Atlas Post Acute

In the surveyor’s words

From the most serious findings on record at Atlas Post Acute, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jul 8, 2021

  Based on observations, interviews and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and likelihood of transmission of Covid-19 and the cross-contamination of wounds. Record review revealed the facility had one staff member who was positive for Covid-19 as of 6/25/21 and one resident who was positive for Covid-19 as of 7/1/21. The facility's failures in implementation of its infection control program created an immediate jeopardy situation with the likelihood of serious harm if not corrected immediately, due to the potential for transmission of the highly infectious Covid-19 virus to all residents residing in the facility. […]

• Immediate jeopardy, widespreadF689Jan 20, 2021

  Based on observation, record review, and staff and resident interviews, the facility failed to provide adequate supervision to prevent accidents/hazard with one (#2) resident who smoked in her room and one (#14) at risk for burns, which had a potential to affect 71 residents residing at the time of survey due to the risk of fire in the facility. The facility failed to prevent Resident #2 from smoking in her room with oxygen. Resident #2, who was on two liters of oxygen continuously, smoked in her room. Resident #2 continued to smoke in her room with oxygen and other flammable materials like bedding and curtains without regard to education provided by the facility or the smoking contract she had in place between her and the facility. […]

• Actual harm, isolatedF689May 14, 2026

  Based on record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#2) of four residents reviewed for accidents/hazards out of 29 sample residents. Resident #2, who was admitted on [DATE], required substantial assistance to roll from her back to her right or left side in the bed. On the afternoon of [DATE], certified nurse aide (CNA) #3 elevated Resident #2's bed and then repositioned the resident onto her side to provide incontinence care. Resident #2 rolled off the elevated bed onto the floor during care. Interviews during the survey revealed Resident #2 was communicating with staff prior to the incident, however, Resident #2's responsiveness deteriorated significantly immediately after the fall. […]

• Actual harm, isolatedF688Nov 2, 2023

  Based on observations, record review and interviews the facility failed to ensure one (#14) of one residents reviewed for activities of daily living were provided with services or treatments to prevent the reduction in range of motion out of 39 sample residents. Specifically, the facility failed to ensure Resident #14 was provided with preventative measures to help minimize the development of and the worsening of contractures. Resident #14 had a contracture to his left hand and no preventative measures were implemented. When Resident #14 was assessed during the survey on 10/31/23, his left hand finger contractures worsened and he developed a contracture to his right hand. Findings include: I. […]

• Actual harm, isolatedF697Nov 2, 2023

  Based on observations, record review and interviews, the facility failed to provide effective pain management program for two (#53 and #4) of three residents reviewed for pain management out of 39 sample residents. Resident #53 had pain control during a wound dressing change on 10/31/23 at 4:15 p.m. The resident experienced severe pain during the dressing change. The resident was administered a pain medication at 3:40 p.m., although the resident told the nurse that she was in pain, the dressing change continued. The resident was not offered any other type of pain intervention. In addition, the facility failed to for Resident #4: -Have a pain parameters for as needed (PRN) pain medications; and, -Thoroughly assess the resident's pain. Findings include: I. […]