Atrium Nursing and Rehabilitation

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to document in the medical record the reason for a facility initiated transfer to another facility when the facility temporarily ceased operations. This affected all 16 residents who had resided in the building and were transferred. Additionally, the facility failed to provide sufficient preparation and involvement with the residents and legal guardians prior to transferring residents. This affected three (#17, #18 and #15) out of three records reviewed for transfers. A total of 16 residents were transferred from the facility. The current census was zero.

Inspectors wroteBased on interview, record review and policy review, the facility failed to provide written notification to residents and the resident's representatives before the transfer of residents to another facility due to a temporary closure, failed notify the State Long-Term Care Ombudsman prior to transferring residents, and failed to notify the State Survey Agency of the plan for the transfers and adequate relocation of the residents. This affected all 16 residents residing in the facility and transferred due to a temporary closure of the facility. The facility census was zero.

Inspectors wroteBased on interview, document review, and policy review, the facility failed to submit the appropriate closure plan procedures to the State Agency regarding the temporary closure of the facility and failed to notify the Ombudsman's office prior to the relocation of the residents. This affected all residents previously residing in the facility. The facility census was zero.

Inspectors wroteBased on staff interview, record review, review of witness statements, review of Self-Reported Incidents (SRI), and policy review, the facility failed to implement their abuse policy with an allegation of sexual abuse. This affected one (Resident #06) out of two residents reviewed for abuse. The facility census was 18.

Inspectors wroteBased on staff interview, record review, review of witness statements, review of Self-Reported Incidents (SRI), and policy review, the facility failed to report an allegation of sexual abuse to the state survey agency in a timely manner. This affected one (Resident #06) out of two residents reviewed for abuse. The facility census was 18.

Inspectors wroteBased on staff interview, record review, review of witness statements, review of Self-Reported Incidents (SRI), and policy review, the facility failed to thoroughly investigate an allegation of sexual abuse. This affected one (Resident #06) out of two residents reviewed for abuse. The facility census was 18.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicaid & Medicare Services (CMS) timely. This affected three Residents (#03, #08, and #10) of three residents reviewed for resident assessments. The census was 18.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident's comprehensive care plan was updated. This affected one (Resident #09) of five residents reviewed for unnecessary medications. The facility census was 18.

Inspectors wroteBased on observation, staff interview, and review of a facility census document, the facility failed to ensure adequate hot water was supplied to a common shower room and resident rooms. This affected six (#8, #9, #11, #12, #13, and #19) of 19 residents that resided at the facility. The facility census was 19.

Inspectors wroteBased on medical record review, staff interview, and review of the Resident Assessment Instrument 3.0 manual, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and submitted per the Centers of Medicare and Medicaid Services requirements. This affected six (#4, #8, #13, #16, #17, and #18) of 19 residents reviewed for resident assessments. The facility census was 19.

Inspectors wroteBased on observation, staff interview, review of a facility census document, medical record review, review of water temperature logs, and facility policy review, the facility failed to ensure hot water temperatures were maintained in a safe manner. This affected 13 (#1, #2, #3, #4, #5, #6, #7, #10, #14, #15, #16, #17, and #18) of 19 residents that resided at the facility. The facility census was 19.

Inspectors wroteBased on observation, staff interview, review of resident trust documentation, review of a resident census report, and medical record review, the facility failed to ensure residents whose care was funded by Medicaid had personal funds in excess of fifty dollars ($50.00) deposited and held in an interest bearing account. This affected one (#8) of four residents reviewed for resident funds accounts. The facility census was 19.

Inspectors wroteBased on medical record review, observations, review of shower schedules, review of shower sheets, resident and staff interview, and review of the Resident Assessment Instrument manual, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurate. This affected one (#13) of five residents reviewed for accurate MDS assessments. The facility censes was 19.

Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to ensure wound care on a resident's surgical wound was completed based on the physician's order. This affected one (#10) of one resident reviewed for surgical wounds. The facility census was 19.

Inspectors wroteBased on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure application of prescribed foot care treatments were completed as ordered. This affected one (#18) of one residents reviewed for prescribed foot treatments. This facility census was 19.

Inspectors wroteBased on medical record review, review of a facility provided medication administration time verification document, staff interview, and review of a facility policy, the facility failed to ensure medications were administered within prescribed timeframes. This affected one (#7) of one resident reviewed for pain medication administration. The facility census was 19.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were reviewed and addressed in a timely manner. This affected one (#9) of five residents reviewed for unnecessary medications. The facility census was 19.

