Atterdag Care Center

Inspectors wroteBased on record review and interview, the facility failed to revise a care plan for one of two sampled residents (Resident 1) after Resident had multiple falls on 2/17/26,3/4/26, and 3/10/26, This facility failure placed Resident 1 at higher risk for falls with injuries. During a review of the admission Record (AR) for Resident 1, admission date 8/26/24, The AR indicated Resident 1 was a [AGE] year old male with diagnosis including Senile Degeneration of the Brain (Progressive loss of cognitive function characterized by memory loss, confusion, behavioral changes, and impaired daily functions) and Alzheimer's Disease (Progressive, incurable disease causing brain shrinkage and neuron death characterized by memory loss, cognitive decline, and behavioral changes), Adjustment disorder with mixed anxiety and depressed mood, Abnormalities of gait and mobility. [...]

Inspectors wroteBased on record review, interview, and policy and procedure, the facility failed to ensure the medical record contained documentation for a reason as needed (PRN) medication was given for one of two sampled residents (Resident 1). This failure had the potential to result in an incomplete medical record for a resident medication administration requirement. [...]

Inspectors wroteBased on record review and interview, the facility failed to meet federal regulatory requirements when the clinical record for one of three sampled residents (Resident 8) had no documented justification for extending a PRN (as needed) psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) order beyond 14 days. This failure had the potential to result in Resident 8 receiving an unnecessary psychotropic medication which could affect the resident's health and safety.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plan interventions were properly implemented and documented in the clinical record for two of three sampled residents (Residents 8 and 2) when:1. Monitoring for wander guard device (a monitoring device used to ensure safety for residents at risk for elopement/wandering) placement and function was not implemented and documented in Resident 8's clinical record.2. Monitoring for pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) status and function was not implemented and documented in Resident 2's clinical record. These monitoring oversight failures inaccurately reflect these residents' current health statuses which could potentially compromise their health and safety.

Inspectors wroteBased on interview and record review, the facility failed to revise one out of five sampled residents (Resident 36) care plan following minimum data set (MDS - a standardized, comprehensive assessment tool used to collect essential resident data) assessments. This failure resulted in inaccurate care planning for Resident 36's healthcare needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of resident care and services were performed within acceptable professional nursing standards for three of six sampled residents (Residents 8, 45 and 36) when:1. Resident 8 missed their medication on several occasions, and there was no subsequent follow-up by the nursing staff.2. Resident 45's oxygen (O2) saturations (02 sats- measure of 02 in the blood) were not consistently documented in the clinical record.3. Resident 36 was treated with Calmoseptine Ointment (a multi-purpose moisture barrier used to soothe and protect irritated skin from moisture, itching, and discomfort) for a wound without a physician's order. These failures had the potential to result in unsafe nursing care practices which could compromise the health and safety of these residents.

