Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Atlantic Memorial Healthcare Center during CMS and state inspections, most recent first.
A resident with immunodeficiency and pancreatic cancer developed shingles with fluid-filled blisters on the right flank and was placed on contact isolation, although the IPN and DON stated airborne precautions were indicated under the facility’s IPCP for airborne-transmitted pathogens. In a separate observation, Medication Cart 1 B was found with sticky spills, hair, and brown stains, and the DON stated medication carts must be kept clean and orderly.
A cook was observed preparing a ready-to-eat peanut butter and jelly sandwich with bare hands instead of gloves or utensils, and the DS acknowledged this could contaminate food. In the same observation, milk and watermelon juice were found at 46.5 F and 48.0 F, above the required 41 F cold-holding limit; the DS confirmed the items were out of range and facility policy required ready-to-eat foods to be handled sanitary and served at proper temperatures.
A resident with a left upper extremity DVT did not have a care plan that included the location of the DVT or specific instructions for staff to avoid taking blood pressure in the affected arm, despite a request from the responsible party. Staff were unaware of the DVT location and the request, and no signage was present above the resident's bed. The care plan lacked necessary interventions and details, and the facility's policies for person-centered care planning were not followed.
The facility failed to define specific, measurable target behaviors for the use of psychotropic medications in several residents, leading to potential unnecessary medication use. A resident was prescribed risperidone and divalproex without documented specific behaviors or diagnoses, while two other residents had unclear monitoring for psychotropic medication use. Staff interviews revealed a lack of clarity and documentation, increasing the risk of adverse effects.
A facility failed to obtain informed consent from a resident or their responsible party before starting divalproex for mood disorder treatment. The resident, diagnosed with unspecified dementia, had fluctuating decision-making capacity. The Director of Nursing acknowledged the oversight, noting staff confusion about consent requirements for non-antipsychotic medications.
A facility failed to develop a care plan for a resident who was unvaccinated and exposed to Influenza A. Despite having intact cognition and requiring assistance with daily activities, the resident's care plan did not address recent exposure to Influenza A from a roommate. Staff interviews confirmed the absence of a care plan, which was contrary to facility policy requiring updates based on medical changes.
A facility failed to provide a communication device for a nonverbal resident with cognitive communication deficit and dysphagia. Despite the care plan specifying the use of a communication board, observations revealed the absence of such a device in the resident's room. Staff interviews confirmed the device was neither used nor available, potentially hindering the resident's ability to communicate needs.
A resident with cognitive impairment and ADL needs did not receive scheduled personal hygiene care or assistance with eating, leading to discomfort and low self-esteem. Staff interviews revealed that the resident was not assisted with setting up their breakfast tray or positioned for eating, contrary to facility policy.
A resident with a history of myocardial infarction, asthma, and other conditions did not have a bowel movement for several days, leading to vomiting. The facility failed to monitor and report the resident's bowel movements and did not notify the physician as required. Staff interviews revealed a lack of awareness and adherence to monitoring protocols, which could have prevented the resident's symptoms.
Two residents in the facility did not receive oxygen therapy as ordered by their physicians. One resident with COPD had an oxygen concentrator set incorrectly and a nasal cannula on the floor, while another resident returned from dialysis with a nasal cannula not connected to an oxygen source. Staff failed to follow facility policies on oxygen administration and infection control.
A facility failed to accurately account for a dose of hydrocodone/apap 10/325 mg for a resident. An LVN administered the medication but forgot to sign the Controlled Medication Count Sheet, leading to a discrepancy between the count sheet and the medication card. The facility's policy requires immediate documentation after administering controlled medications to prevent risks such as medication diversion or overdose.
The facility failed to follow its Antibiotic Stewardship protocol, leading to two residents being prescribed antibiotics without meeting the necessary clinical criteria. One resident was given Ciprofloxacin for a surgical wound, and another was prescribed Levaquin for pneumonia, despite not meeting the McGeer Criteria. The lack of documentation and communication with physicians contributed to the inappropriate use of antibiotics.
A resident with a history of myocardial infarction, asthma, and other conditions did not receive their scheduled medication due to nausea and vomiting. Despite this, an LVN inaccurately signed the MAR as if the medication was administered and failed to notify the physician. This breach in protocol was recognized by the Infection Preventionist Nurse and the DON, highlighting the importance of accurate documentation to prevent miscommunication.
