Inspection Reports for
Atrium Place Health and Rehabilitation
2600 REDMAN RD, SAINT LOUIS, MO, 63136-5863
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
19.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
249% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
82% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 98
Deficiencies: 2
Date: Jan 8, 2026
Visit Reason
The inspection was conducted to assess compliance with pressure ulcer care and infection prevention protocols in the nursing home.
Findings
The facility failed to ensure proper treatment and timely implementation of orders for pressure injuries for multiple residents. Staff also failed to follow Enhanced Barrier Precautions by not wearing gowns during high-contact care activities for residents requiring such precautions.
Deficiencies (2)
F 0686: The facility failed to provide appropriate pressure ulcer care, including timely implementation of treatment orders and updating care plans for residents with pressure injuries.
F 0880: The facility failed to ensure staff followed Enhanced Barrier Precautions policy by not wearing gowns during high-contact care activities for residents requiring such precautions.
Report Facts
Census: 98
Number of residents with pressure injuries sampled: 5
Number of residents observed for Enhanced Barrier Precautions: 5
Inspection Report
Annual Inspection
Census: 100
Deficiencies: 2
Date: Jun 27, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care, including following physician orders and accurate documentation of treatments and vital signs.
Findings
The facility failed to ensure services met professional standards by not following physician orders for obtaining vital signs and by failing to accurately document wound treatments or treatment refusals for one resident. Documentation gaps and treatment omissions were noted despite existing orders.
Deficiencies (2)
F 0658: The facility failed to follow physician orders and did not obtain or document vital signs (blood pressure, temperature, pulse, respirations, oxygen saturation) for one resident as ordered.
F 0842: The facility failed to accurately document completed wound treatments or treatment refusals on the treatment administration record for one resident, with multiple blank entries noted.
Report Facts
Resident census: 100
Treatment documentation opportunities: 43
Treatment documentation blanks: 14
Treatment documentation blanks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) E | Interviewed regarding vital signs documentation and procedures | |
| Certified Nursing Assistant (CNA) B | Interviewed regarding vital signs responsibilities | |
| Wound Nurse | Interviewed regarding vital signs and wound treatment documentation | |
| Director of Nursing (DON) | Interviewed regarding expectations for following physician orders and documentation | |
| Medical Director | Interviewed regarding expectations for vital signs documentation | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding wound treatment documentation | |
| Nurse Practitioner (NP) D | Interviewed regarding resident education and wound treatment refusals |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 2
Date: Feb 25, 2025
Visit Reason
The inspection was conducted due to a complaint investigation triggered by the death of a resident and concerns about the facility's failure to provide appropriate basic life support including CPR.
Complaint Details
The complaint investigation was substantiated. The violation was initially determined to be at the immediate jeopardy level due to failure to provide CPR, but the severity was lowered to Class I and Class II levels after corrective actions were implemented.
Findings
The facility failed to provide CPR to a resident who had physician orders for full code status and was found not breathing. The facility also failed to notify the physician of lab results and ensure proper care related to seizure medications for another resident. The deficiencies were initially cited at an immediate jeopardy level but later lowered to Class I and Class II levels.
Deficiencies (2)
F678 Cardio-Pulmonary Resuscitation (CPR): The facility failed to provide CPR to a resident with full code status who was found not breathing, resulting in the resident's death without CPR being performed.
F684 Quality of Care: The facility failed to notify the physician of lab results for seizure medications and ensure proper treatment, resulting in seizure activity for a resident 18 days later.
Report Facts
Resident census: 94
Total capacity: 94
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 2
Date: Feb 25, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide appropriate basic life support including CPR for a resident with full code status, failure to notify physicians of critical lab results, and failure to properly assess and notify changes in condition for residents.
Complaint Details
The investigation was triggered by a complaint alleging failure to provide CPR to a full code resident who was found unresponsive and deceased. The complaint also included failure to notify physicians of abnormal lab results and failure to notify the on-call nurse practitioner of a resident's change of condition and fall. The complaint was substantiated with findings of immediate jeopardy removed during the survey.
Findings
The facility failed to provide CPR to a full code resident who was found unresponsive and deceased. The facility also failed to notify the physician of low seizure medication lab results for the resident, resulting in seizure activity. Additionally, the facility failed to timely notify the on-call nurse practitioner of a resident's change of condition involving purple discoloration of fingertips and a fall. Documentation and communication deficiencies were noted.
Deficiencies (2)
F 0678: The facility failed to provide basic life support including CPR to a full code resident found unresponsive, resulting in resident death without resuscitation attempts.
F 0684: The facility failed to notify the physician of low seizure medication lab results for a resident, resulting in seizure activity 18 days later, and failed to notify the on-call nurse practitioner timely of a resident's change of condition with purple fingertips and fall.
