Atrium Place Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Feb 25, 2025

  Based on interview and record review, the facility failed to provide appropriate basic life support, including cardiopulmonary resuscitation (CPR, a lifesaving technique that's used in emergencies in which someone's breathing or heartbeat has stopped) for one (Resident #1) of three sampled residents. Resident #1 had physician orders for a full code status. On [DATE] shortly before 7:00 A.M., staff removed the resident's oxygen when transferring the resident to bed, placed him/her on the bed in a flat position and as staff turned him/her, the resident was noted not to be breathing. Licensed Practical Nurse (LPN) A got the Nurse Manager (NM), who said the resident died. The NM told LPN A two nurses could verify a resident's death. Staff did not perform CPR. The resident expired. […]

• Actual harm, isolatedF684Feb 25, 2025

  Based on interview and record review, the facility failed to notify the physician of one resident's (Resident #1) low lab results and to ensure the Medical Director (MD) and other physicians had full access to lab results in the system the physicians use. The MD was not aware of lab results for seizure medications for Resident #1, and the resident sustained seizure activity 18 days later. The facility also failed to ensure the physician was notified when Resident #1 had a change of condition of new purple discoloration to the resident's fingertips at 8:30 P.M. and did not notify the on call Nurse Practitioner (NP) until approximately 4:30 A.M. after the resident had a fall. The facility failed to document the initial assessment of the change of condition in the medical record. […]

• Actual harm, isolatedF697Apr 10, 2024

  Based on interview and record review, the facility failed to provide pain management consistent with professional standards of practice, and care plan interventions related to pain for one of six sampled residents (Resident #3). The facility failed to timely administer pain medications in accordance with the physician's orders. Additionally, facility staff failed to follow up with resident pain medication to ensure availability for administration and failed to implement measures, including use of medication available in the facility starter kit/emergency drug kit, when the resident's pain medications were unavailable. […]

• Actual harm, isolatedF698Dec 12, 2023

  Based on interview and record review, the facility failed to follow their Home Dialysis Treatment policy and Notification of Changes policy for one resident readmitted to the facility on [DATE], with an order for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) three times a week. Facility staff failed to provide or attempt to provide the resident's transportation to/from dialysis on 11/8/23 and to communicate with the dialysis facility to request a different time for dialysis. Staff also failed to contact the resident's physician of the missed appointment timely and was not notified of the missed dialysis until 11/9/23. […]

• Actual harm, isolatedF684Mar 20, 2023

  Based on interview and record review, the facility failed to follow their policies regarding skin assessments and wounds when they failed to immediately put interventions in place when a resident (Resident #1) with a history of amputation had a new wound develop on his/her toe. Facility staff failed to obtain physician orders or send the resident to the hospital until 24 hours after becoming aware of the wound. At the hospital, the resident was diagnosed with osteomyelitis (bone infection) and required surgery. In addition, the facility failed to follow their policy by not performing a full body skin assessment weekly by a licensed nurse (Resident #1). The sample size was seven. […]