Atherton Baptist Home

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision for two of three sampled residents (Residents 12 and 18) under the accidents care area in accordance with facility policy when:1. Resident 12 was observed sliding off the wheelchair unattended in the activity room and unsupervised during a fall on 1/12/2026 in the resident's bedroom.2. Resident 18 was observed unattended in the activity room. This deficient practice placed Resident 12 and 18 at risk for accident and/or injury which had the potential to result in harm like fractures (break in bone), hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician reviewed and took timely action on a medication regimen review (MRR, consists of a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) irregularity (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) identified by the facility's pharmacy consultant for two of five sampled residents (Resident 24 and 58) under unnecessary medications care area by failing to:1 a. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy to ensure resident's drug regimen was free from unnecessary medication use for one (1) of five (5) sampled residents (Resident 2), under unnecessary medications care area, by failing to have a specific indication for Resident 2's use of Seroquel (quetiapine- an antipsychotic medication to treat mental condition by helping balance certain chemicals in the brain). This deficient practice had the potential to increase the risk for Resident 2 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medication (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), possibly leading to impairment or decline in the resident's mental, functional or psychosocial status.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan (a document that outlines a resident's care goals and the activities that will be performed to achieve those goals) for one (1) of 18 sampled residents (Resident 8) by failing to address Resident 8's central venous catheter (CVC, a type of access used for hemodialysis [HD-a procedure removing excess fluid and metabolic waste and products or toxic substances from the bloodstream]), in accordance with the facility's care plan policy. This deficient practice had the potential to not be able to provide specific interventions to address risk for having a CVC, such as accidental dislodgement (displacement/removal of a device thought to be securely in position), which could result in serious harm to Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan was implemented for one (1) of 1 sampled resident (Resident 47), under language and communication care area, by failing to put on the resident's hearing aid and provide a pencil and paper for communication. This deficient practice had the potential for Resident 47 from expressing her needs in a manner that the staff can understand, which could result in a delay in the provision of the resident's necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor, assess, and inform the physician regarding a skin discoloration (bruises - an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) on the resident's left arm for one of one sampled resident (Resident 16) receiving anticoagulant medications (medications that prevent blood from clotting excessively) in accordance with professional standards of practice (authorized, authoritative guidelines established by professional bodies to define the expected behaviors, skills, ethics, and knowledge required for competent practice). This deficient practice had the potential to result in a lack of or delay in assessing for possible complications of Resident 16's skin discoloration which could lead to undetected bleeding and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the personal belongings were documented in the inventory list (a comprehensive, itemized record of all goods, raw materials, and finished products of the resident) in accordance with the facility's Policy and Procedure (P&P) for one (1) of 1 sampled resident (Resident 18) under personal property care area. This deficient practice has the potential to cause Resident 18 to lose his personal belongings and prevent the facility from being able to replenish them.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of 2 sampled residents (Residents 1 and 2) received proper pain management by failing to have pain scale parameters to pain medications ordered when: Resident 1, who had returned from the general acute care hospital (GACH) after a right hip hemiarthroplasty (a surgical procedure that involves replacing half of the hip joint), had a physician's order for Tramadol Hydrochloride (drug commonly used to treat severe pain) as needed (PRN) for pain without a pain scale parameter (mild, moderate, or severe pain). Resident 2 had a physician's order for Tramadol Hydrochloride and Tylenol Extra Strength (drug which reduces fever and relieves minor aches and pain) PRN for pain without a pain scale parameter. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide interventions to prevent accidents (any unexpected or unintentional incident, which results or may result in injury or illness ) for three (3) of 3 sampled residents (Resident 61, 29, and 24) by failing to: 1. Ensure a functional bed sensor pad (alerting device intended to monitor a resident's movement) for Resident 61's use, as indicated on the physician's order and failed to ensure resident's call light was within reach, as indicated on the fall care plan. 2. Identify and eliminate all foreseeable accident hazards and include care plan interventions to address underlying cause of fall for Resident 24 who had a history of falls on 5/25/2024, 7/13/2024, 8/30/2024, and 9/27/2024. 3. Ensure Resident 29's sensor pad alarm was properly positioned and turned on and worked at all times. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label food items in the kitchen with item name, opened and expiration date as indicated in the facility's policy and procedure. This deficient practice had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness such as food poisoning with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident received reasonable accommodation of needs for one of 22 sampled residents (Resident 9) by failing to ensure resident was in a comfortable position during meals. This deficient practice resulted in Resident 9 in feeling exhausted and uncomfortable while eating.