Report Facts
Resident census: 94
Resident full code count: 89
Lab result - Dilantin level: 2.5
Lab result - Keppra level: 2
Seizure duration: 5
Seizure duration: 7
Oxygen flow rate: 2
Resident vital signs - pulse: 101
Resident vital signs - SpO2: 93
Time of death: 658
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Involved in transfer and assessment of Resident #1, failed to initiate CPR, reported resident as full code |
| Nurse Manager (NM) | Nurse Manager | Verified resident death, did not initiate CPR, involved in resident assessment and communication |
| CNA D | Certified Nurse Aide | Assisted in resident transfer, noticed resident not breathing, reported purple fingertips |
| NP C | Nurse Practitioner | Resident's primary NP, not notified timely of lab results or change of condition |
| MD | Medical Director/Physician | Not aware of low seizure medication lab results, commented on failure to follow resident's full code status |
| LPN H | Licensed Practical Nurse | Described lab result notification process and responsibilities |
| LPN I | Licensed Practical Nurse | Described lab result notification and physician communication process |
| DOCI | Director of Clinical Intervention | Described lab result review process and expectations for nurses and physicians |
| CNA F | Certified Nurse Aide | Noticed resident's purple fingertips and reported to nurse |
| CNA J | Certified Nurse Aide | Observed resident's incoherence and condition during night shift |
| NP E | On-call Nurse Practitioner | Received call about resident fall and condition, recommended monitoring and neuro checks |
Inspection Report
Plan of Correction
Census: 91
Deficiencies: 1
Date: Sep 23, 2024
Visit Reason
This document is a plan of correction following a deficiency related to abuse and neglect at Atrium Place Health and Rehabilitation. The visit was conducted to address and correct the cited abuse incident and related policies.
Findings
The facility failed to ensure a resident's right to be free from abuse as evidenced by an altercation between two residents resulting in physical contact. The facility conducted an investigation, separated the residents, provided assessment and services, and implemented interventions to prevent recurrence.
Deficiencies (1)
F 600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to ensure a resident's right to be free from abuse when two residents were involved in a physical altercation. Staff separated the residents and provided interventions to prevent further incidents.
Report Facts
Resident census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner (NP) | Present during resident altercation and involved in assessment and intervention | |
| Director of Nursing (DON) | Notified of resident altercation and involved in response |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: Sep 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident-to-resident physical altercation during a smoke break.
Complaint Details
The complaint involved a physical altercation between Resident #1 and Resident #2 during a smoke break on 9/18/24. The facility's investigation included interviews with residents, staff, and witnesses. It was inconclusive whether Resident #2 ran over Resident #1's foot with a wheelchair. Both residents were assessed with no injuries found and reported feeling safe. Police and regional supervisors were notified. Staff implemented measures to prevent recurrence, including single-file lines for smoking.
Findings
The facility failed to ensure a resident's right to be free from abuse when two residents engaged in a physical altercation after a verbal dispute escalated. The facility investigated the incident, separated the residents, provided assessments, and conducted staff in-service on abuse prevention and de-escalation.
Deficiencies (1)
F 0600: The facility failed to protect residents from physical abuse during a resident-to-resident altercation involving hitting and verbal threats. Staff intervened and separated the residents promptly.
Report Facts
Census: 91
Date of alleged incident: Sep 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Reported and intervened in the resident altercation | |
| Certified Nurse Aide B | CNA | Witnessed the altercation and provided care to Resident #1 |
| Nurse Practitioner (NP) | Notified and involved in resident assessments post-incident | |
| Director of Nursing (DON) | Notified of incident and interviewed during investigation | |
| Administrator | Oversaw investigation and staff in-service |
Inspection Report
Life Safety
Census: 85
Capacity: 120
Deficiencies: 10
Date: Aug 2, 2024
Visit Reason
The inspection was conducted as an emergency preparedness and life safety code survey to evaluate compliance with fire safety and emergency preparedness regulations.
Findings
The facility failed to conduct required emergency preparedness exercises twice annually and did not maintain proper documentation. Multiple fire safety deficiencies were found including blocked exit pathways, inadequate emergency lighting testing, fire alarm system deficiencies, and out-of-service sprinkler and fire alarm systems.
Deficiencies (10)
The facility failed to conduct emergency preparedness exercises twice annually and maintain documentation, affecting all occupants. The facility has a capacity of 120 and a census of 85.
Exit discharge pathways were blocked by foliage, trash, and other items, preventing safe egress in an emergency. The facility has a capacity of 120 and a census of 85.
Emergency lighting was not tested monthly as required, with missing documentation prior to 1/24. The facility has a capacity of 120 and a census of 85.
Annual fire alarm inspection was not completed by a qualified individual and documentation was missing. The facility has a capacity of 120 and a census of 85.
Fire alarm system was out of service for more than 4 hours without adequate fire watch policy or procedures. The facility has a capacity of 120 and a census of 85.
Sprinkler system was out of service for more than 10 hours in a 24-hour period without proper notification and fire watch. The facility has a capacity of 120 and a census of 85.
Electrical panels were unlocked and accessible, posing a safety risk. The facility has a capacity of 120 and a census of 85.
Smoking regulations were not met; ashtrays were not properly maintained and cigarette butts were scattered in designated smoking areas. The facility has a capacity of 120 and a census of 85.
Electrical system inspections were not completed as required every two years, with missing documentation. The facility has a capacity of 120 and a census of 85.
Fire watch policy lacked required components and staff were not properly educated on fire watch procedures. The facility has a capacity of 120 and a census of 85.
