Atrium Center for Rehabilitation and Nursing

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that the sufficient nursing staff was consistently provided to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1). review of the actual staffing schedules dated from 06/01/2024 to 09/30/2024 revealed that staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment for Licensed Practical Nurses, 2). the facility Payroll Based Journal (Quarter 4 2024 (June 1 - September 30) and Quarter 1 2025 (October 1 - December 30) also revealed an excessively low weekend staffing, 3). [...]

Inspectors wroteBased on record review and interviews conducted during a Recertification/Complaint Survey from 03/02/2025 to 03/07/2025, the facility did not ensure a resident had the right to refuse a room transfer. This was evident for 1 (Resident #125) of 2 residents reviewed for Notification of Change out of 38 total sampled residents. Specifically, Resident #125 was transferred from the 3rd Floor to the 1st Floor without their consent.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey and Complaint (NY00365250) survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that residents' right to a clean, comfortable, and homelike environment was maintained. Specifically, multiple resident rooms were observed with water damage on walls, ceiling tiles, and in resident hallways. This was evident on 1 (7th Floor) of 5 resident units observed during the Environment Task.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 03/02/2025 to 03/07/2025, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 1 (Resident #98) of 2 residents reviewed for Resident Assessment, and 1 (Resident #125) of 5 residents reviewed for Unnecessary Medication out of 38 total sampled residents. Specifically, 1). the Minimum Data Set 3.0 assessment for Resident #98 did not accurately reflect the resident's bowel and bladder status, and 2). the Minimum Data Set 3.0 assessment for Resident #125 did not accurately reflect a diagnosis of Bipolar Disorder.

Inspectors wroteBased on record review and interviews conducted during a Recertification/Complaint Survey from 03/02/2025 to 03/07/2025, the facility did not ensure that the resident and/or their representative were provided with a written summary of the baseline care plan and the baseline care plan assessment was completed within 48 hours. This was evident for 1 (Resident #364) of 1 resident reviewed for Care Planning out of 38 sampled residents.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey from 03/02/2025 through 03/07/2025, the facility did not ensure that each resident receives treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #19) of 6 residents observed during the Medication Administration task. Specifically, Resident #19 did not receive Cyanocobalamin Injection Solution, 1000 Microgram Intramuscular, daily for 7 days until 01/21/2025 as per hospital discharge instruction. The medication order contained conflicting routes within one order, and nursing staff continued to administer Cyanocobalamin 1000 Microgram 1 tablet sublingually every week for 8 weeks, without a physician order directing them to continue to administer the medication for longer than one week.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 03/02/2025 to 03/07/2025, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident # 56) of 2 resident reviewed for Position/Mobility out of 38 sampled residents. Specifically, there were multiple observations of Resident #56 without the right-hand roll in place as per Occupational Therapy recommendation and physician orders.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 03/02/2025 to 03/07/2025, the facility did not ensure that the attending physician document review and action, if any, to address pharmacy reported irregularities. This was evident for 1 (Resident #19) of 6 residents observed during the Medication Administration. Specifically, pharmacy recommendation to correct Cyanocobalamin (vit B-12) 1,000 mcg tablet with directions to inject 1 milliliter by intramuscular route every week was not addressed by the Attending Physician.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 03/02/2025 to 03/07/2025, the facility did not ensure that the medication error rate was not less than 5 percent. This was evident for 3 of 27 medications observed during the Medication Administration task. Specifically, Resident #298 did not receive three (Norvasc 5 milligrams 1 tablet by mouth daily, Folic acid 18 milligrams/0.4 milligrams 1 tablet by mouth daily and Cholecalciferol (vitamin d3) 25 microgram (1,000 unit) tablet by mouth daily) of their prescribed medications because those medications were not available, resulting in a medication error rate of 11.11%.

Inspectors wroteBased on observation, record review, and staff interview conducted during the recertification survey, from 03/02/2025 to 03/07/2025, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and stored under proper temperature controls per manufacturer's recommendations. Specifically, 1.) two opened insulin pens (Humalog and Novolog) currently being use were not dated when opened, and 2). One opened Lantus insulin pen was not dated and discarded with 28 days. This was evident for 1 (Unit 6) of 7 medication carts observed during the Medication Storage task.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 4/03/23 to 4/12/23, the facility did not ensure food was stored in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during the Kitchen observation. Specifically, (1) there were 2 boxes of expired half and half creamer in the refrigerator, and (2) there were 2 boxes of expired saltine crackers in the dry storage room.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 4/3/2023 to 4/12/2023, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made, to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident # 26) out of 3 residents reviewed for Falls. Specifically, the facility did not report an unwitnessed incident resulting in a laceration to Resident #26's right eyebrow to the NYSDOH within 2 hours of occurrence.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 4/3/23 to 4/12/23, the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised by the interdisciplinary team after each assessment. This was evident for 1 (Resident #230) of 5 residents investigated for Accidents. Specifically, Resident #230's CCP related to elopement risk was not reviewed and revised upon each quarterly assessment.

Inspectors wroteBased on interview and record review conducted during a Recertification survey from 04/3/23 to 4/12/23, the facility did not ensure pain management was provided to a resident. This was evident for 1 of nine 2 residents reviewed for pain management out of 35 sampled residents. (Resident #217). Specifically, nursing staff did not administer pain medications as per physician's orders to a resident who complained of pain on several occasions. The finding is: The facility policy titled Pain Assessment Procedure dated 7/24/22 documented the facility will utilize the interdisciplinary approach to assess each resident for acute and chronic pain and develop an effective program that will address those needs. Every resident who experiences pain will be re-assessed for pain and will have a treatment plan established to treat the pain. [...]

Inspectors wroteBased on observations, record reviews and interviews conducted during the Recertification/ Complaint Survey from 04/03/23 to 4/12/23, the facility did not ensure that residents' Minimum Data Set (MDS) assessments accurately reflect the residents' status. This was evident for 4 of 35 sampled residents (Resident #s 201, 45, 66, and 230). Specifically, (1) Resident #210's most recent MDS assessment did not reflect the resident used continuous oxygen; (2) The MDS incorrectly documented Resident #45 had a diagnosis of Schizophrenia; (3) The MDS documented Resident #66, who is legally blind, had no vision impiarment; (4) The MDS documented Resident #230, a resident with a wander alert device, had no wander alert device in use.

Inspectors wroteBased on observation, record review and staff interview conducted during the Recertification survey, the facility did not ensure infection control practices and procedures were maintained and followed to help prevent the development and transmission of communicable disease and infection. Specifically, a Certified Nursing Assistant (CNA) did not perform hand hygiene after his hand came in contact with the trash bin as he discarded a cup and before he served water to another resident. The CNA was also observed not performing hand hygiene after exiting the soiled utility room and before entering the dining room. This was evident for random observations of one CNA on 1 of 7 units (Unit 6).