepared over-easy eggs using unpasteurized eggs, removed them from the griddle with visibly runny yolks without checking temperatures, and confirmed that runny yolks were being served, despite the dietary manager stating eggs should not be served over easy. The over-easy eggs were not served for immediate service, and food temperatures for steam table items were not observed being taken or recorded during tray line service; the cook stated he kept temperatures in his mind and recorded them at the end of service, contrary to the dietary manager’s statement that temperatures should be taken and recorded prior to tray line. Additional observations showed improper cleaning and sanitizing practices for food-contact surfaces and equipment. The cook used a dry cleaning cloth stored on top of a cutting board to wipe the edge of a resident’s plate, then returned the cloth to the cutting board used for food preparation, and later used the same cutting board to chop breakfast meat without obtaining a clean board. Clean cutting boards were observed to be scratched and scored with residue remaining in the grooves, and the dietary manager stated such boards should be replaced when residue cannot be cleaned. A sanitation bucket used after lunch tray line tested at less than 200 ppm, and the dietary aide who prepared it reported she knew it had not reached the required concentration but continued to use it to clean kitchen surfaces, acknowledging she should have made a new bucket with at least 200 ppm. Surveyors also observed multiple issues with equipment cleanliness and dish-handling procedures. The interior of the ice machine had a thin line of black residue on the white separation plate, which the dietary manager confirmed, noting maintenance had cleaned it two months earlier and that more frequent cleaning should occur if needed. Dirty dishes were stacked on a kitchen preparation table above clean cutting boards, and the dietary manager and a dietary aide explained that dirty dishes were taken through the clean side of the dish room to be washed, stating they did not believe this procedure was incorrect because dirty dishes should not be taken through a clean kitchen. Cooking skillets were observed with scratched and visibly peeling interior coatings in the area where food would be cooked, and the dietary manager stated these skillets should have been replaced and not used for cooking.
Failure to Offer Cognitively Intact Resident Assistance With Advance Directive
Penalty
Summary
The facility failed to assist a cognitively intact resident in developing an advance directive for health care decisions as required. The resident, admitted with multiple diagnoses including right-sided paralysis following a heart attack, Parkinson's disease, cognitive communication deficit, depression, and anxiety, had a comprehensive MDS assessment documenting intact cognition. Record review of the resident's progress notes showed no documentation that the resident was offered the opportunity to create an advance directive. Additionally, multiple IDT care conferences held over several months did not document that the resident was provided information to formulate an advance directive. On review, the Administrator confirmed there was no documentation that the resident had been provided information to formulate an advance directive. This deficient practice created the potential for harm if residents' instructions for their healthcare were not followed in the event of a life-threatening outcome.
Inaccurate MDS Coding for PASRR Status and Indwelling Catheter
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents’ clinical status for two residents, resulting in inaccurate coding of key assessment items. For one resident with multiple diagnoses including schizophrenia – bipolar type and anxiety, a Significant Change MDS assessment documented “no” in Section A1500 regarding whether the resident was considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, despite the presence of a Level II PASRR dated 9/14/25 in the electronic medical record; the MDS coordinator later acknowledged this should have been coded “yes.” For another resident with end stage renal disease dependent on dialysis, a Quarterly MDS assessment documented “yes” for an indwelling catheter in Section H-A, but an observation of the resident in her room showed she did not have a Foley catheter, and the MDS coordinator stated that the assessment had been coded in error.
Failure to Include Toenail Care in Comprehensive Care Plan
Penalty
Summary
Surveyors found that the facility failed to develop a comprehensive, resident-centered care plan that addressed toenail care for a dependent resident. The resident had a history of stroke with hemiplegia and hemiparesis and was documented on a comprehensive MDS assessment as being dependent on staff for activities of daily living. Review of the resident’s ADL care plan, revised 12/15/25, showed that care for her toenails was not included. On 1/21/26 at 9:44 AM, during an observation with the ADON, the resident’s toenails were noted to appear possibly fungal, brittle, thick, and brownish in color. At 9:56 AM the same day, the ADON reviewed the resident’s care plan and confirmed that the condition of her toenails and related care were not addressed, and acknowledged that the care plan should have included care for her toenails. This omission in the care plan for toenail care constituted a failure to ensure the care plan was complete and comprehensive for this resident’s identified needs.
