Atrium Place Health and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to have physician orders for the resident's immediate care when staff failed to transcribe one resident's surgical wound treatments from the hospital discharge orders into the facility physician orders and failed to obtain a treatment order for the coccyx (tailbone) wound, which was present on admission, which resulted in the treatment not being provided/documented for four days after admission (Resident #111). The sample size was 24. The census was 102. The administrator was notified on 6/26/25, of past non-compliance. When the facility identified the issue, they immediately assessed the resident's current condition, notified the physician/Nurse Practitioner (NP). Treatment orders were put in place per provider's order. The admitting nurse and wound nurse received corrective actions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed the Nurse Practitioner's (NP) order for intravenous (IV) fluids following critical laboratory results for one of 24 sampled residents (resident #68). The NP order for IV fluids was entered into the electronic physician's order sheet (ePOS). There was no documentation the IV fluids were administered. The resident continued to decline and was transferred to the hospital for treatment. The census was 102. Review of the medical provider order policy, reviewed 5/4/26, showed:-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided were consistent with professional standards when one resident (Resident #111) was admitted to the facility with a physician's order for a regular diet with Total Parenteral Nutrition (TPN, a nutrient solution, including lipids, that is administered through a central venous access device. This solution usually consists of proteins. carbohydrates, electrolytes, vitamins. trace minerals, and lipids (as indicated)); and staff failed to transcribe the order into the medical record and/or failed to document communication with the hospital showing the physician order was changed. The sample was 24. The census was 102. The Administrator was notified on 06/26/26, of the past non-compliance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed ensure one resident (Resident #12) received the correct treatment order for a pressure injury (damage to the skin and underlying tissue caused by prolonged pressure) and failed to update the resident's care plan to include the resident's pressure injury. In addition, two residents received new treatment orders for pressure injuries on 1/2/26, that were not implemented until 1/5/26, and staff failed to ensure one of those two residents with an order for off-loading boots (pressure relieving boots) wore those boots at all times as ordered (Residents #4 and #1). Five residents were sampled for pressure injuries, four current residents and one discharged resident, and problems were found with three. The census was 98. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed their Enhanced Barrier Precautions (EBP) policy while providing care to residents that required EBP precautions during high contact activities. Five residents were observed during skin assessments, treatments and/or personal care, and staff failed to wear gowns during four of those five observations. (Residents #1, #4, #7 and #12). The census was 98. Review of the facility Enhanced [NAME] Precautions policy dated 1/1/23 and revised on 4/23/25, showed:-Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs);-Definitions: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards by not following physician orders and not obtaining one resident's vital signs (blood pressure, temperature, pulse rate, respirations and oxygen saturation) (Resident #1). The sample was three. The census was 100. Review of the facility's Medical Provider Orders policy, revised, [DATE], showed: -Policy: The facility shall use uniform guidelines for the ordering and following of medical provider orders; -Following of medication and/or treatment orders: -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contain all required elements; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document completed wound treatments or treatment refusals by the resident on the treatment administration record (TAR) for one resident (Resident #1). The sample was three. The census was 100. Review of the facility's Medical Provider Orders policy, revised, [DATE], showed: -Policy: The facility shall use uniform guidelines for the ordering and following of medical provider orders; -Following of medication and/or treatment orders: -Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contain all required elements; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) for one (Resident #1) of three sampled residents. Resident #1 had physician orders for a full code status. On [DATE] shortly before 7:00 A.M., staff removed the resident's oxygen when transferring the resident to bed, placed him/her on the bed in a flat position and as staff turned him/her, the resident was noted not to be breathing. Licensed Practical Nurse (LPN) A got the Nurse Manager (NM), who said the resident died. The NM told LPN A two nurses could verify a resident's death. Staff did not perform CPR. The resident expired. The facility had 89 out of 94 resident who were listed as full code. The census was 94. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of one resident's (Resident #1) low lab results and to ensure the Medical Director (MD) and other physicians had full access to lab results in the system the physicians use. The MD was not aware of lab results for seizure medications for Resident #1, and the resident sustained seizure activity 18 days later. The facility also failed to ensure the physician was notified when Resident #1 had a change of condition of new purple discoloration to the resident's fingertips at 8:30 P.M. and did not notify the on call Nurse Practitioner (NP) until approximately 4:30 A.M. after the resident had a fall. The facility failed to document the initial assessment of the change of condition in the medical record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when two residents were involved in physical resident to resident altercation, after an argument escalated with both residents hitting each other (Residents #1 and #2). The residents were separated by staff and other nearby residents. The sample was four. The census was 91. The facility was notified of past non-compliance on 9/25/24. Facility staff notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on the abuse and neglect prevention, intervention and de-escalation of resident arguments and disagreements. This deficiency was corrected on 9/18/24. Review of the facility's Abuse, Neglect and Exploitation, showed: -Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents a safe, clean, comfortable and homelike environment. One resident's air conditioning unit leaked into the room, causing puddles under the bed and a wet feel and smell in the room (Resident #78). One resident's call light indicator, above his/her room door, did not work resulting in a delay in staff answering the call light (Resident #16). In addition, staff failed to provide a homelike environment on the 300 hall when there were floor tiles chipped, baseboard and transition strips chipped and broken along the floor, and the door frame for room [ROOM NUMBER] pulled away. The census was 85. The sample was 18. Review of the facility's Nursing Home Residents' Rights, provided to residents upon admission to the facility, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents. One resident was not positioned in an upright position during meals, resulting in a coughing episode (Resident #6). In addition, staff failed to adequately monitor smoke breaks to ensure residents followed facility protocol for safe smoking for two of three smoke breaks observed (Residents #33, #82, and #41). The census was 85. The sample was 18. 1. Review of Resident #6's care plan, in use at the time of the survey, showed: -Diagnoses included dementia and dysphagia (difficulty swallowing); -Focus: Current functional performance Hoyer (mechanical lift) and new recliner wheelchair: -Goal: Will progress towards personal discharge goals; -Interventions included: Eating: independent/set-up help only. Transfer: [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week during the most recent available quarterly payroll-based journal (PBJ) staffing report. The sample was 18. The census was 85. Review of the facility's PBJ Staffing Data Report, dated for Quarter 2 20204 (January 1- March 31), showed: -This staffing data report identifies areas of concern that will e triggered (e.g., requires follow-up during the survey); -One star staffing rating: Triggered; -No RN hours: Triggered; -Infraction dates: Thursday 3/21, Friday 3/22, Saturday 3/23, Sunday 3/24, Saturday 3/30, Sunday 3/31. During an interview during the entrance conference, on 7/29/24 at 10:27 A.M., the Administrator said Corporate Staff B is responsible for the PBJ reports. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for two of two narcotic books reviewed. The census was 85. Review of the Facility's Controlled Substance Administration & Accountability policy, dated 9/1/21, showed: -Policy: it is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure; -Policy explanation and compliance guidelines: -Inventory Verification: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication rate less than 5%. Out of 27 opportunities for errors, four errors occurred resulting in a 14.81% medication error rate (Residents #18, #72 and #50). The sample was 18. The census was 85. Review of the facility's Medication Administration Policy, dated 9/1/21, showed: -Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Policy explanation and compliance guidelines; -Review Medication Administration Record (MAR) to identify medication to be administered; -Compare medication source (bubble pack, vial, etc.) with MAR to verify name, medication, form, dose, route, and time; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards and facility policy in three of three medication carts reviewed. The census was 85. Review of the facility's Medication Storage Policy, dated [DATE], showed it is the policy of this facility to ensure all medication housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Review of the facility's Medication Administration policy, dated [DATE], showed identify expiration date. If expired, notify nurse manager. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program to control the presence of flies in the kitchen. The facility census was 85. Observation of the kitchen on 7/29/24 at 10:30 A.M., showed the backdoor to the outside left opened. There were several flies throughout the food prep areas of the kitchen, outside of the walk-in cooler, and inside the dry food storage room. There were flies outside of the walk-in cool. Observation of the kitchen on 7/30/24 at 6:27 A.M. and 7:05 A.M., showed multiple flies throughout the food prep areas of the kitchen. There was a swarm of flies outside of the walk-in cooler. The backdoor to the outside stood opened. Observation of the kitchen on 8/1/24 at 7:30 A.M. and 12:25 P.M., showed multiple flies throughout the food prep area of the kitchen. The backdoor to outside remained opened. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity and respect for one sampled resident (Resident #59). The sample size was 18. The census was 85. The facility was notified of past non-compliance on 8/3/24. Facility staff immediately intervened, separated the resident and staff, reported the incident, and began their investigation. The investigation consisted of written statements, interviews from witness, and other staff and residents on the unit. Staff were in-serviced on abuse and neglect prevention and promoting/maintaining resident dignity. The deficiency was corrected on 7/2/24. Review of the facility's Promoting/Maintaining Resident Dignity policy, dated 7/2/24, showed: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services based on acceptable standards of practice by not obtaining a physician order for one resident who was using a Bi-level positive airway pressure (bi-pap, helps with breathing) machine (Resident #16) and for failing to complete neuro check documentation for one resident who fell (Resident #63). The sample was 18. The census was 85. Review of the facility's Medical Provider Orders Policy, dated 9/1/21, showed: -Policy: this facility shall use uniform guidelines for ordering and following medical providers orders; -Medications and/or treatments should be administered only upon the signed order of a person lawfully authorized to prescribe. Review of the facility's Fall Prevention Program Policy, dated 9/1/21, showed: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to keep one resident (Resident #92) with a seizure disorder free from a significant medication error, when the facility failed to obtain Vimpat (medication used to prevent seizures) from the pharmacy timely, resulting in the medication not being administered for four and half days. The sample was 18. The census was 85. Review of the facility's Unavailable Medication Policy, dated 9/1/21, showed: -The facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed (PRN), and emergency medications; -Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: [...]

Inspectors wroteBased interview and record review, the facility failed to ensure residents were treated with respect and dignity for one resident (Resident #8) who was left exposed in the hall with other residents present when Certified Nursing Assistant (CNA) F refused to get the resident a gown or blanket when he/she got finished in the shower. The census was 92. The sample was 8. The administrator was notified on 5/14/24, of the past non-compliance. Staff were in-serviced on resident rights, the resident's concerns were addressed, and the staff person responsible was terminated. The deficiency was corrected on 5/10/24. Review of the facility's Resident Rights policy, last revised 9/1/22, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing, for two of three residents observed to receive pressure ulcer care (Residents #2 and #7). The census was 92. The sample was 8. Review of the facility's Wound Treatment Management policy, dated 9/1/22, showed: -Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one resident with a diagnosis of severe protein-calorie malnutrition and who was categorized as severely underweight and who had a wound, when staff failed to accurately monitor the resident's weights, failed to timely document weights obtained, and failed to accurately document nutritional supplement administration, resulting in the registered dietician using inaccurate weights and inaccurate information to determine the resident's nutritional status and nutritional needs. In addition, the facility failed to provide the resident's physician and dietician ordered nutritional supplements to the resident (Resident #7). This resulted in weight loss of 3.9% from March to April 2024, and the resident's continued severely underweight status. The census was 92. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately report an allegation of resident to resident verbal abuse, which was overheard by Licensed Practical Nurse C, involving Resident #1 and Resident #2 to facility management and to the Department of Health of Senior Services (DHSS) within the required two-hour time frame. The sample was three. The census was 95. The Administrator was notified on 5/8/24, of the past non-compliance, which began on 4/28/24. The facility had in-serviced all staff on the Abuse Policy: Reporting and Response. The deficiency was corrected on 4/29/24. Review of the facility's Abuse, Neglect and Exploitation Policy revised 8/22/22, showed: -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, which included verbal aggression, for one sampled resident (Resident #1) out of three sampled residents. The facility census was 95 residents. Review of the facility's Behavior Management policy, revised 9/1/22, showed: -Residents who exhibit behavioral concerns may require a behavior management care plan to ensure they are receiving appropriate services and interventions to meet their needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pain management consistent with professional standards of practice, and care plan interventions related to pain for one of six sampled residents (Resident #3). The