Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 The Atrium Rehabilitation Center during CMS and state inspections, most recent first.
A resident on hospice care with cancer-related pain and anxiety had multiple doses of methadone, morphine, and lorazepam documented on the MAR at times that did not match actual administration, with entries showing doses given hours after scheduled times and without corrected times or explanatory notes. Several LVNs reported that they administered medications on time or after initial refusals but delayed "clicking off" doses in the electronic MAR or recorded them at the scheduled time instead of the actual time, despite facility policy requiring immediate documentation after administration. The ADON confirmed the expectation for real-time documentation and accurate timing of medication entries.
The facility did not send required discharge notices to the State LTC Ombudsman for four residents who were either discharged or given 30-day discharge notices, including individuals with complex medical needs and cognitive impairment. Interviews revealed that staff were unaware of the notification requirement, and affected residents and their families were not informed of their rights or appeal options.
A resident with anxiety and depression did not receive four out of five prescribed doses of alprazolam over two days due to medication aides failing to administer the medication and not reporting the missed doses to nursing leadership. The missed administrations were documented as 'not available,' and required communication and documentation procedures were not followed, resulting in the resident missing multiple doses of a critical medication.
Two residents prescribed and administered antipsychotic medications did not have the required state psychotropic medication consent forms documented in their medical records. The DON confirmed the consents existed but had not been scanned into the records, and both the DON and Administrator acknowledged the deficiency during interviews.
Two residents with complex medical conditions experienced significant unplanned weight loss that was not accurately reflected in their Quarterly MDS assessments, despite documentation in their care plans and medical records. The MDS Coordinator acknowledged that these weight losses should have been recorded in the assessments.
A black substance build-up was observed inside the facility's ice maker, revealing a failure to maintain cleanliness as required by professional standards. The DON acknowledged the issue, and records showed the ice machine was cleaned monthly, in line with facility policy. No other relevant policies were provided.
A nurse failed to change gloves and perform hand hygiene during a wound care procedure for a resident with complex medical needs, proceeding from removing a soiled bandage to cleaning and redressing the wound without following required infection control protocols. This was observed and confirmed by facility leadership as not meeting established standards.
A resident's controlled narcotic medications were misappropriated at an LTC facility. The resident, who was prescribed oxycodone with acetaminophen for pain management, returned from a hospital stay to find 41 pills missing. The facility's search for the medication was unsuccessful, and interviews revealed inconsistent counting and documentation of controlled substances during shift changes.
The facility failed to update care plans for two residents, one with multiple diagnoses and another with hypothyroidism, within the required timeframe. A resident's care plan did not align with MDS dates, and another's lacked interventions for hypothyroidism despite ongoing treatment. Staff interviews revealed a lack of awareness about care plan requirements, and the facility did not provide a policy for care plan revisions.
A resident's grievance regarding a cold meal and lack of personal care was not resolved for 43 days, with missing documentation on follow-up actions and resolution. The resident, with severe cognitive impairment and other medical conditions, felt discriminated against. The ADM acknowledged the oversight, but no policy was provided to support timely grievance resolution.
The facility failed to update and complete comprehensive care plans for two residents, leading to potential inadequate care. One resident's plan did not reflect their use of a manual wheelchair and lower extremity impairment, while another's plan lacked necessary e-signatures and updates. The MDS coordinator was unaware of the need for new care plans, contributing to the deficiency.
A resident with multiple diagnoses, including contractures in both knees, had a care plan that failed to address these contractures. The MDS Coordinator confirmed the omission and acknowledged that the care plan should include all relevant conditions. Facility policies indicated that care plans should describe services to maintain or improve physical well-being, but this was not reflected in the resident's care plan.
A resident's urinary catheter tubing was not properly secured, despite a physician's order and facility policy requiring it. The CNA acknowledged the catheter was disconnected during care and not reconnected, and the new DON was unaware of a specific process to ensure proper securing of catheters.
A facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by an unsecured cup of nystatin powder found on a resident's bedside table. The resident confirmed the powder was for her skin folds, and the responsible LVN admitted he should have removed it. The facility's policy mandates secure storage of all medications, which was not followed in this instance.
A facility failed to maintain an infection prevention and control program during the wound care of a resident with multiple diagnoses. The ADON did not perform hand hygiene appropriately between glove changes, compromising the sterility of the wound care process. The DON was unsure of the frequency of hand hygiene audits, despite the facility's policy requiring hand hygiene after removing gloves.
