Atlas Post Acute

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure medical gas and vacuum systems have documented maintenance programs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: K918 - Generator Reports Missing No reports for May - July 2024 Conductance testing, Transfer time for the generator 8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdiction 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing .. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011. Sprinkler yellow tagged | Both dry system and nitrogen system will need to be repaired NFPA 101: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maint.. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61.Fire Drills Missing | Missing May to August 2024 NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference. During the survey, it was determined that the facility trans-fill room did not meet the oxygen safety requirements in accordance with NFPA 101 (2012) and NFPA 99 (2012). This was evidenced by:1. Ventilation in Oxygen transfer room | Not NFPA 99 compliant | Need a redesign of ventilation to capture gases from within 12inches from the floor and at ceiling level (D)2012 NFPA 999.3.7.4 The transfilling area shall be ventilated in accordance with NFPA 55, the Compressed Gases and Cryogenic Fluids Code.9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously unless the authority having jurisdiction approves an alternative design.9.3.7.5.3.. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is one story, Type V (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 dry-pipe, automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1963 and is license for 146 beds. This re-certification survey conducted on November 19, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012).. Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1. This was evidenced by:Emergency and Exit Lighting Reports Missing June - July 2024 7.9.3 Periodic Testing of Emergency Lighting Equipment.7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:(1)Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks bet..

A recertification survey with complaints #CO36850, #CO37720, #CO37759 and Incident #37981 was completed from 10/16/24 to 10/22/24. One deficiency was cited. An Emergency Preparedness survey was conducted from 10/16/24 to 10/22/24. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for three (#38, #18, #23) of three residents out of 32 sample residents. Specifically, the facility failed to provide food choices according to resident preferences for Resident #38, Resident #18 and Resident #23.I. Facility policy and procedureThe Resident Food Preferences policy, revised 2015, was provided by the nursing home administrator (NHA) on 10/22/24 at 4:30 p.m. It read in pertinent part, "Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident' s or representative' s consent."Nursing staff will document the resident' s food and eating preferences in the care plan."II. Resident #38A. Resident statusResident #38, age greater than 65, was admitted on 5/10/21. According to the October 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with peripheral angiopathy (blood vessel disease). According to the 9/12/24 minimum data set (MDS) assessment the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required set-up assistance with eating. The MDS assessment indicated the resident was on a therapeutic diet.B. Resident interviewResident #38 ..