facility failed to timely administer pain medications in accordance with the physician's orders. Additionally, facility staff failed to follow up with resident pain medication to ensure availability for administration and failed to implement measures, including use of medication available in the facility starter kit/emergency drug kit, when the resident's pain medications were unavailable. The census was 94. Review of the Medication Reordering policy, dated 9/1/21, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide needed care and services to promote the healing of a foot wound for one resident sampled for wounds (Resident #3). The sample size was six. The census was 94. Review of the facility's Wound Treatment policy, revised 9/1/24, showed: -Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change; -In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents (Residents #1 and #3) received room trays with food that was palatable and at the required temperatures for safe consumption. The sample was six. The census was 94. Review of the facility's Record of Food Temperatures policy, dated 9/1/21, showed: -Policy: It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled; -Policy Explanation and Compliance Guidelines: Food temperatures will be checked on all items prepared in the dietary department; -Hot foods will be held at 135 degrees Fahrenheit (F) or greater; -Hot foods will be stirred during holding to redistribute heat throughout the food product; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% by failing to administer medications at the prescribed times to eight out of nine sampled residents, resulting in a 88% error rate (Residents #8, #2, #5, #9, #7, #3, #4 and #6 ). In addition, the facility failed to have a policy that addressed expectations when medications were not administered with 60 minutes prior to or after scheduled time. The sample was 9. The census was 81 Review of the facility's Medication Administration policy, undated, showed: -Medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practices, in a manner to prevent contamination or infection; [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control as the Infection Preventionist for the facility's infection prevention control program. The census was 81. During an interview on 1/9/24 at 10:10 A.M., the Administrator said the facility's designated Infection Preventionist (IP) had resigned at the end of December 2023. Nurse B was meant to act as the facility's backup IP but the Administrator was not sure if Nurse B had finished his/her coursework from the Centers for Disease Control and Prevention (CDC) Infection Prevention training program. During an interview on 1/9/24 at 10:13 A.M., Nurse B said he/she did not complete modules and trainings for the IP program. During an interview on 1/9/24 at 10:14 A.M., the Administrator said the facility currently did not have an IP. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections, by staff failing to follow contact and droplet precautions during a COVID-19 outbreak in the facility for four of eight sampled residents (Residents #2, #15, and #16). The census was 81. Review of the facility's COVID-19 Prevention, Response and Reporting policy, reviewed on 5/15/23, showed: -It is the policy of the facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Home Dialysis Treatment policy and Notification of Changes policy for one resident readmitted to the facility on [DATE], with an order for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) three times a week. Facility staff failed to provide or attempt to provide the resident's transportation to/from dialysis on 11/8/23 and to communicate with the dialysis facility to request a different time for dialysis. Staff also failed to contact the resident's physician of the missed appointment timely and was not notified of the missed dialysis until 11/9/23. In addition, the facility failed to reassess/monitor and notify the physician of the resident's low blood pressure (BP) obtained on the evening of 11/8/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff ordered intravenous (IV) antibiotics from the pharmacy on 11/10/23, causing one resident to miss his/her first scheduled doses of vancomycin and ceftriaxone on 11/11/23 (Resident #5). Staff failed to order seizure and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) medication for one additional resident (Resident #11). Staff failed to notify the Director of Nurses (DON), physician and family of the missed doses of antibiotics and missed doses of seizure and sleep apnea medications. The facility failed to ensure one nurse knew how to mix another resident's antibiotic with a solution to administer the antibiotics as ordered. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident was free from physical abuse (Resident #6). On 11/27/23, Resident #11 had his/her hands around Resident #6's neck, and began to choke and hit him/her on the back of the head. The sample was 11. The census was 82. The Administrator was notified on 12/12/23 of the past non-compliance. The facility immediately intervened and separated the residents, arranged for ongoing medical care for both residents, updated the care plans of both residents and provided training for all staff regarding the facility's abuse prevention policy. Review of the facility's Abuse and Neglect, Exploitation and Misappropriation Prevention policy, updated 4/2021, showed the following: -Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. [...]