The facility failed to maintain infection control practices, including improper handling of a nasal cannula for a resident with multiple diagnoses, delayed communication of a positive Influenza A test result for another resident, and failure to implement droplet precautions. These actions increased the risk of infection transmission among residents and staff.
A facility failed to follow its Antibiotic Stewardship protocol for a resident prescribed Ciprofloxacin, despite not meeting infection criteria. The IP did not document notifying the doctor, and the DSD failed to inform the Wound Care Doctor. The DON acknowledged the lack of documentation, contrary to the facility's policy on optimizing antibiotic use.
A resident expressed discomfort with a transportation driver, but the facility failed to document or resolve the grievance. Despite the resident's medical conditions, including ESRD and anxiety disorder, the concern was not recorded in the grievance logs, violating the facility's policy on addressing grievances.
A resident at risk for foot drop experienced a delay in receiving a properly fitted orthotic device due to miscommunication and insurance changes. The facility failed to update the care plan to reflect necessary modifications and specific usage of orthotic devices, leading to confusion among the care team and the resident's responsible party. Interviews revealed a lack of awareness and communication regarding the resident's care plan and orthotic device usage.
Infection Control Failures with Isolation and Medication Cart Cleanliness
Penalty
Summary
The facility failed to implement its infection prevention and control policy by not placing Resident 69 on airborne precautions for shingles. Resident 69 was admitted with diagnoses including immunodeficiency and malignant neoplasm of the pancreas, and the MDS indicated the resident had cognitive impairment and required maximal assistance with toileting, showering, and lower body dressing. The resident developed a rash with fluid-filled blisters on the right flank, was transferred to a general acute care hospital for treatment, and was later ordered valacyclovir three times daily for shingles. During observation, a contact isolation sign was posted outside the resident’s room, and the LVN stated the resident was in isolation for shingles. The IPN stated the resident was placed on contact isolation, but should have been placed on airborne precautions because the resident was immunocompromised. The DON also stated the resident should have been placed on airborne isolation according to the facility’s policy for pathogens transmitted by the airborne route, including disseminated herpes zoster. The facility also failed to keep Medication Cart 1 B clean and in sanitary condition. During observation, the cart had multiple spills of a sticky substance, threads of human hair, and brown stains at the bottom. The LVN stated the medication cart should be clean and kept in sanitary condition and that there was no excuse not to clean it when it was very dirty. The DON stated the medication cart should be free from dirt and sticky spills, should be cleaned after each shift, and that a dirty cart was an infection control risk. The facility policy for medication equipment and supplies stated that the charge nurse on duty ensures equipment and supplies relating to medication administration are clean and orderly.
Improper Hand Hygiene and Cold Food Temperature Control
Penalty
Summary
The facility failed to ensure staff prepared and handled ready-to-eat foods using sanitary practices. During a concurrent observation and interview, a cook was observed preparing a peanut butter and jelly sandwich and spreading the peanut butter and jelly onto bread with bare hands, without wearing gloves or using utensils to avoid direct hand contact with the ready-to-eat food. The cook stated gloves should have been worn and acknowledged that not wearing gloves could contaminate the food and make residents sick. The Dietary Supervisor stated staff are required to wear gloves or use utensils when handling ready-to-eat foods to prevent contamination and ensure sanitary food preparation, and stated that not wearing gloves could place residents at risk for foodborne illnesses such as vomiting and diarrhea. The facility also failed to maintain proper cold holding temperatures for potentially hazardous foods. During observation, milk and watermelon juice were checked with the facility thermometer and registered at 46.5 degrees Fahrenheit and 48.0 degrees Fahrenheit, respectively. The Dietary Supervisor stated cold food items are required to be maintained at or below 41 degrees Fahrenheit and acknowledged that both items were above acceptable temperature ranges. Facility policies reviewed stated that staff should never use bare hand contact with foods, that meals should be served at appropriate temperatures, and that milk, puddings, salads, and juice should be 41 degrees or less. The FDA Food Code reviewed also indicated time/temperature control for safety foods must be maintained at 41 degrees Fahrenheit or below when cold held.