Report Facts
Facility capacity: 120
Resident census: 85
Trash cans needing replacement: 178
Cigarette butts scattered: 75
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 3
Date: Aug 2, 2024
Visit Reason
The inspection was conducted following a complaint regarding a verbal altercation and potential abuse involving a Certified Nurse Aide (CNA) and Resident #59.
Complaint Details
The complaint involved Resident #59 who reported rough and disrespectful care by a CNA, including use of profanity and aggressive wiping of the resident's face. The facility conducted a thorough investigation including interviews with staff and witnesses. The CNA was found to have used profanity and was terminated. The resident had no injuries and no abuse was substantiated.
Findings
The facility failed to ensure all residents were treated with dignity and respect, specifically for Resident #59 during a verbal altercation with a CNA. The investigation found no substantiated abuse but identified issues with staff communication and resident care. The CNA involved was terminated. Additional findings included environmental concerns and a medication error for another resident.
Deficiencies (3)
F 0550: The facility failed to honor the resident's right to dignity and respect for Resident #59 during a verbal altercation with a CNA who was rough and used profanity. The CNA was removed and terminated after investigation.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment. Resident #78's air conditioning unit leaked causing water puddles and a wet smell. Resident #16's call light indicator above the door did not work, delaying staff response. The 300 hall had chipped floor tiles, broken baseboards, and a pulled door frame.
F 0760: The facility failed to keep Resident #92 free from a significant medication error by not obtaining Vimpat medication timely, resulting in four and a half days without the medication.
Report Facts
Resident census: 85
Sample size: 18
Days medication not administered: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA L | Certified Nurse Aide | Named in verbal altercation and rough care finding; terminated for violation of policy |
| LPN K | Licensed Practical Nurse | Witness and involved in investigation of Resident #59 incident |
| Director of Nursing (DON) | Director of Nursing | Conducted random observations and verifications; involved in investigation and interviews |
| Administrator | Facility Administrator | Interviewed regarding expectations for resident dignity and facility conditions |
| Pharmacist | Pharmacist | Interviewed regarding medication ordering and delays for Resident #92 |
Inspection Report
Routine
Census: 85
Deficiencies: 10
Date: Aug 2, 2024
Visit Reason
Routine inspection of Atrium Place Health and Rehabilitation to assess compliance with regulatory standards including resident dignity, safety, medication administration, environment, staffing, and pest control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during care, unsafe and unsanitary environmental conditions, medication administration errors, inadequate supervision during smoking breaks, failure to maintain required RN staffing hours, incomplete controlled substance documentation, and ineffective pest control in the kitchen.
Deficiencies (10)
F 0550: Facility failed to ensure resident dignity and respect for one resident during care, including rough handling and verbal altercation with staff. Investigation found no substantiated abuse but corrective education and staff removal occurred.
F 0584: Facility failed to provide a safe, clean, comfortable, and homelike environment due to leaking air conditioning unit causing water puddles and wet smell, nonfunctional call light indicator, and damaged floor tiles and door frames on the 300 hall.
F 0658: Facility failed to provide services meeting professional standards by not obtaining a physician order for a resident's Bi-level positive airway pressure (Bi-pap) machine and incomplete neuro check documentation after a resident fall.
F 0689: Facility failed to ensure adequate supervision and assistance to prevent accidents, including improper positioning of a resident during meals causing coughing and inadequate supervision during smoking breaks for multiple residents.
F 0727: Facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week during the most recent quarterly payroll-based journal staffing report.
F 0755: Facility failed to establish a system of records for controlled drugs with sufficient detail to enable accurate reconciliation, with multiple blanks on controlled substance shift change count sheets.
F 0759: Facility failed to ensure medication error rate less than 5%, with four medication errors out of 27 opportunities including failure to prime insulin pen, crushing enteric coated aspirin, and improper eye drop administration.
F 0760: Facility failed to keep a resident free from significant medication errors by not obtaining Vimpat seizure medication timely, resulting in missed doses for four and a half days without documented physician notification or alternative treatment.
F 0761: Facility failed to ensure drugs and biologicals were labeled and stored according to accepted professional standards, with multiple opened and undated insulin pens, eye drops, and liquid medications found in medication carts.
F 0925: Facility failed to maintain an effective pest control program to control flies in the kitchen, with multiple observations of flies in food prep areas and the backdoor to outside left open.
Report Facts
Medication error rate: 14.81
Residents present: 85
Sample size: 18
Controlled substance count blanks: 73
Controlled substance count blanks: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA L | Certified Nurse Aide | Named in resident dignity and verbal altercation finding; terminated for policy violation |
| LPN K | Licensed Practical Nurse | Witness and investigator in resident dignity incident |
| Director of Nursing | Director of Nursing | Provided policy and procedural expectations, interviewed on multiple findings |
| Speech Pathologist A | Speech Therapist | Observed and assisted resident during coughing episode at meal |
| Activity Director | Activity Director | Responsible for supervising smoking breaks; observed lapses in supervision |
| Corporate Staff B | Corporate Staff | Responsible for PBJ staffing reports |
| LPN F | Licensed Practical Nurse | Observed medication administration error with insulin pen |
| LPN N | Licensed Practical Nurse | Observed medication administration error crushing enteric coated aspirin |
| CMT M | Certified Medication Technician | Observed medication administration error with eye drops |
| Pharmacist | Pharmacist | Explained medication reorder process and delays for seizure medication |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 10
Date: Aug 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident rights and dignity, specifically concerning an incident involving a Certified Nurse Aide (CNA) and a resident.