The facility failed to ensure proper documentation and communication during the discharge of a resident with Huntington's disease. The discharge summary report was initially missing and later found, but no policy on discharge summary reports was provided.
A resident with moderate cognitive impairment and diabetes was found with unsupervised medical items, including insulin needles and pen needles, at the bedside. The responsible nurse admitted to leaving the items while searching for a glucometer, and the DON confirmed the risk of harm. No policy was provided before the survey exit.
The facility had a medication error rate of 35.71% due to late administration of medications by two staff members, affecting five residents. Medications were either administered late or not at all, leading to a significant deficiency in care.
The facility failed to ensure all drugs and biologicals were stored in locked compartments, as the Treatment Cart was observed unlocked and unattended in a common area. LVN A admitted responsibility and acknowledged forgetting to lock the cart, which contained prescription and over-the-counter medications, as well as supplies for skin and wound care. The DON confirmed that the facility's policy mandates that medication treatment carts should not be left unlocked and unattended for safety reasons.
The facility failed to provide a minimum of 80 square feet per resident in 32 of 39 resident rooms. Observations revealed that multiple rooms housing one or two residents did not meet the required square footage, with measurements ranging from 66.79 to 79.74 square feet per resident for double occupancy rooms and 68.02 to 77.24 square feet per resident for single occupancy rooms.
Inaccurate MAR Documentation for Hospice Pain and Anxiety Medications
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for one hospice resident when nursing staff did not document medication administration times in accordance with facility policy and accepted professional standards. The resident was an older male admitted under hospice care with malignant neoplasm of the middle third of the esophagus, dysphagia, anemia, and a care plan identifying acute and chronic pain requiring analgesia per orders. His admission MDS showed a BIMS score of 10, indicating moderate cognitive impairment. Physician orders for March included methadone oral solution every 8 hours for pain starting 3/12/2026, and morphine and lorazepam oral solutions every 2 hours for pain and anxiety starting 3/30/2026. Record review of the March 2026 Medication Audit Report showed multiple instances where methadone, morphine, and lorazepam were documented as administered significantly later than their scheduled times, with no corrections or clarifying notes. On several dates, methadone doses scheduled for specific times (1:00 a.m., 5:00 p.m., 9:00 a.m.) were documented as given hours later, and on another date, morphine and lorazepam doses scheduled for early morning hours were documented as given several hours after the scheduled times. The MAR entries did not reflect corrected administration times or explanatory documentation, resulting in a record that did not accurately show when medications were actually given. In interviews, LVNs A, C, F, and D stated they had administered the medications on time or after resident refusals but acknowledged that they documented the administrations late or at the scheduled time rather than the actual time given. LVN A reported being the only nurse on duty during shift change and stated she may have documented after completing other tasks. LVNs C and F stated they sometimes “clicked off” medications later in the shift when they were less busy, despite knowing the policy required immediate documentation after administration. LVN D stated that when the resident initially refused methadone, she would return later to administer it but would sign it off at the scheduled time without correcting the entry or making a note that it was given late. The ADON stated his expectation that medications be signed off immediately after administration and that staff should note the correct time in the MAR, and the facility’s policies specified that medication administration must be documented immediately after, and never before, it is given.
Failure to Notify State LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide required discharge notifications to the Office of the State Long-Term Care (LTC) Ombudsman for four residents who were either discharged to the hospital, discharged home, or issued 30-day discharge notices. In each case, record reviews revealed no evidence that the Ombudsman was notified prior to the residents' discharge or intended discharge. This included residents with significant medical needs, such as end stage renal disease requiring hemodialysis, severe cognitive impairment, and dependence on mechanical assistance for transfers and supplemental oxygen. Interviews with residents and their representatives indicated a lack of awareness regarding their rights and the services available through the LTC Ombudsman. One resident expressed anxiety about being discharged with nowhere to go and was unaware of the Ombudsman’s role until after receiving a discharge notice. Another resident’s family member reported not being informed about appeal options or alternatives to discharge, despite the resident’s high level of care needs and the family’s inability to provide appropriate care at home. Staff interviews revealed that both the Business Office Manager (BOM) and the Director of Nursing (DON) were unaware of the requirement to notify the Ombudsman of resident discharges. The BOM stated she had not been trained to keep evidence of mailing discharge notices and had not notified the Ombudsman of any discharges. The DON confirmed that the facility did not have a system in place to ensure Ombudsman notification. The facility’s policy did state that a copy of the discharge notice should be sent to the Ombudsman, but this was not being followed in practice.