Failure to Develop and Implement Resident-Centered Care Plan for DVT
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for a resident with a diagnosis of left upper extremity (LUE) deep vein thrombosis (DVT). The responsible party (RP) for the resident had specifically requested that signage be placed above the resident's bed instructing nursing staff to avoid taking blood pressures in the affected left arm, but this request was not honored or implemented. Additionally, the care plan did not include the location of the DVT or provide specific instructions for staff on how to assess for complications related to the DVT, such as monitoring for pain, swelling, warmth, discoloration in the affected extremity, or signs of pulmonary embolism (PE) like difficulty breathing, cough, and chest pain. Record review showed that the resident had a history of atrial fibrillation, acute embolism, and thrombosis of the left upper extremity deep veins, with severely impaired cognitive skills for daily decision making. Despite these significant medical issues, the care plan lacked necessary interventions and details. Observations confirmed that no sign was present above the resident's bed, and interviews with staff revealed they were unaware of the DVT location or the RP's request. The MDS nurse and DON both acknowledged that the care plan was generic and did not provide adequate information for staff to deliver appropriate care or assessments. The facility's own policies require the interdisciplinary team to develop a comprehensive, person-centered care plan with measurable objectives and timeframes, and to involve the resident or their representative in the process. However, the failure to include the RP's request and to specify interventions for the resident's DVT resulted in staff not being properly informed or able to assess for complications, as confirmed by staff interviews and record review.
Failure to Define Measurable Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to define resident-specific, objectively measurable target behaviors related to the use of psychotropic medications for several residents. For Resident 16, the facility did not document specific behaviors related to the use of risperidone and divalproex, which were prescribed for agitation and mood disorder/bipolar disorder, respectively. The Director of Nursing (DON) acknowledged the lack of clear, measurable target behaviors, which are essential for monitoring the effectiveness of the medication and preventing unnecessary prolonged use or dosage increases. Additionally, the facility did not ensure that divalproex was used only for documented conditions or diagnoses. Resident 16's clinical records lacked documentation of a mood disorder or bipolar disorder, which were the stated reasons for prescribing divalproex. The DON confirmed the absence of such documentation and expressed concern about the potential adverse effects of using divalproex without a clear indication. For Residents 43 and 10, the facility also failed to define specific measurable target behaviors for the use of psychotropic medications. Resident 43 was prescribed Seroquel for psychosis manifested by disorganized thoughts, but the monitoring of these thoughts was not specific or measurable. Similarly, Resident 10's care plan indicated monitoring for manic episodes such as visual hallucinations, but there was no documentation of what these hallucinations entailed. Interviews with staff revealed a lack of clarity and documentation regarding the behaviors being monitored, which could lead to unnecessary medication use and potential side effects.
Failure to Obtain Informed Consent for Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident or their responsible party before initiating treatment with divalproex, a medication used for mood disorders. This oversight was identified during a review of the resident's clinical records, which showed no documentation of education regarding the risks and benefits of the medication prior to its administration. The resident, who was admitted with a diagnosis of unspecified dementia and had fluctuating capacity to understand and make decisions, was prescribed divalproex for mood disorder/bipolar disorder. The lack of informed consent could have prevented the resident from exercising their right to decline treatment. During an interview, the Director of Nursing acknowledged the failure to obtain informed consent, attributing it to possible confusion among staff regarding the necessity of consent for medications not classified as antipsychotics, antidepressants, anti-anxiety medications, or hypnotics. The facility's policy required informed consent for psychoactive medications, but this was not followed. The Director of Nursing expressed concern that without informed consent, the resident might have taken the medication longer than necessary, potentially leading to adverse effects.
Failure to Implement Care Plan for Unvaccinated Resident Exposed to Influenza
Penalty
Summary
The facility failed to develop and implement a person-centered and individualized care plan for a resident who was unvaccinated and exposed to Influenza A. The resident, who had intact cognition, required assistance with daily activities and had a history of diabetes mellitus, hypertension, and osteomyelitis. Despite being offered vaccines and education on their benefits, the resident refused the influenza vaccine. The care plan in place did not address the resident's recent exposure to Influenza A from a roommate, which was a significant oversight given the resident's unvaccinated status. Interviews with facility staff, including a Registered Nurse Supervisor and an Infection Preventionist Nurse, confirmed that there was no care plan developed to address the resident's recent exposure to Influenza. The Director of Nursing also acknowledged the importance of a care plan to ensure staff are informed about the resident's care needs. The facility's policy indicated that care plans should be updated based on identified problems and changes in medical conditions, but this was not done in this case, leading to a potential delay in care for the resident.