Complaint Details
The complaint investigation was triggered by an incident on 6/29/24 involving a CNA and a resident where the CNA was alleged to have been rude and used profanity. The investigation included interviews with staff, witnesses, and the resident. The facility determined that abuse could not be substantiated but identified issues with dignity and respect. The CNA was terminated for policy violations. The resident had no distress or injuries noted.
Findings
The facility failed to ensure all residents were treated with dignity and respect as evidenced by an incident involving a CNA and a resident. The investigation found that abuse could not be substantiated but identified deficiencies in maintaining a safe, comfortable environment and professional standards in care and medication administration.
Deficiencies (10)
F550 Resident Rights: The facility failed to ensure all residents were treated with dignity and respect, as evidenced by an incident involving a CNA and a resident. The facility conducted an investigation and took corrective actions including staff education.
F584 Safe Environment: The facility failed to provide a safe, clean, comfortable, and homelike environment, including issues with air conditioning leaks, damaged floors, and pest control problems.
F658 Services Provided Meet Professional Standards: The facility failed to provide services meeting professional standards, including lack of physician orders for Bi-level positive airway pressure and incomplete neuro check documentation.
F689 Free of Accident Hazards: The facility failed to ensure adequate supervision and assistance to prevent accidents, including inadequate monitoring of residents during meals and smoking breaks.
F727 RN 8 Hrs/7 days/Wk, Full Time DON: The facility failed to use a registered nurse for at least 8 consecutive hours a day, 7 days a week as required.
F755 Pharmacy Services: The facility failed to provide routine and emergency drugs and biologicals to residents or obtain them under an agreement, and failed to maintain accurate records of controlled substances.
F759 Free of Medication Error Rates 5 Percent or More: The facility failed to ensure medication error rates were less than 5%, with a 14.81% error rate found in the sample reviewed.
F760 Residents Are Free of Significant Medication Errors: The facility failed to keep one resident free from a significant medication error involving seizure medication administration.
F761 Label/Store Drugs and Biologicals: The facility failed to properly label and store drugs and biologicals, including expired medications and improper storage conditions.
F925 Maintains Effective Pest Control Program: The facility failed to maintain an effective pest control program, with multiple flies observed in the kitchen and food prep areas.
Report Facts
Census: 85
Sample size: 18
Medication error rate: 14.81
Residents identified as smokers: 26
Medication error opportunities: 27
Medication error occurrences: 4
Controlled substance count blanks: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA L | Certified Nurse Aide | Named in complaint investigation for alleged rude behavior and use of profanity |
| LPN K | Licensed Practical Nurse | Witness and interviewee in complaint investigation |
| Director of Nursing | Director of Nursing (DON) | Informed of verbal altercation and involved in investigation |
| Speech Therapist E | Speech Therapist | Provided therapy notes and observations |
| Certified Medication Technician M | Certified Medication Technician | Observed medication administration |
| Licensed Practical Nurse F | Licensed Practical Nurse | Observed medication administration and blood sugar check |
| Licensed Practical Nurse N | Licensed Practical Nurse | Observed medication administration and medication cart audit |
| Licensed Practical Nurse J | Licensed Practical Nurse | Interviewed about medication availability |
| Corporate Staff B | Corporate Staff | Responsible for PBJ reports |
| Activity Director | Activity Director | Observed smoking area and resident behavior |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 3
Date: May 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident being left exposed and untreated pressure ulcers and nutritional care concerns.
Complaint Details
The complaint involved Resident #8 being left exposed in the hallway after a shower by CNA F, who refused to provide a gown or blanket. The resident was exposed for about 10 seconds and was emotionally distressed. The facility investigated, confirmed the incident, and terminated the CNA. Additional complaints involved inadequate pressure ulcer care and nutritional management for Residents #2 and #7.
Findings
The facility failed to ensure a resident was treated with dignity after being left exposed in the hallway. The facility also failed to provide appropriate pressure ulcer care and maintain nutritional status for residents, including failure to follow physician orders for wound treatment and nutritional supplements.
Deficiencies (3)
F 0550: The facility failed to honor a resident's right to dignity when a resident was left exposed in the hallway after a shower without a gown or blanket for about 10 seconds.
F 0686: The facility failed to provide appropriate pressure ulcer care for two residents, including lack of treatment orders, failure to apply protective dressings, and failure to follow wound care protocols.
F 0692: The facility failed to maintain acceptable nutritional status for a resident with severe protein-calorie malnutrition by not accurately monitoring weights, failing to document weights timely, and not providing ordered nutritional supplements consistently.
