Atlantic Memorial Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received effective pain management by failing to ensure Licensed Vocational Nurse (LVN) 1 addressed Resident 1's pain when the resident developed dysuria (painful urination) on 6/10/2026. This failure put Resident 1 at risk of unrelieved pain and for delay of care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedures (P&P) to maintain and observe infection control practices by failing to:1. Ensure Resident 69 was on airborne isolation (a set of infection-control measures used in hospitals to prevent the spread of diseases caused by tiny germs that can float in the air and travel long distances) precautions for shingles (painful, blistering skin rash).2. Ensure Medication Cart 1 B was kept clean and in sanitary condition. These failures had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and placed all residents at risk for spread of infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff prepared and handled ready-to-eat foods (any food intended to be eaten without needing further cooking, washing, or preparation to make it safe) using sanitary practices and maintain proper cold handling temperatures for potentially hazardous foods (items that support rapid bacterial growth and require strict temperature controls). These failures had the potential to result in foodborne illnesses (any illness resulting from eating contaminated/spoiled foods), which could result in serious complications for all residents in the facility including hospitalization or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a resident centered Care Plan for one of three sampled residents (Resident 1) who had a diagnosis of left upper extremity (LUE) deep vein thrombosis ([DVT] a blood clot in a deep vein). The facility failed to: 1. Implement Resident 1's Responsible Party (RP) 1 request to display signage over Resident 1 ' s bed instructing nursing staff to avoid taking blood pressures in Resident 1's left upper extremity. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Define resident-specific, objectively measurable target behaviors related to the use of risperidone (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 16.) 2. Ensure divalproex (a medication used to treat mood swings) was used only for conditions or diagnoses as documented in the clinical record in one of five residents sampled for unnecessary medications (Resident 16.) 3. Failing to define specific measurable target behaviors and to ensure a resident did not receive routine psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 43 and Resident 10. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with divalproex (a medication used to treat mood swings) in one of five residents sampled for unnecessary medications (Resident 16). This failure of failing to obtain informed consent prior to initiating treatment with medications used to treat problematic behaviors could have prevented Resident 16 from exercising his right to decline treatment with divalproex. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered and individualized care plan for one of two sampled residents (Resident 63) who was unvaccinated (not having received a vaccine) and exposed to Influenza A (a contagious viral infection that attacks the respiratory system and can cause widespread outbreak). This failure had the potential to result in an inadequate monitoring, and not receiving care specific to resident's needs causing a delay of care to Resident 63.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure communication device (communication board) are accessible to residents for one of four sampled residents (Resident 42) who was nonverbal and lack the capacity to speak. This failure had the potential of placing Resident 42 at risk of not able to communicate needs to staff and misinterpretation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of daily living (activities related to personal care including bathing, showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) to one of four sampled residents (Resident 51). Facility failed to: a. Provide personal hygiene to Resident 51 b. Provide assistance to Resident 51 with morning care, personal hygiene and setting up breakfast tray. This deficient practice resulted in Resident 51 expressing feelings of unkempt, hands dirty, did not feel comfortable eating breakfast in the morning, and low self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary service and care on one of four sampled residents ( Resident 18 and Resident 45) by failing to: 1. Monitor occurrence of bowel movement(movement of feces through the bowel and out the anus) for Resident 79 and provide necessary medications for constipation( a condition in which stool becomes hard, dry, difficult to pass and bowel movements become infrequent) as ordered by the physician. This failure had the potential to put Resident 79 at risk for fecal impaction (hardened stool that's stuck in the rectum or lower colon) that could lead to bowel obstruction(partial or complete blockage of small or large intestines which is life threatening).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident received continuous oxygen as ordered by the physician for two of three sampled residents (Resident 48 and Resident 70) by: a. Failing to ensure Resident 48 received oxygen at two liters per minute (lpm) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) continuously as ordered by the physician. b. Resident 70 nasal cannula was connected to an oxygen concentrator (medical device that help you take in oxygen) These failures had the potential to result in Resident 48 and Resident 70 receiving inaccurate amount of oxygen and cause complications associated with oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for one dose of hydrocodone/apap (a controlled medication used to treat pain) 10/325 milligrams (mg - a unit of measure for mass) affecting Resident 190 in one of two inspected medication carts (Station 1B Cart.) This failure increased the risk of diversion (any use other than that intended by the prescriber) of controlled medications and the risk that Resident 190 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for one of 21 sampled residents (Resident 6 and Resident 242). Resident 6 and Resident 242 was prescribed an antibiotic drug without meeting the Mc Geer Criteria (a set of clinical definitions used for surveillance in long-term care facilities (LTCF) These criteria define the resident symptoms and other clinical criteria that are used to meet infection surveillance definitions.). This failure had the potential to result in Resident 6 and Resident 242 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 79) Medication Administration Record(MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) indicated Resident 79 did not receive his medication on 1/21/2025 for 9:00 a.m. due to nausea and vomiting. This failure indicated an inaccurate Medication Administration Record and had the potential to negatively affect Resident 79's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control practices by failing to: a. Ensure Resident 70's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was kept in a sanitary manner. b. Ensure positive result of Influenza test (test to detect the presence of flu virus) of Resident 79 was relayed to the physician in a timely manner. c. Ensure droplet precaution (actions designed to reduce/prevent transmission of viruses spread or transmittable through air droplets by coughing, sneezing, talking and close contact with an infected patient's breathing) was initiated and observed when Resident 70 tested positive for Influenza A (Flu- a contagious viral infection that attacks the respiratory system and can cause widespread outbreak) and symptomatic (showing symptoms of flu). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) for one of five sampled residents (Resident 6). This failure had the potential to result in Resident 6 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to address one of three sampled residents ' (Resident 1) concerns with documented resolution and follow up. This failure had the potential to violate the resident ' s right to have their grievance addressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise a resident centered care plan for one of three sampled residents (Resident 1) who was at risk for developing permanent foot drop (difficulty in lifting the front part of the foot) extremity by failing to: a. Ensure Resident 1's responsible party (RP) 1 received clear and consistent communication from the Interdisciplinary Team ([IDT] health care professionals who work together with the resident and or RP to plan the residents plan of care) summarizing the changes in Resident 1's insurance payer sources and how it would affect Resident 1's physical therapy plan. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow through with the Preadmission Screening and Resident Review ([PASRR] guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual disability, to ensure their needs will be met ) recommendation to obtain a PASRR level II (results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care) evaluation for two (2) of 19 sampled residents (Residents 12 and 64) who was diagnosed with a mental illness prior to admission in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for dating oxygen tubing and nasal cannula (([NC], a device that deliver extra oxygen through a tube and into the nose) by ensuring the oxygen tubing was maintained weekly for three (3) of 19 sampled residents (Residents 33, 12 and 235) who were receiving oxygen therapy. This deficient practice placed residents at risk of respiratory infections by directly transferring potentially pathogenic (disease causing) organisms through the tubing onto the mucous membranes (moist inner lining of body cavities such as the nose) inside the residents' nasal passages, causing complications associated with oxygen therapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe proper storage of medications, document medications after administration and secure controlled medications by: 1. Failing to ensure the antibiotic medication count sheet for two (2) of two residents (Resident 34 and Resident 44) was signed after medication administration. 2. Failing to ensure the emergency kit #87([E-kit] a small quantity of medications that can be dispensed when pharmacy services are not available) was sealed and locked in the medication storage room. These deficient practices had the potential for medication dispensing errors, theft or diversion for controlled medications and placed staff and residents at risk for unsafe medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide two of 10 sampled residents (Resident 59 and Resident 4) a mechanical soft diet (a diet that was designed for people who have trouble chewing and swallowing) with chopped food items as ordered by the physician. This failure had the potential to result in accidents such as choking and aspirating (food, liquid, or other material enters a person's airway and eventually the lungs by accident, causing infections).

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of infectious agents that could cause food borne illness (food poisoning: any illness resulting from the food spoilage or contaminated food) for 84 out 88 total residents in the facility by not: 1. Ensure Foods were dated, labeled, and discarded before the used by date (expiration dates). 2. Monitoring and maintaining the proper level of the concentration of the quaternary ammonium (a type of chemical that is used to kill bacteria, viruses, and mold) in the sanitization bucket. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide for one (1) of 19 sampled residents (Resident 29) an ongoing program to support the resident in a choice of activities such as activities, regular room visits. This deficient practice has the potential to cause psychosocial harm and feelings of isolation for Resident 29 and further exacerbations (negative feeling) of depression and anxiety.

Inspectors wroteBased on observation and interview the facility failed to ensure a safe, hazard free environment as evidenced by topical medication left in a medication cup at the bedside of one of one Residents (Resident 81). This deficient practice placed Resident 81 and other residents of the facility at risk of adverse effects due to misuse of the medication left at the bedside table.