Failure to Provide Communication Device for Nonverbal Resident
Penalty
Summary
The facility failed to ensure that a communication device was accessible to a nonverbal resident, identified as Resident 42, who lacked the capacity to speak. This deficiency was identified through observation, interview, and record review. Resident 42 was admitted with diagnoses including cognitive communication deficit and dysphagia, and their Minimum Data Set (MDS) indicated severely impaired daily decision-making skills. The resident's care plan, dated 10/13/2024, specified the use of a communication board to assist with communication, yet during observations on 1/22/2025 and 1/23/2025, no communication device was found in the resident's room. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), revealed that the communication device was not used or available for Resident 42. The LVN admitted to not using a communication device with the resident in the past and was unable to locate one at the nurses' station. The RN confirmed that the resident was supposed to have a communication assistive device to facilitate communication during care, but it was not present at the bedside. This oversight had the potential to place Resident 42 at risk of being unable to communicate needs to staff and could lead to misinterpretation.
Failure to Provide ADL Care for Resident
Penalty
Summary
The facility failed to provide necessary activities of daily living (ADL) care to Resident 51, who was admitted with diagnoses including a urinary tract infection and required assistance with ADLs due to cognitive impairment. The resident's care plan indicated the need for personal hygiene and assistance with eating, yet the ADL records showed that Resident 51 did not receive scheduled showers or personal hygiene care. This lack of care led to the resident feeling unkempt and uncomfortable, impacting their self-esteem and ability to eat breakfast. During an observation, Resident 51 was found lying flat in bed with an untouched breakfast tray, expressing discomfort due to unwashed hands and inability to sit up or pour milk on cereal. Interviews with staff revealed that the resident was not assisted with setting up the breakfast tray or positioning for eating, as the CNA responsible was attending to another resident. The facility's policy requires staff to ensure residents receive necessary ADL care, including personal hygiene and feeding assistance, which was not adhered to in this case.
Failure to Monitor Bowel Movements and Administer Medication
Penalty
Summary
The facility failed to provide necessary care for a resident by not monitoring bowel movements and administering medication for constipation as ordered by the physician. The resident, who had a history of myocardial infarction, asthma, sequelae of cerebral infarction, and hypertension, was admitted with impaired cognitive skills and required moderate assistance with daily activities. The resident did not have a bowel movement from January 16 to January 20, 2025, and experienced vomiting on January 21, 2025. Despite the lack of bowel movements, the physician was not notified, and the resident was not on a stool softener until a Dulcolax suppository was administered on January 21, 2025. Interviews with staff revealed that the CNAs and licensed nurses failed to monitor and report the resident's bowel movement frequency as required. The CNA responsible for the resident was unaware of the lack of bowel movements, and the LVN confirmed that the physician was not notified. The RN Supervisor and Director of Nursing acknowledged that the lack of bowel movements could lead to serious health issues, including abdominal discomfort and nausea. The facility's job descriptions for CNAs and RNs emphasized the importance of monitoring and reporting changes in residents' conditions, which was not adhered to in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that two residents received continuous oxygen as ordered by their physicians. Resident 48, who was diagnosed with malignant neoplasm of the right lung and COPD, was observed with an oxygen concentrator set at three liters per minute, contrary to the physician's order of two liters per minute. Additionally, the nasal cannula was found on the floor, and the resident was not wearing it during meal times. The Licensed Vocational Nurse (LVN) confirmed that the resident should have been on continuous oxygen and that the nasal cannula should be stored properly when not in use to prevent contamination. Resident 70, who had diagnoses including enterocolitis, end-stage renal disease, diabetes, and myocardial infarction, was observed with a nasal cannula not connected to an oxygen source. The resident had returned from dialysis treatment, and the LVN responsible for the resident's care admitted to not verifying the connection of the nasal cannula to the oxygen concentrator. The Infection Preventionist Nurse (IPN) stated that the resident should have been assessed upon return from dialysis to ensure vital signs were stable and the oxygen equipment was properly connected. The facility's policies and procedures regarding oxygen use and medication administration were not adhered to, as evidenced by the improper handling and administration of oxygen therapy for both residents. The Director of Nursing acknowledged the potential dangers of providing incorrect oxygen levels, especially for residents with COPD, and emphasized the importance of following physician orders and infection control practices.