Report Facts
Census: 92
Sample size: 8
Weight loss: 3.9
Nutritional supplement administration: 31
Nutritional supplement administration missed: 5
Ice-cream administration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nursing Assistant | Named in the finding for leaving Resident #8 exposed and terminated for poor customer service and discourteous behavior |
| CNA E | Certified Nursing Assistant | Witnessed Resident #8 exposed and assisted with covering the resident |
| Licensed Practical Nurse D | Licensed Practical Nurse | Nurse on duty during the incident with Resident #8, interviewed about the event |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident with Resident #8 and wound care and nutritional care findings |
| Wound Nurse | Wound Nurse | Provided wound care observations and interviews regarding pressure ulcer care deficiencies |
| Certified Medication Technician A | Certified Medication Technician | Interviewed regarding nutritional supplement administration for Resident #7 |
| Dietary Manager | Dietary Manager | Interviewed regarding nutritional supplement availability and administration |
| Registered Dietician | Registered Dietician | Interviewed regarding nutritional care and supplement orders for Resident #7 |
| Medical Director | Medical Director | Interviewed regarding expectations for following physician orders for nutrition and wound care |
Inspection Report
Plan of Correction
Census: 92
Deficiencies: 3
Date: May 14, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to resident rights, skin integrity, and nutrition/hydration status at Atrium Place Health and Rehabilitation.
Findings
The facility failed to ensure residents were treated with respect and dignity, failed to provide necessary treatment for pressure ulcers for multiple residents, and failed to maintain acceptable nutritional status for a resident with severe protein-calorie malnutrition. Corrective actions and plans of correction were submitted.
Deficiencies (3)
F550 Resident Rights: The facility failed to ensure residents were treated with respect and dignity, evidenced by an incident where a resident was left exposed in the hallway after a shower. The responsible staff member was terminated.
F686 Skin Integrity: The facility failed to provide necessary treatment and services to promote healing and prevent new pressure ulcers for two of three residents with pressure ulcers.
F692 Nutrition/Hydration: The facility failed to maintain acceptable nutritional status for a resident with severe protein-calorie malnutrition, including inaccurate weight documentation and failure to provide physician and dietician ordered nutritional supplements.
Report Facts
Census: 92
Sample size: 8
Weight loss percentage: 3.9
Weight log dates: 5
Medication administration opportunities: 36
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 4
Date: May 3, 2024
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving Resident #1 and Resident #2 at Atrium Place Health and Rehabilitation.
Complaint Details
The complaint involved allegations of verbal abuse between Resident #1 and Resident #2. The facility was found to have failed to report the verbal abuse within the required timeframe and failed to provide adequate behavioral health services to Resident #1. The complaint was substantiated based on interviews, record reviews, and staff statements.
Findings
The facility failed to immediately report an allegation of verbal abuse involving Resident #1 and Resident #2 within the required two-hour timeframe. The facility also failed to provide necessary behavioral health care services for Resident #1, including addressing verbal aggression and updating the behavioral management care plan.
Deficiencies (4)
F609: The facility failed to immediately report an allegation of verbal abuse involving Resident #1 and Resident #2 within the required two-hour timeframe. The verbal abuse was reported to the Department of Health and Senior Services over 17 hours after the incident occurred.
F740: The facility failed to provide necessary behavioral health care services for Resident #1, including addressing verbal aggression and updating the behavioral management care plan. The resident's care plan lacked documentation of interventions to de-escalate behaviors and failed to notify the physician of behavior changes related to medication dosage.
A4075: Each resident shall receive personal attention and nursing care in accordance with his/her condition and consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiency cited at F740.
A4108: Facilities shall ensure that the clinical record contains sufficient information to reflect the initial and ongoing assessments and interventions by each discipline involved in the care and treatment of the resident. This regulation was not met as evidenced by the deficiency cited at F740.
Report Facts
Census: 95
Deficiencies cited: 4
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 2
Date: May 3, 2024
Visit Reason
The investigation was conducted due to a complaint regarding the facility's failure to timely report an allegation of resident-to-resident verbal abuse and failure to provide necessary behavioral health care services for a resident exhibiting verbal aggression.
Complaint Details
The complaint involved an allegation of resident-to-resident verbal abuse where Resident #1 threatened Resident #2. The facility failed to report the incident within the required two-hour timeframe and did not adequately address the resident's behavioral health needs. The allegation was substantiated with interviews and record reviews confirming the delay in reporting and insufficient behavioral interventions.
Findings
The facility failed to report an allegation of verbal abuse between residents within the required two-hour timeframe and did not provide adequate behavioral health care services or interventions for a resident with documented psychiatric and behavioral issues. Staff failed to document behaviors, notify appropriate parties timely, and implement care plan interventions to manage the resident's behaviors.
Deficiencies (2)
F 0609: The facility failed to timely report suspected resident-to-resident verbal abuse to management and the Department of Health within the required two-hour timeframe, reporting it over 17 hours late.
F 0740: The facility failed to provide necessary behavioral health care services and interventions for a resident exhibiting verbal aggression and threatening behavior, including lack of documentation and care planning for behavioral issues.