Inspectors wroteBased on interview, observation and record review, the facility failed to obtain monthly weights for one of four sampled residents (Resident 4). This failure had the potential for undetected weight fluctuations that could signal underlying health problems.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician provided timely consultation or treatment when contacted by the facility to address a change in condition for two of five sampled residents' (Residents 23 and 28). This deficient practice resulted in a delay in care and treatment to meet Residents 23's and 28's immediate care needs and had the potential to result in an avoidable deterioration in health. During review of the facility's policy and procedures (P&P) titled, Change of Condition, dated 9/30/24, the P&P indicated in part, Purpose: To ensure that appropriate care and documentation occurs when residents experience a change of condition. Procedure: 2. Notify the attending physician promptly.5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nursing staff signed the controlled drug record after administering medication. This failure had the potential to result in unauthorized tampering and diversion of resident medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired medical supplies from a wound treatment cart (a mobile cart containing equipment, and supplies needed to treat wounds.)This facility failure had the potential for staff to utilize deteriorated and ineffective healthcare supplies for treatment of patients.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety requirements were met when:1) Two dietary aides (DAs 1 and 2) did not completely cover their hair, with the required hair restraint, while in the food preparation area. 2) Dietary staff did not follow the facility's policy and procedure when cleaning and sanitizing kitchen surfaces. 3) Contaminated food was not removed from dry food storage area. These failures had the potential to cause food borne illness to the residents. 1) During an observation on 1/9/26 at 9:41 a.m. with Director of Nutrition Services (DNS), in the food preparation area, DAs 1 and 2 hair restraints were noted not properly covering the hair area. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the informed consent [a resident's right to make an informed voluntary decision about their care, requiring providers to clearly explain their health status, treatment risks/benefits, alternatives (including refusal)] for psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) had accurate information for one of three sampled residents (Resident 8). This failure had the potential to result in Resident 8 receiving inappropriate care and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were implemented when: Laundry washing machine water temperatures were below the minimum required temperature for infection control. Personal protective equipment (PPE - protective equipment such as gloves, gowns, masks, and eye protection that creates a barrier to protect patients, healthcare workers from infectious materials, bloodborne pathogens, and other hazards, and to prevent the spread of illness to others) was not readily available in four out of four residents (Residents 6, 27, 36, and 48) on enhanced barrier precautions (EBP - Infection control measures the involves wearing PPE for specific high-contact tasks such as bathing, transfers, and wound care for at-risk residents to stop germ spread). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation by Social Services Designee (SSD) was completed for one of three sampled residents (Resident 1) medical records regarding allegations of abuse involving Resident 1. This facility failure resulted in Resident 1's medical record not accurately reflecting SSD follow-up on abuse allegations, potentially impacting the adequacy of care for Resident 1. During a review of Resident 1's admission Record, [undated], the admission Record indicated, Resident 1 was 94 years-old, admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the personal property inventory list was updated for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1's belongings to be lost or unaccounted for.

Inspectors wroteBased on observation, interview and review of facility documents, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety when: 1. The high temperature dish machine was not reaching 150 degrees Fahrenheit (F) for the wash cycle and 180 degrees F for the rinse cycle and the facility did not have a mechanism to verify the plate level temperature was reached according to their policy and procedure; and 2. [NAME] 2 (C2) did not change gloves after touching raw meat then touching other items. These failures resulted in equipment, utensils, dishware and silverware not being properly cleaned and sanitized and had the potential to result in the growth of microorganisms which can cause foodborne illness for the 49 residents eating food from the kitchen.

Inspectors wroteBased on review of the medical record for resident and interview with the facility's Director of Nursing (DON) on 1/23/2025, regarding resident 20's blood pressures, the facility had failed to ensure that this resident's blood pressure monitoring had been ordered by the resident's physician and not by the facility's nursing staff. The facility also failed to develop a policy and procedure which identified hypotension for the nursing staff. The facility's failure had the potential to put this resident at risk of severe hypotension which could result in ultimate organ failure and shock.

Inspectors wroteBased on interview and record review, the facility failed to monitor the medication refrigerator temperature twice a day and maintain the temperature within acceptable range. This failure had the potential for the residents to receive ineffective medications due to improper storage.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure residents were provided a well-balanced, physician prescribed diet that met their nutritional needs when meal ticket and diet order did not match for seven (7) residents (Residents 7, 23, 29, 34, 35, 37, and 38). This failure had the potential for residents to receive incorrect diets and have nutritional deficits.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menus were followed when: 1. The incorrect portion sizes for meat and vegetables were served for the puree diet during the lunch meal on 1/22/25 for four residents (Residents 2, 3, 29, 35); and 2. The incorrect portion sizes were served for one resident (Resident 30) for the lunch meal on 1/21/25. This failure has the potential to result in residents not having their nutritional needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST- a form that documents a resident's treatment wishes in the event of a medical emergency) matched the electronic medical record (EMR) in one of one sampled resident (Resident 23). This failure had the potential to cause a delay in receiving or incorrectly administering life-sustaining treatments.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan to address Restorative Nursing Assistant (RNA) services for one of three sampled resident (Resident 27). This failure had the potential for care and services not to be provided to Resident 27 that could potentially cause a decline in mobility and muscle strength.