Failure to Accurately Account for Controlled Medication
Penalty
Summary
The facility failed to accurately account for a dose of hydrocodone/apap 10/325 mg, a controlled medication, for Resident 190. During an observation and interview with a Licensed Vocational Nurse (LVN 1), it was discovered that there was a discrepancy between the Controlled Medication Count Sheet and the medication card. The count sheet indicated 14 doses remaining, while the medication card showed only 13 doses. LVN 1 admitted to administering the missing dose to Resident 190 earlier that morning but forgot to sign the Controlled Medication Count Sheet at the time of administration. The facility's policy and procedures for controlled medications, revised in December 2019, require that the licensed nurse immediately document the date, time, amount administered, and their signature on the accountability record after administering a controlled medication. LVN 1 acknowledged that failing to sign off on the narcotic log at the time of administration poses a risk of medication diversion or overdose, potentially leading to medical complications for the resident.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship for two residents, leading to the prescription of antibiotics without meeting the necessary clinical criteria. Resident 6 was prescribed Ciprofloxacin for a surgical wound despite not meeting the McGeer Criteria for cellulitis, soft tissue, or wound infection. The Infection Preventionist (IP) acknowledged the lack of documentation regarding notifying the doctor about the criteria not being met, and the Director of Staff Development (DSD) confirmed that the doctor was informed but chose to continue the antibiotic. The Wound Care Doctor was unaware of the McGeer Criteria and was not informed that the criteria were not met. Resident 242 was prescribed Levaquin for pneumonia based on a chest x-ray, despite not meeting the McGeer Criteria for antibiotic use. The Surveillance Data Collection Form indicated that the resident had only two criteria for using Levaquin, lacking symptoms such as cough, sputum production, fever, or leukocytosis. The DSD confirmed the absence of documentation about notifying the physician that the criteria were not met, and the Infection Preventionist Nurse (IPN) noted that the antibiotic use did not align with the facility's surveillance criteria. The facility's policy on unnecessary medications, updated in 2019, states that each resident's medication regimen must be free from unnecessary drugs, defined as those used without adequate indications. The facility's Antibiotic Stewardship Program, reviewed in 2023, aims to ensure antibiotics are used only when necessary and appropriate. However, the lack of adherence to these protocols resulted in the inappropriate prescription of antibiotics for both residents, potentially leading to antibiotic resistance and other adverse effects.
Inaccurate MAR Documentation for Resident
Penalty
Summary
The facility failed to ensure accurate documentation in the Medication Administration Record (MAR) for a resident who did not receive their scheduled medication due to nausea and vomiting. On the specified date, the resident, who had a history of myocardial infarction, asthma, sequelae of cerebral infarction, and hypertension, experienced two episodes of vomiting at the time their medication was due. Despite this, the Licensed Vocational Nurse (LVN) signed the MAR indicating that the medications were administered, although they were not given due to the resident's condition. The LVN admitted to signing the MAR without administering the medications and did not notify the physician about the resident's inability to take the medication. This inaccurate documentation was acknowledged by both the Infection Preventionist Nurse and the Director of Nursing, who emphasized the importance of accurate MAR documentation to prevent miscommunication and ensure proper resident care. The facility's policy requires that any withheld or refused medication be documented accurately, which was not adhered to in this instance.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances, leading to potential risks of infection transmission. Resident 70, who had multiple diagnoses including end-stage renal disease and diabetes, was observed with a nasal cannula that was not connected to an oxygen source and was lying on the floor, potentially contaminated. The Licensed Vocational Nurse (LVN 3) acknowledged the oversight and stated that the nasal cannula should have been stored in a plastic bag when not in use, as per the facility's policy. The Infection Preventionist Nurse (IPN) confirmed that the nasal cannula should have been replaced to prevent possible contamination. In another instance, the facility failed to promptly communicate a positive Influenza A test result for Resident 79 to the physician. Resident 79, who had a history of myocardial infarction and asthma, developed a fever and cough, and a test was conducted. The test result was received by the facility, but the Registered Nurse Supervisor (RN 1) did not notify the physician in a timely manner, nor did she contact the Medical Director when the physician did not respond. This delay in communication could have led to a delay in care for Resident 79 and increased the risk of exposure to other residents and staff. Additionally, the facility did not implement droplet precautions for Resident 79 after the positive Influenza A result was received. No signage or isolation cart was present, and Resident 79 remained in the same room with a roommate. RN 1 did not initiate droplet precautions, waiting instead for instructions from the Director of Nursing and IPN, despite knowing that licensed nurses did not need an order to start isolation precautions. The IPN confirmed that droplet precautions should have been implemented immediately to prevent the risk of transmission to other residents and staff.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement their Antibiotic Stewardship protocol for a resident, leading to the potential for antibiotic resistance due to unnecessary or inappropriate antibiotic use. The resident, who was admitted with chronic and duodenal ulcers and a rectal fistula, was prescribed Ciprofloxacin for an abnormal wound culture. However, the Infection Preventionist (IP) noted that the resident did not meet the criteria for a definitive infection according to McGeers Criteria, and there was no documentation that the medical doctor was informed of this finding. The Director of Staff Development (DSD) confirmed that the doctor was informed but failed to document the response in the progress notes. Additionally, the DSD did not notify the Wound Care Doctor who ordered the antibiotic. The Director of Nursing (DON) stated that the IP should have documented the communication with the doctor in the Nursing Progress Notes. The facility's policy on Antibiotic Stewardship emphasizes the importance of optimizing antibiotic use to prevent resistance and ensure resident safety, which was not adhered to in this case.