Failure to Provide Toenail Care and Podiatry Referral for Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received appropriate toenail care as part of assistance with activities of daily living. The resident, who had a history of stroke with hemiplegia and hemiparesis and was documented on a comprehensive MDS assessment as dependent on staff for ADLs, was observed on two occasions to have thick, brittle toenails that were whitish to yellowish and brownish in color, which the ADON described as possibly indicating a fungal infection. A podiatrist visits the facility every three months and had last been at the facility on 11/6/25, but the resident had not been seen by the podiatrist and had not been referred for podiatry services. When questioned, the ADON could not explain why the resident had not been referred and acknowledged that the resident should have been referred to the podiatrist. This failure to provide toenail care services for a resident dependent on staff for ADLs resulted in a deficiency related to nail care and placed the resident at risk of embarrassment that could affect her socially due to the appearance of her toenails, as stated in the report.
Failure to Clarify Indication for Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice by not clarifying the indication for a psychotropic medication for one resident. The resident was admitted with multiple diagnoses including diabetes, protein calorie malnutrition, and dysphagia, and had undergone a gastrostomy tube placement. A hospital discharge summary documented that the resident had lack of sleep and depression related to increased stress and sleep difficulties from ongoing medical issues, and that psychiatry was consulted and started the resident on Mirtazapine nightly. However, the resident’s January 2026 MAR documented Mirtazapine 7.5 mg via G-tube at bedtime for appetite stimulant, which did not match the hospital documentation of use for insomnia and depression. During an interview, the DON reviewed the hospital progress notes and stated that the Mirtazapine was for the resident’s insomnia and depression, confirming that the indication on the MAR was not consistent with the hospital records and had not been properly clarified. These practices had the potential to adversely affect or harm residents whose care and services were not delivered to accepted standards of clinical practice.
Failure to Provide Ordered Nutritional Interventions and Assess Dietary Preferences
Penalty
Summary
The facility failed to ensure a resident was adequately assessed for dietary needs and provided nutritional interventions as ordered by the physician. The resident was admitted with multiple diagnoses including stroke with hemiplegia and hemiparesis, dysphagia, hepatitis C, and alcohol abuse. A physician’s order dated 12/31/25 specified a regular diet with mechanical soft texture, regular consistency, no plain eggs, bacon, or milk products, extra gravy and sauces, yogurt on the breakfast tray, and ice cream on the lunch or dinner tray. Skin & Weight Notes documented significant weight loss of 5% in 30 days and then 6% in one month, with oral intake ranging from poor to fair and 26–75%. The dietitian recommended adding a strawberry health shake twice daily, and the care plan included yogurt, ice cream, and health shakes as part of the resident’s nutritional support. Despite these orders and interventions, surveyor observations showed that the resident’s lunch tray on one date did not include ice cream or a health shake, and the breakfast tray on another date did not include yogurt or a health shake. The Dietary Manager (DM) stated the resident had previously been served milk shakes, yogurt, and ice cream, but after receiving a communication from the Speech Language Therapist indicating no eggs, bacon, or milk products due to diarrhea, the resident was no longer served the milk-based health shake. The DM also stated the facility did not have non-dairy nutritional supplements and acknowledged she did not inform the Administrator about this lack of non-dairy options, though she believed she should have. Additionally, the resident’s Dietary Profile documented a preferred beverage (orange juice) but did not include food likes and dislikes, and the DM confirmed she did not obtain this information from the resident’s representative when the resident was unable to provide it herself.
Failure to Follow Hand Hygiene and Device Change Orders for Infection Control
Penalty
Summary
The facility failed to maintain an infection prevention and control program when nursing staff did not follow CDC hand hygiene practices and did not use appropriate barriers during medication administration. One LPN prepared an insulin pen and transdermal patches at the medication cart, then entered a resident's room without performing hand hygiene or donning gloves. She placed the insulin pen directly on a bedside table next to a bedside urinal without a barrier, applied a transdermal pain patch with an ungloved hand, then donned gloves without prior hand hygiene to administer an insulin injection. After removing gloves and performing hand hygiene, she applied a transdermal nicotine patch with an ungloved hand. When questioned, the LPN stated she was not aware a barrier was needed between the insulin pen and the bedside table and did not respond when asked about hand hygiene upon room entry and prior to donning gloves. In a separate observation, an RN prepared oral medications at the medication cart, then entered a resident's room and handed the medications and water to the resident without performing hand hygiene or donning gloves. The DON stated her expectation was that nurses perform hand hygiene upon entering a resident's room and don gloves prior to administering insulin or transdermal patches. The facility also failed to follow a physician's order related to infection control for a resident with a gastrostomy tube. This resident had multiple diagnoses including diabetes, protein calorie malnutrition, and dysphagia, and had undergone a procedure for gastrostomy tube placement. A physician's order directed staff to change and date the resident's syringe and graduated cylinder every night shift. During observation, the resident's graduated cylinder and syringe were found on top of the dresser, with the graduated cylinder dated several days earlier and the syringe undated. The ADON confirmed that the graduated cylinder and syringe should be changed every night and dated, and the DON stated that the nightly change was ordered for infection control purposes.