Inspectors wroteBased on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety by failing to wear hair restraints to fully cover their hair and/or facial hair and by failing to perform hand hygiene after touching contaminated surfaces. Additionally, staff failed to ensure the floors in the dry storage area were free from grime and debris, and to ensure trashcans were covered while not in use. These deficient practices had the potential to affect all residents who ate meals at the facility. The census was 73. 1. Review of the facility's Handwashing Guidelines for Dietary Employees policy, revised 9/1/21, showed: -Policy: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses; -Compliance Guidelines included: -Dietary employees shall keep their hands and exposed portions of their arms clean; [...]

Inspectors wroteBased on interview and record review, the facility failed to schedule and organize resident council meetings for residents who wished to participate in group meetings. This deficient practice had the potential to affect all residents in the facility. The census was 73. Review of the facility's Statement of Resident Rights, provided to residents upon admission, showed: -Under federal and state laws, you have the following rights and responsibilities; -The right to participate in the resident council. During an interview on 7/20/22 at 10:19 A.M., the Activity Director said resident council meetings should be held on a monthly basis and should be scheduled by the Activity Director. The Activity Director started her position with the facility three months ago and obtained her certification for the position two weeks ago. She has not held any resident council meetings, yet. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents a safe, clean, comfortable and homelike environment, for two of two central baths observed. Staff failed to ensure air conditioning units, light covers, vanity drawers, chairs, and dresser draws were in good repair and the facility failed to ensure water temperatures were at a comfortable level for six residents (Residents #6, #61, #55, #33, #45 and 13). The sample was 18. Then census was 73. 1. Review of the facility's housekeeping project schedule, for July 2022, showed shower rooms scheduled for deep cleaning on Thursdays. 2. Observation of the 300 A central bath, on 7/18/22 at 8:33 A.M., 7/19/22 at 6:57 A.M. and 7/20/22 at 8:25 A.M., showed: -The bottom left corner of the closet next to the sink, with water damage. The wood swollen, peeled and chipped; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status, by failing to ensure all required sections of the residents Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) were assessed for seven residents (Residents #47, #39, #45, #30, #22, #6 and #46). The sample was 18. The census was 73. 1. Resident #47 admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Interview for activity preferences, blank; -Staff assessment of daily and activity preferences, blank. Review of the resident's quarterly MDS, dated [DATE], showed: -Should the brief interview for mental status (BIMS) be conducted: Yes; -BIMS, blank; -Should the resident mood interview be conducted: Yes; -Resident mood interview, blank. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for four residents (Residents #30, #7, #6 and #39) to include smoking needs that matched the smoking assessment and transfer status. The sample was 18. The census was 73. Review of the facility's Resident Smoking policy, dated 9/1/21, showed: -This facility provides a safe and healthy environment for residents, visitors and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents; -Safe smoking measures will be documented on each resident's care plan and communicated to staff, visitors, and volunteers, who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities. The facility failed to offer activities in the evenings or weekends. A group of residents said they wanted evening and weekend activities and activities that were more meaningful to them. One resident (Resident #46) reported feeling bored. In addition, the facility failed to ensure resident activity preferences were assessed and/or document activity participation (Residents #8 and #47). The sample was 18. The census was 73. Review of the facility's Activity Evaluation policy, revised June 2018, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents when the facility staff failed to provide oversight to residents who smoked as required per their smoking assessment, failed to ensure one resident had a smoking apron on when smoking per their smoking assessment, and failed to ensure the smoking blanket was available in the event of an emergency, for four residents sampled for smoking safety (Residents #30, #7, #22 and #6). The facility identified 11 residents who smoked. The survey team identified two additional residents who smoked. The census was 73. Review of the facility's Resident Smoking policy, dated 9/1/21, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to immediately conduct a complete investigation and implement interventions to protect the resident, after an allegation of resident to resident verbal abuse. This affected two residents (Residents #14 and #55). The census was 73. Review of the facility's Abuse, Neglect and Exploitation policy, revised on 3/3/22, showed the following: -Under Section V, Investigation of Alleged Abuse, Neglect and Exploitation, showed an immediate investigation is warranted when a suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur; -Written procedures for investigations include: -Identifying staff responsible for the investigation; -Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders and/or facility policy by failing to obtain blood pressures on dialysis days for one of five residents receiving dialysis, failed to ensure one resident's protein supplement, recommended by the Registered Dietician, was ordered timely and failed to ensure one resident had their wanderguard discontinued and ensure another resident with a wanderguard had their wanderguard assessment completed (Residents #210, #4, #57 and #11). The census was 63. 