Inspectors wroteBased on observation, medical record review, resident and staff interview, hospice staff interviews, hospice contract review, and facility policy review, the facility failed to ensure collaboration with hospice providers for resident care. This affected two (#1 and #13) of two residents reviewed for hospice care. The facility census was 19.

Inspectors wroteBased on record review, staff interview, review of the Legionella Environmental Risk Assessment, review of the Water Management Plan, review of the Legionella Control measures and Monitoring, review of water temperature logs, review of weekly monitoring logs, review of the online resources from the Centers for Disease Control and Prevention (CDC), and review of facility policy, the facility failed to follow their Water Management Plan and Legionella Risk Assessment. This had the potential to affect all 18 residents who resided in the facility. The facility census was 18.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to provide a clean and homelike environment. This had the potential to affect all 18 residents residing on the secured behavioral unit. The facility census was 18.

Inspectors wroteBased on staff interviews and record review, the facility failed to convey resident funds within 30 days of residents being discharged from the facility. This affected three Residents (#87, #88 and #89) out of the five residents reviewed for conveyance of personal funds. The facility census was 18.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure residents' advanced directives were updated and accurate in the medical record. This affected one Resident (#30) out of the two residents reviewed for advanced directives. The facility census was 18.

Inspectors wroteBased on observations, staff interviews, record review, and review of facility policy, the facility failed to provide a comfortable, safe, and homelike environment. This affected three Residents (#25, #30 and #29) of three residents reviewed for environment. The facility census was 18.

Inspectors wroteBased on record reviews, staff interviews, and review of facility policy, the facility failed to ensure residents, and their representatives were offered and received care conferences or the ability to participate in care planning. This affected two Residents (#18 and #19) out of the two residents reviewed for participation in care planning and care conferences. The facility census was 18.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to obtain signed refusal forms for vaccinations and failed to obtain any information related to prior immunizations and vaccinations for newly admitted residents. This affected two Residents (#08, and #13) out of five Residents reviewed for immunizations and vaccinations. The facility census was 18. Findings Include: 1) Review of the medical record for Resident #08 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, schizophrenia, hyperlipidemia, diabetes mellitus (DM), gastro-esophageal reflux disease (GERD), and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 01/09/25, revealed Resident #08 had impaired cognition. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure there was a Registered Nurse (RN) scheduled for at least eight consecutive hours daily. This had the potential to affect all 41 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 41 residents who resided in the facility.

Inspectors wroteBased on review of facility's mold testing results, physician interview, review of Quality Assurance and Performance Improvement (QAPI) documentation, and staff interview, the facility failed to inform Medical Director (MD) #500 of high levels of mold discovered in the facility. This had the potential to affect all the residents of the facility. The census was 41.

Inspectors wroteBased on observation, staff interview, review of facility audits, and review of operation manuals, the facility failed to ensure essential equipment was maintained in a safe and properly functioning manner. This had the potential to affect all residents in the facility. The facility census was 41.

Inspectors wroteBased on observation, resident interview, mold testing company interview, staff interview, and review of the facility's mold testing results, the facility failed to abate and remediate the presence of mold in the facility and the facility failed to ensure residents were provided with a clean, safe, homelike environment. This had the potential to affect all 41 residents residing in the facility.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the medical record, review of a facility self-reported incident (SRI), observations, resident and staff interviews, and policy review, the facility failed to provide supervision and intervention to prevent Resident #31, who had impaired cognition, was at risk for elopement and resided on a secured behavioral unit, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (Resident #31) was placed at potential risk for serious life-threatening harm and/or injury when the resident eloped from his bedroom window without staff knowledge and was found 2.6 miles from the facility pushing a shopping cart in a shopping center parking lot. This affected one (#31) of five residents reviewed for risk for elopement. [...]

Inspectors wroteBased on record reviews, observations, resident and staff interviews, review of the facility policy, the facility failed to provide a clean and safe environment for residents. This affected 12 (#28, #69, #32, #33, #35, #36, #17, #02, #03, #05, #06 and #07) residents out of 12 residents reviewed. The facility census was 71.