Failure to Administer COVID-19 Vaccine After Consent Obtained
Penalty
Summary
The deficiency involves the facility’s failure to ensure administration of a COVID-19 vaccination to an eligible resident after consent was obtained. One resident over the age of 65, with multiple diagnoses including systemic lupus erythematosus, was admitted to the facility and had a COVID-19 vaccination consent form dated 9/30/25, on which her POA signed informed consent for her to receive the COVID-19 vaccine. A progress note dated 10/25/25 at 1:33 PM documented that the COVID-19 vaccine was not available and that the pharmacy was contacted. Record review by the DON and the Regional Resource Nurse on 1/22/26 showed no documentation that the COVID-19 vaccine was ever administered to this resident. The DON confirmed that the only documentation present was the progress note indicating the vaccine was not available and that there was no evidence the vaccination had been rescheduled. This failure occurred despite CDC guidance stating that protection from COVID-19 vaccines and immunity after infection decrease over time and that the 2025–2026 vaccine is especially important for individuals 65 years and older and those living in LTC facilities.
Failure to Administer Physician-Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to administer physician-ordered medications as prescribed for two residents reviewed for medication administration. For one resident with multiple diagnoses including bipolar disorder, depression, and migraine disorder, the medication administration record showed that several essential medications, such as cyanocobalamin, lysine, topiramate, and Venclexta, were not administered as ordered. The records indicated that these medications were coded as not given, with progress notes stating the medications were not available for administration during the specified period. Another resident with diagnoses including heart disease, urinary tract infection, and COPD also did not receive several prescribed medications. The medication administration record documented missed doses of Breztri inhaler, methylprednisolone, and cefdinir, all coded as not administered due to unavailability. The DON confirmed that the medications were not available at the time they were scheduled to be given, resulting in missed doses for both residents.
Failure to Prevent Resident Fall Due to Inadequate Supervision and Device Use
Penalty
Summary
The facility failed to provide adequate supervision and functioning devices to prevent a resident's fall, resulting in harm. A resident with multiple diagnoses, including Parkinson's disease and cognitive decline, was at risk for falls due to impaired mobility and other factors. The resident's care plan included the use of a foot device for wheelchair positioning, but this intervention was not followed. During transport to the restorative dining room, the resident's legs were outstretched, and he suddenly dropped his feet to the floor, causing a fall that resulted in a head laceration. The incident investigation revealed that the resident had been transported without foot pedals before without incident, and there was no documentation of the resident refusing to use the foot pedals. The administrator acknowledged that the resident did not like the foot pedals due to discomfort and potential pressure ulcers. The facility could have ensured wheelchair safety measures were followed, such as going slower or using a wheelchair seatbelt while the resident was in motion. This deficiency represents past non-compliance with the regulatory requirement to ensure a safe environment free from accident hazards.
Failure to Serve Meals Simultaneously Affects Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance residents' dignity during dining by serving meals at different times to residents seated at the same table. In the Main Dining Room, Resident #96 received her meal 19 minutes after Residents #7 and #9 had started eating. Similarly, Resident #94 was served her meal 38 minutes after Residents #93 and #95 began their meals. This delay was due to a miscommunication, as the kitchen was incorrectly informed that Resident #94 would not be eating breakfast. The Director of Nursing (DON) acknowledged the confusion and stated that the facility was attempting to serve meal trays in the order residents were seated. In the Assisted Dining Room, Resident #30 experienced a delay of 15 minutes in receiving her meal compared to other residents at the same table. This was attributed to a failure to update the resident's dining room location in the kitchen records after she changed dining rooms over the weekend. The Dietary Director explained that the kitchen relies on updates from nurses regarding changes in residents' dining locations, which are then recorded in the residents' charts. The Administrator and Clinical Resource Nurse confirmed that the kitchen was not informed of Resident #30's change, resulting in the delay.
