Atkins Nursing And Rehabilitation Center

Number of residents sampled: Number of residents cited: Based on record review and interviews it was determined the facility failed to send a written notice of transfer or discharge to the Ombudsman for one (Resident #59) of one resident, upon discharge. The findings include: Review of Resident #59's admission Record revealed the facility admitted Resident #59 on 02/10/2026 from a local hospital. Review of Resident #59's Medical Diagnosis report revealed Resident #59 had diagnoses which included acute kidney failure, encephalopathy, hypothyroidism, dementia, hypertension and congestive heart failure. Review of Resident #59's discharge, return anticipated Minimum Data Set with an Assessment Reference Date of 02/12/2026 revealed the discharge status was discharged to an inpatient rehabilitation facility. The MDS coded the discharge as a planned discharge. Review of Resident #59's Care Plan dated 02/12/2026 revealed Resident #59 wished to discharged . Review of Resident #59's Progress Notes dated 02/12/2026 at 10:57 PM revealed Resident #59 had discharged to a local rehab. Review of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, interviews and facility policy review, the facility failed to ensure an indwelling catheter was stored off the floor to reduce the risk of infection, cross contamination and injury for one (Resident #3) of one resident reviewed. The findings include:Review of Resident #3's Medical Diagnosis revealed Resident #3 had diagnoses which included urine retention, overactive bladder, chronic kidney disease, tubulointerstitial nephritis (inflamed kidney tubules) and anxiety.Review of an admission Minimum Data Set (MDS) with an Assessment Reference Date of 03/30/2026 revealed, Resident #3 had a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. The MDS also revealed Resident #3 had a catheter and had not had a UTI in the last 30 days. Review of Resident #3's Care Plan revealed Resident #3 had potential/actual impaired skin integrity related to catheter, poor mobility, and use of anticoagulant with an initiated date of 03/31/2026. Care Plan interventions included to keep the residents' nails short, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure hot foods were served hot to maintain palatability and encourage adequate nutritional intake for 1 of 2 meals observed. The findings are: 1. On 10/14/24 at 11:12AM, Resident #51 stated food is cold when served. 2. On10/15/24 at 8:11 AM, a food cart that contained 8 meal trays for breakfast was delivered to the 500 Hall by Certified Nursing Assistant (CNA) #3. At 8:22 PM, the temperature of the food items on the last resident tray, was taken and read by the District Dietary Manager. The temperatures were as follows: a. Scrambled eggs - 98 degrees Fahrenheit. b. Sausage - 84 degrees Fahrenheit. c. Pan cake - 100 degrees Fahrenheit. d. Gravy - 102 degrees Fahrenheit. 3. On 10/15/24 at 8:11 AM, the first breakfast meal tray for the 300 Hall was placed in an unheated food cart in the hall outside the kitchen window by Certified Nursing Assistant (CNA) #4, who left it open while loading the meal trays. When the staff began removing the meal trays, there were 7 trays in the food cart to be delivered to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure dietary employees washed their hands or changed gloves before handling food items and clean equipment when contaminated; expired food products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria. The findings are: 1. On 10/14/24 at 9:42 AM, Dietary [NAME] (DC) #1 wore gloves on her hands while using scissors to cut open a bag of shredded cheese which contaminated the gloves. Without washing her hands, she removed shredded cheese from the bag and sprinkled it on top of enchiladas to be baked and served to the residents for lunch. 2. On 10/14/24 at 9:52 AM, an opened box of fish was on a shelf in the walk-in refrigerator. The box was not covered or sealed 3. On 10/14/24 at 9:56 AM, the following observations were made in the storage room: a. One box with 24 count of probiotics drink, was on a shelf with an expiration date of 10/6/2024. b. On bag of butter fingers was on a shelf with an expiration date of 6/19/2024. c. One…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure lint traps for two of two dryers located in the facility laundry room were cleaned to prevent the potential for fire hazard. The findings are: During a tour of the facility laundry room on 10/16/2024 at 9:04 AM, two clothing dryers used to launder resident clothing were observed. The Housekeeping/Laundry Supervisor was