Atlantic Specialty Care

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to notify the resident's representative in writing and the state ombudsman of a transfer to the hospital for 1 of 2 residents (#8). The facility also failed to provide a bed hold with reserve bed payment information for 2 of 2 residents (#6 & #8). The facility reported a census of 72 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interviews, and the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, October 2025, the facility failed to complete and submit the admission Minimum Data Set (MDS) in the required time frame for 1of 19 residents reviewed (Resident #83). The facility reported a census of 72 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to develop a care plan to address risk factors and interventions for 1 out of 19 residents (Residents #54) reviewed for comprehensive care plans. The facility reported a census of 72 residents.

Inspectors wroteBased on observation, staff interview, clinical record review, and policy review, the facility failed to provide appropriate incontinence care for 1 of 1 resident (#49). The facility reported a census of 72 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review, the facility failed to lock the wheelchair for 1 of 16 residents dependent on mechanical lift transfers (#49). The facility reported a census of 72 residents.

Inspectors wroteBased on clinical record review, staff interview, and guidance from the Centers for Disease Control and Prevention (CDC), and policy review, the facility failed to provide the recommended influenza vaccine for 1 of 5 eligible residents (#2) and the recommended pneumococcal (pneumonia) vaccine for 1 of 5 eligible residents (#8). The facility reported a census of 72 residents.

Inspectors wroteBased on observations, documentation review, resident interviews, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility failed to take and document temperatures of food in the kitchen prior to distribution. The facility reported a census of 61 residents.

Inspectors wroteBased on observations, staff interviews, and policies reviewed the facility failed to store, prepare, serve, and distribute food in accordance with professional standards. The facility reported a census of 61 residents.

Inspectors wroteBased on clinical record review, staff interview, hospital document review, staff interviews and facility assessment review the facility failed to implement care and treatment consistent with the resident care plan and physician orders placing the resident at risk for 1 of 16 residents reviewed. Resident #61 required special monitoring of weights and vital signs related to diagnosis of congestive heart failure. Staff failed to consistently monitor the weight and intervene with diuretic medication, and failed to conduct daily vital signs. The facility reported a census of 61 residents.

Inspectors wroteBased on observations, staff interview and clinical record review the facility failed to implement interventions for the prevention of pressure ulcers for 1 of 3 residents reviewed. Resident #54 was at risk for chronic pressure injuries and was found to be without the treatment dressing or protective boots. The facility reported a census of 61 residents.

Inspectors wroteBased on observation, interview and policy review the facility failed to ensure that medications were secured to prevent residents from access. In an observation the survey team found an unlocked, unattended medication cart in the hallway of resident rooms. The facility reported a census of 61 residents.

Inspectors wroteBased on observation, document review, staff interview, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by use of incorrect serving size portions for meals for 1 of 61 residents reviewed. The facility reported a census of 61 residents.

Inspectors wroteBased on observation, resident interview, clinical record review, staff interview and policy review the facility failed to maintain accurate medical records for 1 of 16 residents reviewed. Staff documented that the vital signs for Resident #61 had been completed and the chart lacked documentation of those vitals. The facility reported a census of 61 residents.

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to ensure that staff used appropriate infection control practices to prevent the spread of pathogens for 1 of 3 residents reviewed. Staff failed to change gloves after adjusting a soiled brief for Resident #27 she then touched other surfaces with the same gloved hand. The facility reported a census of 61 residents

Inspectors wroteBased on interviews, clinical record review, and facility policy review the facility failed to provide dignity by staff swearing in the hallways outside the residents' rooms for 2 of 6 residents (Resident #2 and #5) reviewed. The facility reported a census of 57 residents. Findings Include: 1. Record review of the Minimum Data Set (MDS) for Resident #2, dated 8/8/24 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating normal cognitive functioning. The document revealed the resident had adequate hearing and did not utilize hearing appliances. On 10/22/24 at 12:43 PM Resident #2 stated he had heard staff using swearing when having conversations in the hall. The resident confirmed it was not another resident using swear words. Resident #2 stated the language that he heard did bother him. 2. [...]

Inspectors wroteBased on clinical record review, resident and family interviews, staff interviews and facility policy review the facility failed to provide the needed services in accordance with professional standards by not completing neuroogical assessments after falls for 2 of 2 residents (Resident #1 and #5) reviewed. Resident #1 self reported an unwitnessed fall from bed on 8/24/24 and sustained a hematoma on the right side of his forehead. Resident #5 had a witnessed fall involving a motorized scooter, and sustained a hematoma on the forehead and 3 skin tears on 9/12/24. The facility reported a census of 57 residents.

Inspectors wroteBased on clinical record review, interviews, and facility policy reviews, the facility failed to provide adequate nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 6 residents (Resident #2, #3, #5, and #6). The facility reported a census of 57.

Inspectors wroteBased on observations, clinical record review, staff interviews and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during medication administration (Resident #8, #7, and #3). The facility reported a census of 63. 1. During continuous observation of medication administration on 8/12/24 at 11:40 AM Staff A, Certified Medication Aide (CMA) did not consistently complete hand hygiene between 4 residents. 2. During continuous observation of medication administration on 8/12/24 at 11:55 AM Staff B, CMA, did not complete consistent hand hygiene between 16 residents. 3. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating normal cognitive function, and the resident independent with toileting and transfers. [...]

Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to protect residents from possible accidents and injuries for 2 of 3 residents (#3, #9). The facility reported a census of 63 residents.