Report Facts
Residents present during inspection: 95
Sample size: 3
Time delay in reporting: 17
Dosage of Invega medication: 156
Correct dosage of Invega medication: 234
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | LPN | Witnessed verbal abuse incident and attempted to redirect Resident #1 |
| Licensed Practical Nurse D | LPN | Witnessed incident and described Resident #1's threatening behavior |
| Licensed Practical Nurse E | LPN | Aware of resident's psychiatric issues and behavior but did not document or intervene specially |
| Director of Nurses | DON | Interviewed about incident, medication dosage error, and lack of behavioral interventions |
| Administrator | Administrator | Interviewed about delayed reporting and lack of knowledge of resident behavior issues |
Inspection Report
Routine
Census: 94
Deficiencies: 3
Date: Apr 10, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to wound care, pain management, and food service quality at Atrium Place Health and Rehabilitation.
Findings
The facility failed to provide appropriate wound care and pain management for Resident #3, including failure to follow physician orders and timely medication administration. Additionally, the facility failed to ensure food was served at safe and palatable temperatures for Residents #1 and #3.
Deficiencies (3)
F684: The facility failed to provide needed care and services to promote healing of a foot wound for Resident #3, including failure to follow wound treatment orders and document treatments accurately.
F697: The facility failed to provide safe, appropriate pain management for Resident #3, including failure to timely administer pain medications and failure to implement alternative pain relief measures when medications were unavailable.
F804: The facility failed to ensure residents received food trays with food at safe and appetizing temperatures, with observations of cold food served to Residents #1 and #3.
Report Facts
Census: 94
Wound sample size: 6
Pain intensity: 8
Food temperature: 122.7
Food temperature: 111
Food temperature: 168
Food temperature: 168
Food temperature: 160
Food temperature: 192
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Confirmed wound treatment orders and performed wound care on Resident #3 |
| LPN B | Licensed Practical Nurse | Reported on medication availability and administration issues for Resident #3 |
| Regional Nurse C | Regional Nurse | Provided information on medication administration and pharmacy communication for Resident #3 |
| Administrator | Provided expectations for staff compliance with physician orders, medication administration, and food temperature standards |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 3
Date: Apr 10, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for Atrium Place Health and Rehabilitation.
Findings
The facility was found deficient in quality of care, pain management, and food and drink services. Deficiencies included failure to provide adequate wound care, inconsistent pain medication administration, and serving food at unsafe temperatures.
Deficiencies (3)
F684 Quality of care: The facility failed to provide needed care and services to promote healing of a foot wound for one resident. Wound treatments were not consistently provided per physician orders and facility policies.
F697 Pain Management: The facility failed to provide pain management consistent with professional standards for one of six sampled residents. Pain medications were not timely administered and follow-up was inadequate.
F804 Food and drink: The facility failed to ensure residents received food that was palatable and served at safe temperatures. Observations showed food was served cold and food temperature logs indicated unsafe temperatures.
Report Facts
Resident census: 94
Sample size: 6
Pain medication doses observed: 6
Food temperature: 122.7
Food temperature: 111
Inspection Report
Routine
Census: 81
Deficiencies: 3
Date: Jan 10, 2024
Visit Reason
The inspection was conducted to evaluate medication administration practices, infection prevention and control programs, and designation of an infection preventionist at Atrium Place Health and Rehabilitation.
Findings
The facility failed to ensure medication error rates were below 5%, with an 88% error rate in medication administration timing for sampled residents. The infection prevention program was inadequate, with staff failing to follow contact and droplet precautions during a COVID-19 outbreak. The facility also lacked a designated qualified infection preventionist.
Deficiencies (3)
F0759: The facility failed to ensure medication error rates were less than 5%, with 8 of 9 sampled residents receiving medications late, and lacked a policy addressing late medication administration beyond 60 minutes.
F0880: The facility failed to maintain an infection prevention and control program, with staff not following contact and droplet precautions during a COVID-19 outbreak affecting four of eight sampled residents.
F0882: The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program; the previous IP resigned and no qualified replacement was in place.
Report Facts
Medication error rate: 88
Sample size: 9
Census: 81
COVID positive residents: 36
COVID positive residents: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Nurse | Interviewed regarding medication administration and infection preventionist training |
| CMT C | Certified Medication Technician | Interviewed regarding medication administration on 600 hall |
| CMT D | Certified Medication Technician | Interviewed regarding medication administration on 600 hall |
| Nurse E | Nurse | Interviewed regarding medication administration |
| Administrator | Facility Administrator | Interviewed regarding medication administration expectations and infection control policies |
| CNA F | Certified Nurse Assistant | Observed and interviewed regarding infection control practices during COVID-19 outbreak |
| CNA G | Certified Nurse Assistant | Observed and interviewed regarding infection control practices during COVID-19 outbreak |
Inspection Report
Plan of Correction
Census: 81
Deficiencies: 3
Date: Jan 10, 2024
Visit Reason
The inspection was conducted to assess compliance with medication error rates and infection control standards, including a COVID-19 outbreak investigation and infection prevention program evaluation.
Findings
The facility failed to maintain a medication error rate below 5%, with an 88% error rate observed. The infection prevention and control program was deficient, particularly during a COVID-19 outbreak, and the facility failed to designate a qualified Infection Preventionist.