Inspectors wroteBased on medical record review, review of hospital records, review of a fall investigation, observations, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place for a resident identified at high risk for falls and failed to conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in Actual Harm when Resident #07 fell from the bed that was not in the lowest position and sustained a leg fracture requiring surgical intervention. This affected one (#07) of three residents reviewed for falls. The census was 72.

Inspectors wroteBased on record review, observations and resident and staff interviews, the facility failed to provide a safe environment for residents. This affected three (#39, #40, and #41) out of four residents sampled for the physical environment and the potential to affect all independently ambulatory residents 100 hallway (#04, #05, #06, #07, #08, #11, #12, and #13). The census was 72.

Inspectors wroteBased on record review, observation, staff interview, and review of facility policy, the facility failed to have an effective pest control program. This affected four (#05, #06, #07, and #08) out of four residents reviewed for pest control. The census was 72.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide a comfortable, safe, and homelike environment by ensuring the residents had hot water. This affected 33 residents (#41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, and #73) out of 72 residents at the facility. The facility census was 72.

Inspectors wroteBased on observations, resident and staff interviews and review of facility policy, the facility failed to maintain essential equipment to provide hot water to the residents. This affected 33 residents (#41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, and #73) out of 72 residents at the facility. The facility census was 72.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure an egress door's push bar was maintained and working properly on the secured behavioral unit. This affected 33 residents (#41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, and #73) out of 72 residents at the facility. The facility census was 72.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, hospital record review, laboratory results review, staff and physician interview, and policy review, the facility failed to properly monitor Coumadin (an anticoagulant medication) use for Resident #20. Resident #20 had a high Prothrombin Time/International Normalized Ratio (PT/INR) (a laboratory test to measure how long it takes for blood to clot) of 52.4 seconds (PT) and 4.9 (INR) that was drawn on [DATE] and was not reported to the physician until [DATE]. Resident #20 was to have the next PT/INR drawn on [DATE]; however, it was not obtained. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure portable space heaters were not used in resident accessible areas. This had the potential to affect 28 Residents (#2, #4, #5, #7, #8, #9, #10, #11, #12, #13. #14, #15, #16, #17, #18, #19, #20, #21, #23, #24, #25, #26, #28, #29, #32, #33, #34, and #35) who were able to access a common/dining area. The census was 59.

Inspectors wroteBased on observation, staff interviews, and review of a plumbing company repair estimate, the facility failed to ensure a clean and sanitary kitchen due to a substance backing up through a drain in a kitchen closet. This had the potential to affect all the residents in the facility except one resident (#70) who did not receive food from the kitchen. The facility census was 59.

Inspectors wroteBased on medical record review, staff and resident interviews, and interview with receptionist at wound clinic, the facility failed to ensure resident was seen by the wound clinic physician as scheduled. This affected one resident (#34) out of the three residents reviewed for wound care. The facility census was 59.

Inspectors wroteBased on clinical record review, staff interviews, observations, and policy review, the facility failed to provide adequate supervision to prevent a resident's elopement and failed to timely identify the root cause of the resident's elopement. This affected one (Resident #1) of three residents reviewed for elopement. The facility identified 29 residents residing on the secured unit. The facility census was 63.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the phone system was working properly. This had the potential to affect all 68 residents residing in the facility. The facility census was 68.

Inspectors wroteBased on staff interview and review of personnel files, the facility failed to ensure dietary staff were trained and competent to perform the job duties prior to beginning employment. This had the potential to affect all 68 residents residing in the facility. Facility census was 68.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure recipes were followed. This had the potential to affect all 68 residents residing in the facility. The facility census was 68.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure a physical environment was maintained in a safe and sanitary manner regarding the presence of a black substance on the wall in the laundry room. This had the potential to affect all 68 residents residing in the facility. Additionally, the facility also failed to ensure a homelike environment was maintained regarding a sticky substance on the floors and a towel around a toilet to catch urine. This affected three residents (#18, #19 and #20) out of three residents sampled for comfortable living environment. Facility census was 68.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to maintain air conditioning equipment to keep resident rooms at a comfortable temperature. This affected one (#17) out of three residents sampled for comfortable room temperatures. Facility census was 68.

Inspectors wroteBased on observation, staff and resident interviews, the facility failed to ensure resident call lights were working correctly. This affected three (#17, #21 and #22) out of three residents residents sampled for functioning call lights. Facility census was 68.