Staffing Deficiencies Lead to Delayed Care and Resident Falls
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of residents, leading to delays in care and potential harm. Multiple residents and their representatives reported insufficient staff during meal times and delays in responding to call lights. Specific incidents included residents waiting for assistance with toileting and personal care, resulting in discomfort and accidents. For instance, one resident's representative noted delays during meal times, while another resident reported waiting for help to change incontinence products. A resident council meeting further highlighted these concerns, with several residents stating they experienced long wait times for assistance. The report also documented incidents where residents were found on the floor after attempting to manage their needs independently due to delayed staff response. One resident, with a history of stroke and Parkinson's disease, was found on the floor twice after trying to get help or use the bathroom. Another resident, with bladder disorder and other conditions, fell in the bathroom after waiting for assistance. A third resident, requiring assistance for toileting, fell while returning from the restroom. The Director of Nursing acknowledged the staffing issues and the lack of documentation regarding staff education on residents' care plans and call light response times.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting three residents. Resident #4, who had multiple diagnoses including fibromyalgia and hypothyroidism, received an accidental second dose of Oxycontin, leading to symptoms of slow and slurred speech. Resident #145, with conditions such as COPD and chronic kidney disease, did not receive her prescribed medications, including Miralax and Vitamin C, due to a delay in processing physician orders. Resident #16, diagnosed with dementia and PTSD, missed two doses of Clindamycin due to a nurse's oversight. These medication errors were identified through record reviews, incident reports, and staff interviews. The errors were attributed to failures in medication administration and order processing, as documented in the facility's policies. The Director of Nursing acknowledged these incidents, although she was not in her current role at the time of the errors. The involved staff members were no longer employed at the facility at the time of the survey.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by multiple observations of improper food storage and labeling practices. During inspections, it was noted that several food items, including mashed potato flakes, steel cut oats, and spices, were opened and undated in the dry storage area. Additionally, some spices were found to be expired, and large plastic bins containing white substances were not labeled with the item or use-by date. The Dietary Director was unaware of why these issues occurred, despite staff being trained to label and date food items. Further inspections revealed additional deficiencies in the facility's food storage and sanitation practices. Ice build-up from condensation in the freezer was observed, leading to water droplets covering boxes of unopened sausages. Dust accumulation was noted on refrigerator fan covers and shelves near the oven. The dish cloth sanitization buckets were found to be less than 50 parts per million, indicating inadequate sanitization. The Dietary Director admitted to not having records of when the shelves were last cleaned or when the freezer and refrigerator fans were last serviced. The facility's failure to adhere to its own policies and the FDA Food Code resulted in a lack of proper food storage and sanitation. The temperature logs for the resident snack and personal refrigerator and freezer were incorrectly dated and lacked daily temperature recordings. The Dietary Director and the Administrator were unable to provide maintenance records for the freezer fan cleaning or repairs to the resident fridge, indicating a lack of oversight and documentation in maintaining kitchen equipment and ensuring food safety.
Failure to Obtain Informed Consent for Medication
Penalty
Summary
The facility failed to obtain informed consent prior to administering medications to a resident, specifically Trazodone for bipolar disorder. The facility's policy on psychotropic medication use, dated July 2022, requires that residents or their representatives be informed of their right to decline treatment and be made aware of the risks and alternatives. Resident #144, who was admitted with diagnoses including stroke, hemiplegia, and bipolar disorder, had a physician's order for Trazodone to be administered via PEG-Tube at bedtime. However, a signed consent form for this medication was not found in the resident's medical record. Despite a request from the surveyor, the Clinical Resource Nurse confirmed the absence of the signed consent form, indicating a failure to comply with the facility's policy and potentially placing the resident at risk of receiving medication without proper informed consent.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide transfer notices to the ombudsman for a resident who was reviewed for transfers to the hospital. This deficiency was identified for one of two residents reviewed, specifically a resident with multiple diagnoses including end stage renal disease, diabetes, and congestive heart failure. The resident, who was cognitively intact, experienced two unplanned hospitalizations. Upon review of the resident's medical record, it was found that there was no documentation of ombudsman notification for these hospital transfers. The facility's administrator confirmed that the ombudsman was not notified, acknowledging that the notification should have been made.