Deficiencies (3)
F759 Medication error rates are not 5 percent or greater; the facility failed to ensure medication administration was timely and properly assigned, resulting in an 88% error rate among sampled residents.
F880 Infection control program deficiencies included failure to maintain infection prevention practices during a COVID-19 outbreak affecting four of eight sampled residents, and failure to follow contact and droplet precautions.
F882 The facility failed to designate one or more qualified Infection Preventionists responsible for the infection prevention and control program.
Report Facts
Resident census: 81
Medication error rate: 88
COVID-19 positive residents: 41
COVID-19 positive residents at outbreak start: 36
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 3
Date: Dec 12, 2023
Visit Reason
Investigation of complaints regarding physical abuse between residents, failure to provide dialysis transportation and care, and medication administration errors.
Complaint Details
The complaint investigation was substantiated. The facility failed to prevent physical abuse between residents, failed to provide necessary dialysis transportation and monitoring, and failed to properly administer and document significant medications.
Findings
The facility failed to protect a resident from physical abuse by another resident, failed to ensure transportation and monitoring for a resident requiring dialysis resulting in hospitalization, and failed to properly administer and document significant medications including IV antibiotics and seizure/sleep apnea medications.
Deficiencies (3)
F 0600: The facility failed to protect Resident #6 from physical abuse by Resident #11 who choked and hit Resident #6 on 11/27/23. The facility intervened, provided medical care, updated care plans, and trained staff on abuse prevention.
F 0698: The facility failed to provide or arrange transportation for Resident #4's dialysis on 11/8/23, failed to notify the physician timely, and failed to monitor low blood pressure, resulting in hospitalization with critical hyperkalemia and other complications.
F 0760: The facility failed to ensure timely ordering and administration of IV antibiotics for Resident #5, failed to notify the DON, physician, and family of missed doses, and failed to properly document medication administration for Residents #5, #10, and #11.
Report Facts
Resident census: 82
Dialysis missed date: 1
Potassium level: 7.4
Medication missed doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Sent Resident #4 to hospital on 11/8/23; involved in medication administration and interviews |
| Nurse B | Nurse | Failed to initial cefepime dose and did not know how to reconstitute antibiotic for Resident #10 |
| Nurse E | Nurse | Admitted Resident #11 and called pharmacy about missing medications |
| Director of Nurses | Director of Nursing (DON) | Interviewed regarding abuse incident, dialysis transportation failure, and medication administration failures |
| Administrator | Facility Administrator | Interviewed regarding dialysis transportation and medication administration expectations |
Inspection Report
Plan of Correction
Census: 82
Deficiencies: 3
Date: Dec 12, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Atrium Place Health and Rehabilitation following a survey completed on 12/12/2023. The visit was conducted to address deficiencies related to abuse prevention, dialysis care, and medication administration.
Findings
The facility was found noncompliant with requirements to protect residents from abuse and neglect, ensure proper dialysis treatment and communication, and prevent significant medication errors. Specific incidents of resident-to-resident physical abuse and failures in dialysis transportation and medication administration were documented.
Deficiencies (3)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to ensure one resident was free from physical abuse by another resident on 11/27/23. The facility intervened and updated care plans and staff training.
F698 Dialysis: The facility failed to follow dialysis treatment and notification policies for a resident readmitted on 11/7/23, resulting in missed dialysis appointments and failure to notify the physician timely.
F760 Residents are Free of Significant Medication Errors: The facility failed to ensure staff ordered and administered intravenous antibiotics correctly, causing missed doses and failure to notify responsible parties for multiple residents.
Report Facts
Resident census: 82
Deficiency counts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nursing (DON) | Named in findings related to resident abuse and medication errors |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Jun 5, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to complete neurological checks for a resident who was hit in the face and failure to order medications in a timely manner, resulting in missed medication doses for three residents.
Complaint Details
The investigation was complaint-driven, focusing on failure to complete neurological checks after a resident was hit in the face and failure to reorder medications timely, resulting in missed doses for three residents. The deficiencies were substantiated.
Findings
The facility failed to perform neurological assessments for a resident after a head injury and failed to reorder medications timely, causing missed doses for three residents. Staff education and process improvements were needed to ensure compliance with policies.
Deficiencies (2)
F 0658: The facility failed to complete neurological checks for Resident #2 after a head injury, despite policy requiring assessments for 72 hours post-incident. Documentation of neuro checks was missing.
The facility failed to ensure timely medication reordering, resulting in missed doses of prescribed medications for Residents #1, #2, and #3 over multiple dates in March through May 2023.
Report Facts
Census: 87
Sample size: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Interviewed regarding neuro checks and medication reordering responsibilities | |
| Assistant Director of Nurses (ADON) | Interviewed about neuro check documentation and medication administration | |
| Certified Medication Technician (CMT) B | Interviewed about medication cart contents and medication reordering | |
| Administrator | Interviewed regarding expectations for neuro checks and medication reordering |
Inspection Report
Plan of Correction
Census: 87
Deficiencies: 2
Date: Jun 5, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically related to neurological checks and medication administration following a resident injury and medication management issues.