Failure to Administer and Report Missed Anti-Anxiety Medication Doses
Penalty
Summary
The facility failed to ensure that a resident received medication administration in accordance with physician orders, professional standards of practice, and the resident’s care plan. Specifically, over a two-day period, medication aides did not administer four out of five prescribed doses of alprazolam, an anti-anxiety medication, to a resident diagnosed with anxiety disorder and major depressive disorder. The medication administration record showed that the missed doses were documented as 'not available,' and the medication aides did not report these missed administrations to nursing leadership as required. The resident’s care plan indicated the use of anti-anxiety medication and outlined the need for monitoring for adverse reactions and safety concerns. Despite this, the medication aides failed to ensure the medication was available and did not follow procedures for reporting missed doses. One medication aide stated she verbally reported the missed doses to a charge nurse but did not document this communication, and the charge nurse denied receiving such a report. The facility’s policy required notification of supervisors and proper documentation when medications are not administered, which was not followed in this instance. The resident, who had moderate hearing difficulty and highly impaired vision, was unable to recall if all medications were received during the period in question. Interviews confirmed that the missed doses were not promptly reported or documented, and the medication was not reordered in a timely manner, resulting in the resident missing multiple doses of a critical medication.
Missing Psychotropic Medication Consent Forms in Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents who were prescribed and received antipsychotic medications. For one resident with schizophrenia and severe cognitive impairment, there was no evidence in the medical record of the required state psychotropic medication consent form, despite the resident receiving risperidone as prescribed. Similarly, another resident with bipolar disorder and no cognitive impairment received aripiprazole for depression, but the required consent form was also missing from her medical record. In both cases, the medication administration records confirmed that the medications were administered as ordered by the physician, but the necessary documentation was not present in the residents' files. Interviews with the DON and Administrator confirmed that the required consent forms were not included in the medical records at the time of review. The DON acknowledged that the consents existed but had not yet been scanned into the electronic medical records, as the responsibility for scanning had not been assigned to a specific staff member and had defaulted to the DON. Both the DON and Administrator agreed that all residents prescribed antipsychotic medications should have the appropriate consent forms documented in their medical records, and the absence of these forms was confirmed during the survey.
Failure to Accurately Document Significant Weight Loss in Resident Assessments
Penalty
Summary
The facility failed to conduct accurate comprehensive assessments of two residents' functional capacity, specifically regarding significant weight loss. For one resident with metabolic encephalopathy, dependence on renal dialysis, and end stage renal disease, medical records showed a weight loss from 118 lbs. to 109.2 lbs. within a little over a month, amounting to a 7.46% decrease. Despite this, the resident's Quarterly MDS assessment did not reflect the weight loss under Section K - Swallowing/Nutritional Status. The resident's care plan did note unplanned weight loss and included interventions such as dietary supplements. Similarly, another resident with sepsis, encephalopathy, and type 2 diabetes experienced a weight loss from 242 lbs. to 225.4 lbs., a 7% decrease, but the Quarterly MDS assessment did not indicate this significant weight loss. The care plan for this resident also documented unplanned weight loss and included interventions like alerting the dietician and notifying the physician if further weight loss occurred. The MDS Coordinator confirmed during interview that the significant weight loss for both residents should have been documented in their respective MDS assessments.
Ice Maker Not Maintained According to Professional Standards
Penalty
Summary
Surveyors observed a black substance build-up inside the facility's ice maker, indicating a failure to maintain cleanliness in accordance with professional standards. The Director of Nursing (DON) confirmed awareness of the buildup and stated that the Kitchen Manager is generally responsible for cleaning the ice machine. Review of the facility's Ice Machine Cleaning and Sanitizing Log showed that the ice machine was cleaned approximately once per month on specified dates. The facility's policy requires ice machines and storage containers to be drained, cleaned, and sanitized per manufacturer instructions and facility policy. No additional policies regarding the cleanliness of the ice maker were provided.