Failure to Provide Bed Hold Notices Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to residents or their representatives upon transfer to the hospital, as required by their Transfer or Discharge policy. This deficiency was identified for two residents who were reviewed for transfer. The policy, dated October 2022, mandates that a notice of facility Bed-Hold and Return policies be provided within 24 hours of an emergency transfer. However, in the cases of Resident #40 and Resident #6, there was no documentation that such notices were given. Resident #40, who had multiple diagnoses including acute cholecystitis and diabetes, was transferred to the hospital after experiencing abdominal pain. Despite the transfer, there was no record of a bed hold notice being provided to her or her representative. Similarly, Resident #6, who had end-stage renal disease, diabetes, and congestive heart failure, experienced two unplanned hospitalizations due to complications with her colostomy. In both instances, there was no documentation of bed hold paperwork being provided. The Director of Nursing and the Administrator confirmed that the notices should have been provided but were not.
Inaccurate MDS Assessment Due to PASARR Level II Documentation Error
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including dementia, PTSD, and major depressive disorder, had a Preadmission Screening and Resident Review (PASARR) Level II completed on two occasions. However, the resident's annual MDS assessments inaccurately documented that the resident did not have a completed PASARR Level II. The MDS Coordinator explained that the resident's PASARR Level II was no longer needed due to an exemption, and therefore, it was not marked in the MDS. Despite this, the resident's admitting diagnoses had not changed, indicating a discrepancy in the assessment documentation.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards, specifically concerning the administration of insulin to a resident with diabetes and a history of stroke. The resident was prescribed 12 units of Insulin Aspart to be administered subcutaneously once a day. During an observation, an LPN administered the insulin without priming the insulin pen, which is a necessary step to avoid injecting air and to ensure proper dosing. The LPN incorrectly believed that the insulin pen did not require priming, contrary to the instructions provided by the Insulin Aspart manufacturer.
Failure to Address Pharmacist Recommendations for Medication Use
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were followed or addressed by the attending physician for a resident, leading to a potential for unnecessary medication use. The facility's Medication Regimen Reviews (MRR) policy requires the Consultant Pharmacist to perform a monthly drug regimen review for each resident and provide a written report to the attending physician within 24 hours if a non-life-threatening medication irregularity is identified. The attending physician is then expected to document in the medical record that the irregularity has been reviewed and what action was taken. However, in the case of a resident with multiple diagnoses, including breast cancer and diabetes, the pharmacist identified the use of haloperidol in ABHR cream for anxiety as potentially inappropriate and requested clarification or discontinuation of the medication. The Pharmacy Consultation Report did not include a response from the physician regarding this recommendation. The Director of Nursing (DON), who had been in her position for about three weeks, stated that the resident was a hospice patient and that the pharmacist's recommendation should have been sent to the Hospice Physician immediately upon receipt. The DON was unaware of why the recommendation was not addressed by the facility. This oversight created the potential for the resident to use unnecessary medications, as the pharmacist's recommendation was not acted upon or documented by the attending physician.
Infection Control Lapse in Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control measures, as evidenced by the observation of a registered nurse (RN) not adhering to Enhanced Barrier Precautions (EBP) while administering medication to a resident. The resident, who was admitted with multiple diagnoses including a stroke, had an enteral feeding tube and was on NPO status. EBP signage was clearly posted outside the resident's door, instructing staff to wear gloves and gowns during high-contact care activities involving medical devices. However, during the administration of crushed medication via the resident's enteral tube, the RN was observed wearing gloves but not a protective gown, contrary to the posted EBP requirements. The RN later acknowledged the oversight, admitting that she should have worn a protective gown while administering the medication. This lapse in following infection control protocols had the potential to impact all residents in the facility by increasing the risk of infection transmission. The deficiency was identified through record review, observation, and staff interview, highlighting a failure in maintaining a safe and sanitary environment as per the guidelines provided by the CDC for residents with indwelling medical devices.
Failure to Administer Influenza Vaccine to Consenting Resident
Penalty
Summary
The facility failed to administer the influenza vaccine to a resident who had consented to receive it, as part of their Infection Prevention and Control Program (IPCP). This deficiency was identified during a review of immunizations for five residents, with one resident being affected. The facility's IPCP policy, revised in 2018, emphasized the importance of immunizations as a primary prevention measure against communicable diseases. The resident in question, who had multiple diagnoses including hypertension and osteoporosis, was admitted to the facility and had consented to the influenza vaccine. However, despite the consent being documented, the vaccine was not administered. The Director of Nursing (DON), who also served as the Infection Preventionist, acknowledged that the vaccinations were offered upon admission but was unaware of why the vaccine was not given to the resident.