Inspectors wroteBased on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October1 - December 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, facility record review, staff interviews and facility policy review the facility failed to ensure that residents received accurate and timely assessments and interventions for 5 of 6 residents reviewed. Staff failed to intervene when Resident #25 and #57 had significant weight loss. Resident #120 had a change in condition and staff failed to monitor vitals. Resident #59 was at risk for dehydration related to tube feedings and a catheter and staff failed to monitor his urinary output. Staff failed to complete the recommended neurological assessments after Resident #119 had an unwitnessed fall. The facility reported a census of 65 residents.

Inspectors wroteBased on resident interviews, staff interviews, grievance log review, clinical record review and policy review, the facility failed to ensure that call lights were answered in a timely manner for 11 of 21 residents reviewed. The facility reported a census of 65 residents.

Inspectors wroteBased on observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 4 of 15 residents (Residents #7, #9, #38, and #60) reviewed. The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, observations, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices when providing personal care to a resident, during medication administration, and when providing care to a resident on enhanced barrier precautions (EBH) for 5 of 12 residents reviewed for infection control. The facility reported a census of 65 residents.

Inspectors wroteBased on resident interview, family interview, staff interviews, clinical record review and personnel record review, the facility failed to ensure that all residents were treated with dignity and respect for 2 of 4 residents reviewed. Resident #57 reported that he has been left to sit on the bed pan for over 50 minutes and he felt upset and angry because he had a sore on his bottom. Resident #35 reported that staff scolded her for drinking too much water and urinating in the bed. The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, staff interviews and policy review the facility failed to enter accurate assessment information in the Minimum Data Set (MDS) for 2 of 21 residents reviewed (Resident #36 and #33). The facility reported a census of 65 residents.

Inspectors wroteBased on electronic record review (EHR), observations, policy review, resident interview, and staff interviews the facility failed to provide a comprehensive care plan that included goals or interventions for activities or activities of interests and documented insulin on a care plan for a resident who was not on insulin for 1 of 5 residents reviewed (Resident #61). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review and facility policy review the facility failed to update resident care plans with changes. Resident #57 admitted to the facility on insulin for type 2 diabetes. The order was discontinued on 4/15/24 due to lack of use. Staff failed to update the care plan. Resident #36 was on an antiplatelet medication (Plavix). Staff failed to use the proper classification on the care plan and referred to the medication as an anticoagulant/blood thinner. The facility reported a census of 65 residents.

Inspectors wroteBased on observation, staff interviews, resident interview and clinical record review, the facility failed to follow physician's orders for 1 of 21 residents reviewed. Resident #57 had chronic skin damage on his gluteal area related to moisture and positioning. In an observation it was discovered that the ordered barrier cream and treatments were not in place. The facility reported a census of 65 residents.

Inspectors wroteBased on electronic record review (EHR), resident observation, policy review, resident interviews, and staff interviews the facility failed to implement resident centered activities for 1 of 5 residents reviewed (Resident #61). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical document review, resident interview, staff interview, and policy review the facility failed to provide services to increase range of motion or prevent a decrease in range of motion for 1 of 3 residents (Resident #42) reviewed. The facility reported a census of 65 residents.

Inspectors wroteBased on electronic health records review (EHR), staff interviews, policy review, and observations, the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by not accurately administering supplemental formula according to physician's order and pushing medications with a piston syringe into feeding tube for 1 of 1 residents (Resident #59) reviewed. The facility reported a census of 65 residents.

Inspectors wroteBased on resident interview, staff interview and clinical record review the facility failed to conduct post-dialysis assessments for 1 of 1 resident reviewed (Resident #57). The facility reported a census of 65 residents.

Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to document accurate information in the residents electronic file for 1 of 4 residents reviewed for falls. Resident #119 had an unwitnessed fall and staff began neurological assessments to determine change in status. The neuro assessments included notation that the vital signs had been completed as directed. Further review revealed the chart lacked the vital signs. The facility reported a census of 65 residents.

Inspectors wroteBased on observation, clinical record review, resident interview and staff interviews, the facility failed to assure each resident received care in a manner that maintained privacy of a resident's body for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 67 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to assure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers from developing, promote healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents reviewed (Resident #6). The facility reported a census of 67 residents.

Inspectors wroteBased on clinical record review, resident interviews, family interviews, staff interviews and facility policy review the facility failed to treat residents with respect and dignity for 4 of 4 residents reviewed (Resident #7, #2, #15 and #10). The facility reported a census of 67 residents.

Inspectors wroteBased on clinical record review, resident interviews, family interviews, staff interview and facility policy review the facility failed to ensure residents were provided with routine toileting assistance throughout the day to avoid being incontinent for 4 of 4 residents reviewed (Resident #7, #15, #9 and #10). The facility reported a census of 67 residents.

Inspectors wroteBased on clinical record review, family interview, staff interview, and facility policy review, the facility failed to notify family after an incident for 1 of 3 residents. Resident #9 sustained an injury to her leg when her motorized wheel chair ran into the bed frame and staff failed to call the family after the incident. The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, family interview, staff interviews and facility policy review the facility failed to provide timely and complete assessments for 1 of 3 residents reviewed. Resident #9 sustained an injury on her leg after she ran her electric wheel chair into the bed and her leg got wedged under the bed frame. The facility failed to assess for safe use of an electric wheel chair and failed to provide ongoing monitoring and documentation of the cellulitis of the leg that ensued after the accident. The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to ensure 1 of 3 residents (Resident #4) was provided adequate nursing supervision to prevent him from exiting the building. The facility reported a census of 67 residents.

Inspectors wroteBased on clinical record review, resident interviews and staff interviews the facility failed to ensure that staff responded to call lights in a timely manner for 2 of 3 residents reviewed. Resident's #15 and #9 stated that during the evening and overnight hours, at times it took over an hour for staff to respond to the call lights and they became incontinent because they had to wait so long. The facility reported a census of 68 residents.