Failure to Follow Hand Hygiene and Glove Change Protocols During Wound Care
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow standard and transmission-based precautions during wound care for a resident with multiple medical conditions, including respiratory failure, diabetes mellitus, and a laceration on the left lower leg. The resident was under Enhanced Barrier Precautions (EBP) and required daily wound care as per physician's orders. During an observed dressing change, the LVN wore a gown and gloves, removed the soiled bandage, but did not change gloves or perform hand hygiene before proceeding to clean the wound and apply new treatment and dressings. The LVN later acknowledged not changing gloves or performing hand hygiene as required. Interviews with the infection preventionist and the director of nursing confirmed that facility policy and training require staff to change gloves and perform hand hygiene when transitioning from a soiled to a clean procedure during wound care. The facility's wound care policy also outlines these steps, emphasizing glove changes and hand hygiene to prevent infection. The failure to adhere to these protocols was observed and confirmed through staff interviews and record reviews.
Misappropriation of Resident's Controlled Medications
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their controlled narcotic medications. A resident, who was hospitalized for a period, returned to the facility to find that 41 pills of their prescribed hydrocodone acetaminophen were missing. The resident had been admitted with diagnoses including pain, psychotic disorder, and quadriplegia, and was assessed to have intact cognition. The resident was prescribed oxycodone with acetaminophen for moderate to severe pain, which was administered as needed prior to the hospitalization. Upon the resident's return from the hospital, it was discovered that the medication card containing the oxycodone/acetaminophen tablets was missing. The facility conducted a search of medication carts, locked control boxes, and medication rooms, but the medication card was not located. The facility's records indicated that the medication card was dispensed with 60 tablets, and 19 doses had been administered before the resident's hospitalization, leaving 41 doses unaccounted for. Interviews with staff members revealed that there was a lack of consistent counting and documentation of the controlled medications during shift changes. Several staff members, including medication aides and nurses, could not recall if the oxycodone was specifically counted during their shifts. The facility's policy required controlled substances to be counted at the end of each shift, but there was a documented lapse in this procedure, contributing to the loss of the resident's medication.
Failure to Update Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and update care plans within the required timeframe for two residents, leading to deficiencies in their care management. Resident #1's care plan was not updated to coincide with the Minimum Data Set (MDS) dates, despite having current revision dates. This oversight occurred after the resident was readmitted with multiple diagnoses, including a fracture, end-stage renal disease, and dementia, among others. The resident's care plan did not reflect the necessary updates following the comprehensive assessment, which is a requirement to ensure that the care provided aligns with the resident's current health status. Resident #5's care plan was not revised to include interventions for managing hypothyroidism, despite the resident having a diagnosis and being prescribed levothyroxine. The resident's medical records indicated ongoing monitoring of thyroid-stimulating hormone (TSH) levels, yet the care plan lacked focus, goals, or interventions related to hypothyroidism. This omission was noted during interviews and record reviews, where it was revealed that the resident's representative was not invited to participate in care plan meetings, and the facility staff failed to document the necessary interventions for the resident's condition. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Minimum Data Set (MDS) coordinator, highlighted a lack of awareness and understanding of the requirements for updating care plans. The MDS coordinator, who was new to the role, was unaware of the need to start a new care plan for each resident assessment. Additionally, the facility did not provide a policy for care plan revisions upon request, indicating a potential gap in procedural adherence and staff education regarding care plan management.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure that a resident's right to voice grievances without fear of discrimination or reprisal was upheld. A grievance was filed by the family of a resident regarding an incident where staff brought a food tray into the resident's room, initially stating it was for the roommate, and then later claiming it was for the resident. This led to the resident feeling discriminated against and receiving a cold meal. Additionally, the resident was not changed or cleaned as needed. The grievance form lacked documentation of follow-up actions, resolution, and notification to the resident or their representative. The resident involved had a history of severe cognitive impairment, diabetes, and other medical conditions, and was dependent on a manual wheelchair. Despite the grievance being reported to the Administrator (ADM) on a specific date, it remained unresolved for 43 days. The ADM acknowledged the oversight in documentation and stated that grievances were typically resolved within 24 hours, but no policy was provided to support this claim. The lack of resolution and communication regarding the grievance could potentially affect all residents, as it indicates a systemic issue in handling grievances promptly and effectively.
Deficiency in Comprehensive Care Plan Development
Penalty
Summary
The facility failed to ensure the development and implementation of comprehensive, person-centered care plans for two residents, which is a requirement to meet their medical, nursing, and psychological needs. Resident #2's care plan was not updated to reflect the use of a manual wheelchair and the presence of lower extremity impairment, despite these being identified in the resident's assessments. This oversight could lead to inadequate care and support for the resident's mobility and safety needs. Resident #3's care plan was incomplete, lacking several necessary e-signatures and updates, which could result in staff not providing appropriate care. The resident was identified as being at risk for falls, attending activities, and having bowel incontinence, yet the care plan was not fully executed. The MDS coordinator, who was new to the role, was unaware of the requirement to start a new care plan for each resident's MDS, contributing to the deficiency. The facility did not provide a policy regarding care plan updates prior to the survey exit.
