Atrium Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Atrium Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 28, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the medical record, review of a facility self-reported incident (SRI), observations, resident and staff interviews, and policy review, the facility failed to provide supervision and intervention to prevent Resident #31, who had impaired cognition, was at risk for elopement and resided on a secured behavioral unit, from leaving the facility unsupervised. […]

• Immediate jeopardy, isolatedF757Jan 3, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, hospital record review, laboratory results review, staff and physician interview, and policy review, the facility failed to properly monitor Coumadin (an anticoagulant medication) use for Resident #20. Resident #20 had a high Prothrombin Time/International Normalized Ratio (PT/INR) (a laboratory test to measure how long it takes for blood to clot) of 52.4 seconds (PT) and 4.9 (INR) that was drawn on [DATE] and was not reported to the physician until [DATE]. Resident #20 was to have the next PT/INR drawn on [DATE]; however, it was not obtained. […]

• Immediate jeopardy, isolatedF607Aug 22, 2023

  Based on observations, medical record review, staff interview, review of the facility's self-reported incidents (SRIs), review of personnel records, review of the facility investigation, review of a police report, and review of facility policy, the facility failed to implement their abuse policy, recognize sexual abuse of a resident by a staff member, thoroughly investigate an allegation sexual abuse and failed to protect one resident (#28) from continued sexual abuse and exploitation due to staff failing to intervene when they learned of Housekeeper #100 having a sexual encounter with Resident #28 in his room. […]

• Actual harm, isolatedF689Mar 14, 2024

  Based on medical record review, review of hospital records, review of a fall investigation, observations, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place for a resident identified at high risk for falls and failed to conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in Actual Harm when Resident #07 fell from the bed that was not in the lowest position and sustained a leg fracture requiring surgical intervention. This affected one (#07) of three residents reviewed for falls. The census was 72. Findings include: Review of Resident #07's medical record revealed an admitted [DATE]. […]

• Actual harm, isolatedF684Apr 27, 2023

  Based on medical record review, staff interviews, and facility policy review, the facility failed to ensure residents attended outside medical appointments as ordered. This resulted in actual harm when the facility failed to ensure Resident #53 was transported to a follow-up appointment on 03/09/23 with a vascular surgeon for treatment/assessment of a vascular wound to Resident #53's left lower leg. The appointment was rescheduled for 03/23/23 (two weeks later) and Resident #53's wound was found to have worsened with necrotic tissue present during that timeframe. This affected two (Resident #53 and #66) out of three residents reviewed for transportation. Additionally, the facility also failed to ensure residents were assessed for placement on a secured unit. […]