asked to provide the surveyor with access to the dryer's lint traps. The lint trap of one dryer was found to contain what appeared to be five white pieces of paper, a dryer sheet, and a buildup of lint. The lint trap of the second dryer contained what appeared to be ten dryer sheets and a buildup of lint. During an interview on 10/16/24 at 9:04 AM, the Housekeeper/Laundry Supervisor explained that the lint area of dryers are cleaned every hour. Upon further observation of the dryer lint traps, it appeared to not be cleaned recently in either dryer. The Housekeeper/Laundry Supervisor explained that laundry was told to clean the lint screens every hour instead of every two hours as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review, it was determined that the facility failed to ensure dignity was maintained while performing Activities of Daily Living (ADL) for 1 resident (Resident #56) of 1 receiving incontinent care. Findings included: 1. Review of a facility policy titled, Resident Rights, (not dated), indicated, Each resident has the right to be treated with consideration, respect and full recognition of dignity and individuality. Review of an admission Record, indicated Resident #56 was admitted with a diagnosis of dementia and anxiety disorder. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/8/2024 revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated Resident #56 was moderately cognitively impaired. On 10/15/2024 at 07:14 AM, observed Certified Nursing Assistants #6 and #7 performing incontinent care on Resident #56 without pulling the privacy curtain. On 10/15/2024 at 9:50 AM, Certified Nursing Assistant (CNA) #6 was asked if the privacy curtain should have been pulled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and document review, the facility failed to ensure a Significant Change in Status Minimum Data Set (MDS) comprehensive assessment was completed within 14 calendar days from the determination that a significant change has occurred for one (Resident #2) of one resident reviewed for assessments. The findings are: Upon review of the residents admission Record, it showed Resident #2 was admitted on [DATE], with a primary diagnosis of encephalitis (inflammation of the brain). The most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/25/2024 documented the resident scored 03 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status. Upon review of Resident #2's (R#2) scanned documents, hospice care was ordered on 5/11/24. Upon review of all completed MDS assessments, R#2 did not have a significant change in status MDS comprehensive assessment completed within 14 calendar days following readmission on [DATE]. On 10/16/2024 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and document review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to reflect the resident's needs, and failed to ensure it was accurate to represent the resident's current health status for one resident (Resident #2) of one resident reviewed for comprehensive care plans. The findings are: On 10/14/2024 at 12:55 PM, observed Resident #2 (R#2) sitting in a geriatric chair in the designated dayroom/dining area for the memory unit with Certified Nursing Assistant (CNA) #10 assisting R#2 with lunch. CNA #10 continued to offer each bite of food, and each drink of fluid to R#2. After the meal, CNA #10 was interviewed regarding care for R#2. When asked how much assistance R#2 requires for during meals and for fluids, and she confirmed R#2 requires full assistance with all food and drinks. Upon review of the residents admission Record, it showed Resident #2 (R#2) was admitted on [DATE] with a primary diagnosis of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure staff followed Enhanced Barrier Precautions to reduce the potential risk of infection for 1 (Resident #41) sampled resident who was reviewed for Enhanced Barrier Precautions. The findings are: Review of the admission Record revealed Resident #41 was admitted with a diagnosis of pressure ulcer of right heel, stage 3 (Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed). The quarterly 5 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/13/2024 revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 01, which indicated the resident had severe cognitive impairment. Review of Resident #41's care plan, completed 8/21/2024, revealed the resident had a stage 3 pressure ulcer to the right foot. Interventions included but were not limited to: Low Air Loss Mattress to bed for pressure relief as tolerated. Ensure functional and operational and encourage good nutrition and hydration