Inspectors wroteBased on interview and record review, the facility failed to follow its Change in a Resident's Condition or Status policy by failing to notify the physician regarding a significant weight loss for one of three sampled residents (Resident 31) as indicated on the care plan. This deficient practice had the potential to result in delayed provision of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain confidentiality of the resident's electronic health record (EHR) for one (1) of 22 sampled residents (Resident 45) by failing to turn off the computer screen and leaving it unattended, exposing the resident's EHR which included the resident's medical condition, list of medications, and other information regarding resident care to others not authorized to view. This deficient practice had the potential to result in the violation of Resident 45's privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to provide Restorative Nursing Services (a program available in nursing homes to help residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) as ordered by the physician to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for one of three sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the extremities (a limb of the body, such as the arm or leg) for not receiving the ordered exercises.

Inspectors wroteBased on interview and record review the facility failed to ensure the physician addressed the medication regimen review (MRR/Drug Regimen Review - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to indicate a reason for disagreeing with the pharmacist recommendation for gradual dose reduction (GDR- the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Ativan (lorazepam- a medication used for anxiety [feeling of fear, dread, or uneasiness that can be mild or severe]) for one of 22 sampled residents (Resident 17) on 10/25/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regimen for one (1) of five sampled residents (Resident 17) was free from unnecessary drugs by failing to assess the continued need for Tylenol (acetaminophen- used relieve mild to moderate pain from headaches, muscle aches, and to reduce fever) after it was not administered as needed for pain for more than ninety (90) days. This deficient practice had the potential for Resident 17 to suffer adverse reactions from unnecessary drug including bleeding easily and bruising.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to properly label the medications with the date opened of one (1) of 8 sampled residents as indicated on the facility policy. This deficient practice had the potential for adverse reaction if these improperly labeled medications were administered to Resident 45.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that accommodated food preferences for one (1) of two sampled residents (Resident 40). This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident centered care plan to address functional assistance needed with Activities of Daily Living (ADL) for one of two sampled residents (Resident 1) in accordance with the facility policy. This failure had the potential for Resident 1 not to receive interventions specific to the residents needs, which could result in injury and fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Label food in the kitchen with item name, opened and expiration date, and discard expired food as indicated on the facility's policy and procedure. a. Two opened packages of bread (English muffin and white loaf bread) in the working station were not labeled to indicate date food items were opened. b. Three trays of blueberry dessert, cornbread, and chocolate cake placed on a rack in the dry storage room were not labeled with item name and date when they were made. c. An opened box of cinnamon streusel coffee mix and corn flakes crumbs were not labeled to indicate date when it was opened. d. A container with brown grains in the dry storage did not have a label to indicate the food item. e. Four packages of mandarin orange sauce were not labeled to indicate expiration date. f. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (device used by residents to call staff) was within reach for one of 19 sampled residents (Resident 75). The call light was observed on the floor, out of reach (more than the arm's length) of Resident 75. This failure had the potential to put Resident 75 at risk for fall that could lead to a serious injury and/ or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a homelike environment for three of 19 sampled residents (Resident 53, Resident 76, and Resident 57) by failing to provide a working wall clock with the correct time. This deficient practice had the potential to negatively impact the resident's quality of life and further confuse the residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-specific care plan addressing the Preadmission Screening and Resident Review II (PASRR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care) recommendations for one of 19 sampled residents (Resident 27). This deficient practice had the potential for Resident 27 to not get the appropriate care and interventions for her mental needs.

Inspectors wroteCross Reference with F692 and F726 Based on interview and record review, the facility failed to review and revise a care plan to address a significant weight loss (weight loss of five percent in one month) for one of 19 sampled residents (Resident 35). This deficient practice placed Resident 35 at risk for further decline in nutritional status and continued weight loss, which could result in serious harm.

Inspectors wroteCross Reference with F657 and F726 Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 35) in accordance with the facility policy by failing to: a. Notify the resident's physician of Resident 35's significant weight loss (weight loss of five percent in one month) of 5.5 percent (%) in a month . b. Conduct an Interdisciplinary Team Nutrition Alert meeting (a systematic and interdisciplinary approach to identify, track, intervene, monitor, and follow-up with residents at high risk for significant weight changes, dehydration (harmful reduction in the amount of water in the body), and any other nutrition-related concerns) to address Resident 35's significant weight loss. c. Obtain and implement interventions to prevent further weight loss. [...]

Inspectors wroteCross Reference with F657 and F726 Based on interview and record review, the facility failed to ensure Restorative Nursing Aide 1 (RNA 1) had the appropriate skill sets and proficiencies to provide nursing services for resident in response to a change in condition of significant weight loss (five percent weight loss in one month) for one of 19 sampled residents (Resident 35). This deficient practice had the potential to place Resident 35 and other residents who may be at risk for decline in nutritional status, suffer from unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the effectiveness of psychotropic medications (a type of medication that affects brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 76). This failure had the potential to put the resident at risk for not receiving the appropriate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for one of one sampled resident (Resident 2) when the oxygen tubing observed touching the floor. This deficient practice had the potential to spread respiratory infection to Resident 2.