Latest citations in Idaho
Surveyors found that kitchen staff failed to follow food storage and labeling standards, including multiple dry goods with past or missing use-by dates, undated and improperly sealed refrigerated and frozen items such as cut vegetables, meats, and prepared salad dressings, and a tray where leaking salami was stored with cheese. An allegedly clean skillet was observed with encrusted food on its surfaces. The Food Service Manager acknowledged that items should have been sealed, dated, and cleaned in accordance with the Idaho Food Code.
The facility failed to accurately complete and post daily nurse staffing information for each shift. Surveyors found that on multiple days, required census data was missing from Daily Staffing sheets, some Daily Staffing sheets were not available at all, and on other days nursing data, including the number of hours worked by nurses, was not documented. Facility leadership acknowledged that these Daily Staffing sheets should not have been missing or incomplete. This deficiency had the potential to affect all residents, their representatives, visitors, and others seeking to review staffing levels.
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
A resident with multiple medical conditions, including respiratory disorders and diabetes, had physician orders for scheduled laxatives and a three-step PRN bowel protocol to be used when no bowel movement occurred within specified timeframes. Over a four-day period without a documented BM, the MAR showed that none of the ordered bowel protocol steps were administered, and there was no documentation of bowel care on one of those days. Facility records also lacked any notes of medication refusal or staff education regarding bowel care, and leadership confirmed the absence of documentation and implementation of the ordered bowel protocol.
Surveyors found that staff failed to follow physician orders and facility policy for oxygen and respiratory care. One resident with COPD was ordered continuous O2 at 2 LPM via nasal cannula, but was observed without the cannula and the RN did not intervene. Another resident’s CPAP mask was left uncovered and not stored in a bag as required. A third resident with acute and chronic respiratory failure and asthma had been using O2 at 3.5–4 LPM without a documented MD order or care plan, with the nasal cannula and tubing observed on the floor and then rehung without replacement, while the only documented order was for 2 LPM.
The facility did not maintain the required minimum of eight consecutive hours of RN coverage in a 24-hour period, instead providing only three hours of RN presence on one reviewed day. Review of daily staffing sheets and licensed nurse timesheets confirmed the shortfall in RN hours, and the Director of Clinical Resources acknowledged that an RN had not worked the required duration and should have. This lapse created the potential for routine and emergency nursing needs of all residents to go unmet.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Improper Food Storage, Labeling, and Equipment Cleanliness in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and cleanliness of food and equipment. Review of the Idaho Food Code showed that refrigerated, ready-to-eat, time/temperature control for safety foods held more than 24 hours must be clearly date-marked and used or discarded within seven days, counting the day of preparation as Day 1. During a kitchen observation with the Food Service Manager, surveyors found multiple dry storage items with past or missing use-by dates, including a container of garlic powder with a use-by date of 12/18/24, a container of chili powder with a use-by date of 2/25/25, an opened bag of taco seasoning with no opened or use-by date, and a container of chocolate sauce with a use-by date of 3/13/26. In the refrigerators, surveyors observed cut onions in a container with a use-by date of 4/10/26, an opened undated bag of cut cabbage, and a tray holding both bagged cheese and an unsealed bag of salami with liquid that had leaked onto the shared tray. Ham was stored in a container with no use-by date, and small individual cups labeled as salad dressing were marked only with a prep date of 3/28 and no use-by date. In the freezers, there was an opened undated bag of chicken wings and an opened, unsealed, undated box of seasoned beef patties. In the clean pan area, a skillet was found with encrusted food on both the inside and outside surfaces. The Food Service Manager acknowledged that opened food items should have been properly closed and sealed, all food items needed use-by dates, and the encrusted pan should have been cleaned correctly.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was accurately completed and posted daily for each shift as required. On review of the facility’s Daily Staffing sheets, the surveyor found that for several specified dates in September 2025, census data was missing on some Daily Staffing sheets, and on other dates the Daily Staffing sheets themselves were missing entirely. Additionally, for multiple dates in January 2026, the Daily Staffing sheets lacked nursing data, specifically the number of hours worked by nurses. During an interview, the CNO and Director of Clinical Resources acknowledged that the Daily Staffing sheets should not have been missing or incomplete but confirmed that they were. This deficiency had the potential to affect all residents in the facility, as well as their representatives, visitors, and others who wished to review the facility’s staffing levels. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency pertained to facility-wide staffing documentation and posting practices rather than to an individual resident’s care.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Implement Ordered Bowel Protocol for Constipation Management