Failure to Document and Address Resident Grievance
Penalty
Summary
The facility failed to address a resident's grievance regarding discomfort with a transportation driver, as there was no documented resolution or follow-up. The resident, who was admitted with diagnoses including End Stage Renal Disease, anxiety disorder, and major depressive disorder, expressed discomfort with a driver from the transportation company used for hemodialysis trips. The Social Services Assistant reported the concern to the Social Services Manager, who instructed them to file a complaint with the transportation vendor. However, there was no documentation in the resident's medical record regarding the situation or its resolution. Further investigation revealed that the grievance was not recorded in the facility's grievance logs, and the Director of Nursing Services emphasized the importance of documenting residents' concerns to ensure their safety. The facility's policy on grievances, last revised in December 2023, requires the Grievance Official to evaluate, investigate, and take immediate action to resolve concerns and prevent further violations of residents' rights. The lack of documentation and follow-up on the resident's grievance indicates a failure to adhere to this policy.
Failure to Revise Care Plan for Resident at Risk of Foot Drop
Penalty
Summary
The facility failed to revise a resident-centered care plan for a resident at risk for developing permanent foot drop. The deficiency involved a lack of clear and consistent communication from the Interdisciplinary Team (IDT) to the resident's responsible party (RP) regarding changes in insurance payer sources and their impact on the resident's physical therapy plan. Additionally, the direct care team, including licensed nurses, Certified Nurse Assistants (CNAs), and Restorative Nurse Assistants (RNAs), were not adequately educated on the proper use of the resident's orthotic devices, specifically the Ankle Foot Orthosis (AFO) and Pressure Relief Ankle Foot Orthosis (PRAFO). The resident, who had a history of compartment syndrome and major depressive disorder, was admitted with a risk of foot drop. Despite being fitted for an orthotic boot, the resident experienced delays due to miscommunication and insurance changes, resulting in the improper fitting of the device. The care plan did not reflect the necessary modifications or the specific usage of the orthotic devices, leading to confusion among the care team and the resident's RP. The IDT failed to update the care plan to include the pending arrival of a properly fitted orthosis and the specific instructions for using the AFO and PRAFO boots. Interviews with various staff members, including the Director of Rehabilitation (DOR), Physical Therapist (PT), and the Director of Nursing (DON), revealed a lack of awareness and communication regarding the resident's care plan and orthotic device usage. The care team, including CNAs and licensed nurses, were not informed of the resident's care plan goals and interventions, resulting in a delay in care and services. The facility's policies and procedures emphasized the importance of a comprehensive, person-centered care plan developed by the IDT, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Beach Post-acute | 0 mi | ★★★★★ | 20 | 0 |
| Pacific Care Nursing Center | 1 mi | ★★★★★ | 6 | 0 |
| Long Beach Healthcare Center | 1 mi | ★★★★★ | 8 | 0 |
| Pacific Villa, Inc | 1.1 mi | ★★★★★ | 35 | 0 |
| Bixby Towers Post-acute Rehab | 1.3 mi | ★★★★★ | 6 | 1 |
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