Failure to Address Contractures in Resident's Care Plan
Penalty
Summary
The facility failed to provide services as outlined by the comprehensive care plan for a resident with multiple diagnoses, including cerebral infarction, contractures in both knees, muscle wasting and atrophy, and a stage 3 pressure ulcer. The resident's care plan did not address the contractures, which was confirmed by the MDS Coordinator during an interview. The MDS Coordinator acknowledged that the care plan should include all relevant diagnoses and conditions but was unsure who created the deficient care plan and how frequently it was reviewed by the corporate nurse. Observation revealed that the resident was in bed with contractures in both lower extremities, causing his knees to bend. The facility's policy on comprehensive care plans and resident mobility and range of motion indicated that care plans should describe services to maintain or improve the resident's physical well-being, including specific interventions for mobility and range of motion. However, the resident's care plan lacked these necessary components, failing to meet professional standards of quality care.
Failure to Secure Urinary Catheter Tubing
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter tubing was properly secured, which is necessary to prevent urinary tract infections and other complications. The resident, who had diagnoses including lack of coordination, erythema intertrigo, acute pyelonephritis, and obstructive and reflux uropathy, was observed with a stabilization device on her left thigh that was not being used to anchor the urinary catheter. Despite the presence of a physician's order to monitor the catheter leg strap for proper placement every shift, the catheter remained unsecured during multiple observations and interviews with staff and the resident herself. The CNA responsible for the resident's care acknowledged that the catheter had been disconnected from the stabilization device during care and had not been reconnected. The Director of Nursing (DON), who was new to the position, was unaware of a specific process to ensure urinary catheters were secured appropriately but confirmed that unsecured catheters could lead to negative outcomes such as dislodgement or trauma. The facility's policy on catheter care, dated 6/18/18, explicitly stated that catheters should be secured with a leg strap to reduce friction and movement at the insertion site, a practice that was not followed in this instance.
Failure to Secure Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and only accessible to authorized personnel. Specifically, Resident #2's nystatin powder was found unsecured on the resident's bedside table. The resident confirmed that the white powder was a medicated powder for her skin folds and mentioned that someone had brought it into her room and left it there. LVN D, who was responsible for Resident #2, acknowledged seeing the medication cup earlier but did not know how it got there or who placed it. He admitted that he should have removed the medication from the room when he first saw it. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) conducted daily rounds to ensure medication security, but this incident indicates a lapse in their protocol. Resident #2 had multiple diagnoses, including lack of coordination, erythema intertrigo, acute pyelonephritis, and obstructive and reflux uropathy. The physician's orders included cleaning abdominal folds and applying nystatin powder daily or as needed for redness. Despite these orders, the medication was not stored securely, posing a risk of misuse and diversion. The facility's policy on medication storage, dated December 2023, mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, which was not adhered to in this case.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program during the wound care of a resident with multiple diagnoses, including heart failure, depression, chronic ulcer, and Type 2 Diabetes Mellitus with complications. During the wound care procedure, the Assistant Director of Nursing (ADON) did not perform hand hygiene appropriately. Specifically, the ADON failed to wash hands between glove changes on multiple occasions, which is a critical step in preventing infections. The ADON removed soiled gloves and either did not perform hand hygiene or only partially performed it before donning new gloves, which compromised the sterility of the wound care process. The ADON acknowledged the importance of hand hygiene in preventing infections but believed his hand hygiene practices during the wound care were adequate. However, observations and interviews revealed that the ADON did not consistently follow proper hand hygiene protocols. The Director of Nursing (DON) also indicated that the facility conducted audits as part of their monthly Quality Assurance and Performance Improvement (QAPI) meetings but was unsure of the frequency of hand hygiene audits. The facility's hand hygiene policy, dated December 2021, mandates the use of alcohol-based hand rub or soap and water after removing gloves, which was not adhered to in this instance.
Failure to Document and Communicate Resident Discharge
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer or discharge of a resident. Specifically, Resident #35, who was admitted with Huntington's disease and on hospice services, was discharged due to behaviors but did not have a discharge summary report in the chart. The VP Clinical RN was unable to initially provide the discharge summary, which was later found and signed by the MD on the same day as the interview. No policy on discharge summary reports was provided before the exit.