Penalty
Summary
Surveyors identified a failure to follow physician orders for bowel care for one resident. The resident was readmitted with multiple diagnoses including pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema. Physician orders included scheduled Miralax twice daily, Bisacodyl 5 mg daily for constipation prevention, Senna Plus twice daily, and a three-step PRN bowel protocol: Senna tablets as step #1 if no bowel movement (BM) in 72 hours, oral Bisacodyl tablets as step #2 if no BM in 96 hours, and a Bisacodyl rectal suppository as step #3 if no BM by the following morning after completing oral Bisacodyl. Record review showed the resident had no documented BM from 4/9/26 through 4/12/26, a four-day period that met criteria for activation of the ordered bowel protocol. The MAR from 4/9/26 to 4/13/26 documented that the resident did not receive bowel protocol step #1, step #2, or step #3 during this time. There were no records available for 4/12/26 related to bowel care, and there were no progress notes documenting any refusal of bowel medications by the resident or any education provided by staff. The ACNO confirmed that the MAR lacked documentation of bowel protocol medications on 4/12/26 and 4/13/26 and that there were no related progress notes.
Failure to Follow Oxygen Orders and Respiratory Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen administration and respiratory care policy and to provide respiratory services as ordered by physicians. For one resident with paranoid schizophrenia and COPD, surveyors observed the resident not wearing his ordered continuous oxygen via nasal cannula, and an RN entered and exited the room without addressing the missing cannula, despite an active order and care plan for continuous oxygen at 2 LPM. Another resident with a history of stroke and diabetes had a CPAP mask left uncovered and unbagged on the bedside table, contrary to the facility policy requiring respiratory supplies to be stored in a bag labeled with the resident’s name when not in use. A third resident with acute and chronic respiratory failure with hypoxia and asthma was observed with an oxygen concentrator at the bedside, with the nasal cannula and tubing on the floor and later hanging over the concentrator. The resident reported using oxygen at 4 LPM since admission and stated the cannula had not been replaced after falling on the floor, only relabeled with a new date. Record review on two consecutive days showed no physician order for oxygen and no care plan for oxygen therapy until a later date, even though the concentrator was observed set at 3.5–4 LPM. The CNO confirmed that an oxygen order was only in place for 2 LPM and acknowledged that oxygen should not have been provided or set above the ordered amount without a physician’s order.
Insufficient RN Coverage for Required 8-Hour Minimum
Penalty
Summary
The facility failed to ensure an RN was on duty for at least eight consecutive hours in a 24-hour period as required. During review of the facility’s Daily Staffing sheets and licensed nurse timesheets, the surveyor identified that on August 10, 2025, the facility had only three hours of RN coverage in the entire 24-hour period. On April 14, 2026, at 3:36 PM, the Director of Clinical Resources confirmed that an RN had not worked for at least eight hours on that date and acknowledged that an RN should have been on duty for that minimum period. This deficiency had the potential to affect all residents residing in the facility by leaving routine and/or emergency nursing services potentially unmet.
Failure to Maintain Secure Medication Storage and Control
Penalty
Summary
The facility failed to ensure medications were stored securely, as required by its Medication Storage & Labeling policy, which mandates that medications be stored and labeled in accordance with CMS regulations, state law, and acceptable professional principles. One resident, admitted with diagnoses including toxic encephalopathy and acute respiratory failure with hypoxia, was observed keeping a bottle of Lactaid in her bedside nightstand and reported taking one or two tablets as needed, despite there being no physician order for Lactaid on her MAR when it was later reviewed by an LPN. In a separate observation, an LPN left the medication cart to enter a resident’s room while a medication cup containing a small pill remained unattended on top of the cart, and the LPN acknowledged that this should not have been done. These observations showed that the facility did not maintain secure control of medications, including an over-the-counter product used independently by a resident without a corresponding physician order, and a prescribed medication left unattended on the medication cart.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
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