Inspectors wroteBased on review of the medical record for resident, interview with the resident's nurse, and interview with the facility's Director of Nursing (DON) on 1/23/2025, regarding resident 247, the facility failed to ensure that Standards of Practice regarding Tachycardic pulses which resulted in abnormal results, had been addressed by the facility and medical staff. The facility also failed to develop a policy and procedure which identified tachycardia. This failure had the potential to put this resident at risk for a heart attack or a stroke.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure and validate the dishwashing machine was functioning properly and was in safe operating condition when the temperatures of the wash and rinse were not reaching manufacturer's directions. This failure had the potential to result in temperatures not reaching proper temperature levels which led to all the dishware, silverware, utensils, pots and pans not being sanitized to which can result in the growth of microorganisms which can lead to food borne illness for the highly susceptible population that was eating at the facility. The facility census was 49.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe food handling and sanitation when: 1. Expired pizza sauce per the facility's refrigerated shelf- life guidance was available for use in the walk-in refrigerator. 2. Opened bag of cheese was not dated when opened to have a system to follow the facility's Refrigerated Storage Chart, shelf-life guidance. 3. The dry food storage room stored an undated opened bag of pasta, multiple large, unopened canned foods not dated with a received date, ingredient bins containing flour, and thicken-up were not dated, and a dented can of tuna was available for use. 4. The wall located by the clean side of the high temperature dish machine had extensive black colored substance on the surface of the wall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection control practices were followed when: 1. A Housekeeping Staff (HK 1) did not use gloves while sweeping and collecting trash inside a resident's room (room [ROOM NUMBER]), and did not perform hand hygiene after contact with potentially contaminated items. 2. A Licensed Nurse (LN 1) did not sanitize the handheld inhaler of one unsampled resident (Resident 34) before and after use and did not perform hand hygiene after contact with the resident. 3. LN 5 did not sanitize a glucometer test kit (a kit containing test strips and a device used to measure blood sugar) and perform hand hygiene after checking the blood sugar of one of 14 sampled residents (Resident 24). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a care plan for one of 14 sampled residents (Resident 19), to prevent a pressure ulcer (an injury that breaks down the skin and underlying tissue) on the buttocks from developing or getting worse. This failure resulted in the development of two stage I (first stage- shearing off of the first layer of the skin ) pressure ulcers to the left and right buttocks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate, and effective system for monitoring parameters of nutritional status when: 1. An order for a therapeutic (to cure or restore to health) liquid nutritional supplement (Mighty Shake) was not documented as being provided and lacked documentation of quantity of consumption of the therapeutic nutrition supplement for effective monitoring pertaining to parameters of nutritional status for one of ? sampled residents (Resident 41). 2. Speech therapist (ST) recommendation for 1:1 supervision during mealtimes was not communicated via an order to ensure the recommendation based on ST assessment would be implemented for Resident 41's health and safety when the texture of a diet order was modified. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a nutrition services employee had the appropriate competency and skill set to carry out the function of accurately completing the Dishmachine Temperature Log. The facility failure to have accurate documentation of dish machine temperatures and lack of monitoring of the dishmachine temperature log impeded the facility's ability to identify temperature problems that could have occurred for prompt resolution to ensure the health and safety of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu as planned when: 1. The SB 6 (Soft, Bite Sized Food) diet was not followed related to the size of meat in accordance with the facility's planned menu, and Diet Manual for SB 6 diet for two of 14 sampled residents (Resident 35 and Resident 3). 2. A regular portion diet was not followed per the planned menu, and diet order, for one of 14 sampled residents (Resident 8) when small portions were served by a cook in the main kitchen. This failure had the potential to not meet the resident's nutritional needs per the planned menu as approved by the facility's Registered Dietitian. In addition, not following the correct size of meat for a SB 6 diet had the potential to place resident's at an increased risk of choking.

Inspectors wroteBased on interview and record review, the facility failed to ensure its required QAA (Quality Assessment and Assurance) Committee (a committee organized by the facility which is responsible for developing and implementing corrective action plans for identified quality deficiencies) members included a credentialed Infection Preventionist [(IP - a staff trained to have oversight of the facility's infection prevention and control program (IPCP)]. This failure had the potential to result in the facility's IPCP not getting implemented effectively which could lead to misinformation, inadequate surveillance and reporting, and spread of healthcare associated infections.

Inspectors wroteBased on interview, and record review, the facility failed to designate a credentialed Infection Preventionist [(IP - a staff trained to have oversight of the facility's infection prevention and control program (IPCP)]. This failure had the potential for no coordination of infection control practices, increasing the risk of infections for residents, staff, visitors and others in the facility.