1. Review of Resident #210's admission record, dated 9/6/19, showed: -admitted on [DATE]; -Diagnoses included diabetes, end stage renal disease and dependence on renal dialysis. Review of the resident's physician's order sheet (POS), dated 9/1/19 through 9/30/19, showed: -An order, dated 2/8/19, for dialysis on Tuesdays, Thursdays and Saturdays; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure three of three unopened insulin pens were stored in the refrigerator until in use. The facility had two medication carts containing insulin. The census was 63. Review of the facility Storage of Medications policy, revised in April of 2007, showed the following: Policy Statement: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; Policy Interpretation and Implementation: -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location. Medications must be stored separately from food and must be labeled accordingly. Observation on 10/17/19 at 12:06 P.M. of the 100/700 medication cart, showed five insulin pens. Three of the pens had been opened and were dated with the opening date. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident admitted with reverse isolation precautions had a sign placed on the door alerting staff and or visitors to inquire with a nurse prior to entering the room (Resident #110). In addition, the facility failed to ensure staff followed their policy for infection control during two of three observations of residents receiving perineal care and one of one observation of staff completing a blood sugar check (accu-check) (Residents #10 and #41). The census was 63. 1. Review of the facility Isolation - Initiating Transmission-Based Precautions policy, revised on January 2012, showed the following: Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions; Policy Interpretation and Implementation; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly notify the physician of abnormal lab results and failed to ensure nursing staff tracked a resident's bowel movements during the month preceding a hospitalization in which the resident (Resident #58) was found to have a fecal impaction, urinary tract infection and sepsis (blood infection). Additionally, the facility failed to assess and document a resident's vital signs in the resident's medical record, preceding the resident's hospitalization for a change in condition (Resident #16). The census was 63. 1. Review of Resident #58's 5-day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/27/19, showed: -admission date 9/1/11; -Severe cognitive impairment; -Rejection of care not exhibited; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate treatment and documentation consistent with professional standards of practice for pressure ulcers acquired and after pressure ulcers were identified for one resident (Resident #41). The facility also failed to ensure dressings were replaced after being soiled or removed by the resident (Resident #6). The facility identified six residents with pressure ulcers. All six were sampled and problems were found with two. The census was 63. Review of the facility's Pressure Ulcer/Injury Risk Assessment Policy, revised July 2017, showed: -Purpose: The purpose of this procedure is to provide guidelines for the structured assessment and identifications of residents at risk of developing pressure ulcers/injuries; -General Guidelines: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff maintained proper placement of an indwelling urinary catheter (a tube inserted into the bladder for purpose of continual urine drainage) and ensure a resident received the correct catheter size, as ordered by the physician. The facility identified four residents with indwelling urinary catheters. Of those four, all were selected for the sample and problems were found with one (Resident #58). The census was 63. Review of Resident #58's 5-day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/27/19, showed: -admission date 9/1/11; -Severe cognitive impairment; -Rejection of care not exhibited; -Extensive assistance of one person required for bed mobility and transfers; -Total dependence of one person required for toilet use; -Indwelling catheter; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rates are not 5 percent or greater. Out of 31 opportunities observed, there were two errors, resulting in a 6.45% medication error rate (Residents #34 and #17). The census was 63. 1. Review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/6/19, showed the following: -Extensive assistance for bed mobility; -Diagnoses of high blood pressure, paraplegia (paralysis in the lower half of the body), anxiety and depression. [...]