in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure leftover food items were used to maintain food quality; 1 ice machine and 1 scoop holder were maintained in clean and sanitary condition to prevent contamination of airborne particles; foods stored in the dry storage area refrigerator, and freezer were covered, and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen; failed to ensure foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; cold foods on ice were maintained at a temperature at or below 41 degrees Fahrenheit while awaiting service to prevent potential bacteria growth; hot food items on the steamtable were maintained at a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on Observation, Interview and Policy Review the facility failed to remove expired medications from 1 of 2 medication carts. The Findings include: On 9/6/23 at 2:15 PM observed the following medications on medication cart # 2. a. one vial of Novolin R insulin with an opened date of 6/3/23. b. one Albuterol Inhaler with an opened date of 7/21/03. c. one ProAir Inhaler with an opened date of 7/2/23. d. one Albuterol Inhaler with an opened date of 6/13/23. e. one Albuterol Inhaler with an opened date of 10/31/22. f. four bottles of Artificial Tears with an opened date of 6/20/23, 7/20/23, and 7/26/23 and 1 was not dated. g. one bottle of Dorzolamide eye drops with an opened date of 7/28/23. h. one bottle of Timol Eye drops with an opened date of 7/27/23. i. one Albuterol Sulfate Inhaler with an opened date of 6/15/23. j. one bottle of Latanoprost eye drops with an expiration date of 6/30/23. k. one bottle of Xalatan eye drops not dated. l. one bottle of Latanoprost eye drops with an opened date of 4/21/23. During an interview on 9/6/23 at 2:40 PM, Licensed Practical Nurse (LPN) #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. This failed practice had the potential to affect 12 residents who received pureed diets and 13 residents who received mechanical soft diets and 33 residents who received regular diets from 1 of 1 kitchen, according to a list provided by the Dietary Supervisor on 09/06/2023 at 9:00 AM. findings are: 1. The menu for the dinner meal showed the residents who received pureed diets were to receive 2 #8 scoop (1 Cup) of fish sandwich with 2 slices of cheese, residents on mechanical soft diets were to receive 3 ounces of hamburger patties with 2 slices of cheese and residents on regular diets were to receive 2 slices of cheese. 2. On 8/05/23 at 3:28 PM during the supper meal preparation Dietary Employee (DE) #4 placed 4 breaded fried fish cod pieces into a blender, ground and poured it into a pan. He covered the pan with foil and placed it in the oven to be served to 13…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 12 residents who received pureed diets, as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 09/06/2023 The findings are: On 09/05/23 at 11:48 AM, the following observations were made on the steam table: a. A pan of pureed potato salad was on the cold side of the steam table. The consistency of the pureed potato salad was lumpy and was not smooth. Pieces of potatoes were visible in the mixture. b. A pan of pureed barbeque chicken was on the steam table. The consistency of the pureed barbeque chicken was lumpy and not smooth. On 09/05/23 at 12:55 PM The surveyor asked Dietary Employee (DE) #3 to describe the consistency of the pureed foods served to the residents on pureed diets. She stated, pureed barbeque chicken has little pieces of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure a Continuous Positive Airway Pressure (CPAP) and mask were properly changed and bagged in a closed container to prevent infections for 1 of 1 sampled resident (Resident # 8) who had a physician's order for the use of a CPAP. The findings are: On 9/05/23 at 11:22 AM Resident #8 was sitting in the resident room with a CPAP on the bedside table with no date on the tubing. The tubing and mask were not bagged. On 9/06/23 at 10:56 AM, observed the mask and tubing on a bedside table. The CPAP was not bagged or dated. On 9/06/23 at 3:35 PM observed the CPAP was not in a bag or dated and the mask was lying on the bed. Review of a Physician's order dated 8/13/23 for Resident #8 showed the oxygen tubing for the CPAP machine to be changed every Sunday night. Review of a care plan with an initiated date of 6/30/23, for Resident #8 for oxygen therapy showed the Resident wears CPAP at night, and the nurse to assist with putting it on at night and removing it in the morning. On 9/7/23 at 8:30 AM Certified Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.