Failure to Maintain a Hazard-Free Environment
Penalty
Summary
The facility failed to ensure the resident environment remained free from accident hazards for one resident. Specifically, Resident #2 was found with multiple medical items, including insulin needles, pen needles, alcohol wipes, and a test strip container, left unsupervised at the bedside. This was observed during a room inspection, and the responsible nurse admitted to leaving the items while searching for a glucometer device. The resident had a moderate cognitive impairment and a diagnosis of diabetes, which necessitated careful management of medical supplies to prevent harm. Interviews with the RN and the Director of Nursing (DON) confirmed that leaving such items unsupervised posed a risk of harm to the resident and potentially others. The DON acknowledged that the nurse should not have left the medical items at the bedside without supervision. The facility did not provide a policy regarding the handling of medical paraphernalia at the bedside before the survey exit, indicating a lapse in procedural adherence and oversight.
High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to ensure that the medication error rate was not 5 percent or greater, resulting in a medication error rate of 35.71%. This involved five residents and two staff members. Specifically, LVN B failed to administer Resident #13's eye drops, Benzonatate, and Buspirone at the prescribed times. Additionally, MA C failed to administer Resident #29's Refresh liquid gel eye drops, Resident #2's Lidocaine Patch, and Resident #17's Calcium Carbonate, Vitamin D3, Claritin, Multivitamin, and Docusate at the prescribed times. Resident #13, who had moderate cognitive impairment and was diagnosed with a chronic cough and dry eye, did not receive her medications on time. LVN B administered Benzonatate and Buspirone late and did not administer Olopatadine eye drops because they were not available. Similarly, Resident #29, who had intact cognition and was diagnosed with dry eye syndrome, received his Refresh Liquigel eye drops late from MA C. Resident #2, who had moderate cognitive impairment and chronic pain, did not receive his Lidocaine Patch because it was not available in the cart. Resident #17, who had intact cognition and was diagnosed with acute pancreatitis, received her medications late due to MA C being called in last minute to cover for another staff member. The facility's policy required medications to be administered within a two-hour window, but this was not adhered to, leading to the high medication error rate.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys. Specifically, the Treatment Cart was observed unlocked and unattended in the common area of the 300-hallway. This cart contained prescription and over-the-counter medications, as well as supplies for skin and wound care. LVN A admitted responsibility for the cart and acknowledged forgetting to lock it when she walked away to assist a resident. She confirmed that the items in the cart could be harmful if not used properly and that she had been trained to lock the cart when not in active use. The Director of Nursing (DON) confirmed that the facility's policy mandates that medication treatment carts should not be left unlocked and unattended for safety reasons. The DON emphasized that residents could be harmed if items were taken from the Treatment Cart and not used as intended. The facility's policy, reviewed in December 2023, explicitly states that compartments, including carts, must be locked when not in use and should not be left unattended if open. The DON also mentioned that new hires are trained in this procedure, and annual competencies for all nursing staff include this principle. Spot checks are conducted by the Assistant Directors of Nursing (ADONs) and the DON, along with randomized checks by the pharmacy during their rounds and reviews.
Failure to Provide Minimum Square Footage per Resident
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident in 32 of 39 resident rooms. During an interview, the Administrator confirmed that there were no changes to the room waivers and requested room waivers for the 32 rooms in question. Observations revealed that multiple rooms housing one or two residents did not meet the required square footage per resident, with measurements ranging from 66.79 to 79.74 square feet per resident for double occupancy rooms and 68.02 to 77.24 square feet per resident for single occupancy rooms. This deficiency was identified during observations conducted on 3/6/2023 and an interview on 4/25/2024. The lack of adequate space could potentially result in inadequate care provision and resident dissatisfaction with their living environment. Specific rooms identified with this issue include Rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 202, 203, 204, 205, 206, 208, 209, 210, 211, 302, 304, 307, 308, 309, 310, 311, 312, 313, 314, 317, and 319, among others.
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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 San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Park Nursing And Rehabilitation Center | 0.5 mi | ★★★★★ | 25 | 0 |
| Wurzbach Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 0 | 0 |
| The Heights At Medical Center | 1 mi | ★★★★★ | 13 | 0 |
| The Lev At San Antonio | 1.2 mi | ★★★★★ | 30 | 0 |
| Sorrento | 1.2 mi | ★★★★★ | 17 | 0 |
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