Findings
The facility failed to meet professional standards by not completing neurological assessments for a resident who was hit in the face, resulting in a swollen eye, and by failing to ensure timely medication administration for three residents. Documentation and staff education regarding neuro checks were also inadequate.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to complete neurological checks for a resident with a head injury and failed to ensure timely medication administration for three residents.
A4075 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation is not met as evidenced by the deficiency cited at F658.
Report Facts
Census: 87
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of a resident's funds by staff at the facility.
Complaint Details
The complaint was substantiated. The resident reported that CNA A misappropriated $400 from his/her debit card after being authorized to withdraw only $20. The resident did not leave the facility on the date of the withdrawal. Police were notified and an investigation was initiated.
Findings
The facility failed to ensure residents were free from misappropriation when a staff member withdrew $400 from a resident's personal account without consent. The resident's debit card was activated by a Certified Nurse Aide (CNA) who then misused the card beyond the authorized $20 reimbursement.
Deficiencies (1)
F 0602: The facility failed to protect residents from misappropriation of their belongings or money when a staff member withdrew $400 from a resident's account without consent. This affected one of four sampled residents.
Report Facts
Residents present during inspection: 95
Amount misappropriated: 400
Authorized withdrawal amount: 20
Withdrawal amount on grocery store transaction: 403
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Staff member who activated and misappropriated funds from resident's debit card |
| Administrator | Facility management notified of incident and involved in investigation | |
| Social Worker | Spoke with resident regarding incident | |
| Transportation Aide B | Concierge/Transport Aide | Escorted resident to doctor appointment and assisted with identifying misappropriation |
| Director of Nursing | Notified of allegation and involved in investigation | |
| Police Officer | Responded to allegation of theft and verified facts with facility and resident |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 2
Date: Apr 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation/exploitation of resident property and funds at St Louis Place Health & Rehabilitation.
Complaint Details
The complaint investigation substantiated that a staff member misappropriated $400 from a resident's personal account without consent. Multiple interviews with the resident, staff, and administrators confirmed the incident. The resident was confused about the debit card usage and reported the theft. Police and facility management were notified.
Findings
The facility failed to ensure residents were free from misappropriation when staff misappropriated $400 from a resident's personal account without consent. The investigation included interviews, record reviews, and policy evaluations revealing deficiencies in protecting residents from abuse and exploitation.
Deficiencies (2)
F602: The facility failed to ensure residents were free from misappropriation when staff misappropriated $400 from a resident's personal account without the resident's consent. This affected one of four sampled residents and violated the resident's right to be free from abuse and exploitation.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds. This regulation was not met as evidenced by the deficiency cited at F602.
Report Facts
Resident census: 95
Amount misappropriated: 400
Amount paid by staff: 20
Deposit amount: 822.6
Withdrawal amount: 403
Inspection Report
Census: 88
Deficiencies: 1
Date: Apr 12, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with dialysis care and services for residents requiring dialysis, including physician orders, documentation, and communication with dialysis centers.
Findings
The facility failed to ensure one resident had physician orders for dialysis and related assessments. Additionally, the facility did not maintain ongoing communication with dialysis centers for two residents receiving dialysis. Documentation of dialysis communication forms and assessments was missing for multiple residents.
Deficiencies (1)
F 0698: The facility failed to ensure one resident had physician orders for dialysis and documented assessments related to dialysis. The facility also failed to maintain communication with dialysis centers for two residents receiving dialysis.
Report Facts
Sample size: 14
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Provided interview about dialysis care and documentation expectations | |
| Nurse B | Provided interview about dialysis communication forms and assessments | |
| Assistant Director of Nurses (ADON) | Provided interview about dialysis communication forms and documentation | |
| Administrator | Provided interview about expectations for dialysis assessments and communication |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 6
Date: Mar 20, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding water temperature issues, wound care deficiencies, dialysis care, and food quality at the facility.
Complaint Details
The investigation was complaint-driven, focusing on water temperature issues, wound care failures, dialysis care deficiencies, and food quality complaints.
Findings
The facility failed to maintain appropriate hot water temperatures in resident rooms and shower rooms, failed to follow wound care policies resulting in delayed treatment and hospitalization of a resident, lacked proper dialysis orders and communication with dialysis centers for some residents, and did not follow menus or provide palatable, adequate food to residents.
Deficiencies (6)
F 0584: The facility failed to maintain hot water temperatures between 105 and 120 degrees Fahrenheit in resident rooms and shower rooms, with observed temperatures as low as 77.9 degrees F and no documented shower room temperatures.
F 0684: The facility failed to follow wound care policies by not performing weekly skin assessments and delaying interventions for a resident with a new toe wound, resulting in osteomyelitis and surgery.
F 0689: The facility failed to ensure hot water temperatures remained at or below 120 degrees Fahrenheit in one resident room and two hallway shower rooms, with temperatures reaching up to 129.2 degrees F.
F 0698: The facility failed to ensure one resident had physician orders for dialysis and assessments, and failed to maintain ongoing communication and documentation with dialysis centers for three residents receiving dialysis.
F 0803: The facility failed to ensure menus were followed and updated, and residents received adequate portions and nutritionally comparable items when substitutions were made.
F 0804: The facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature, with multiple residents and staff reporting poor food quality and repeated complaints in resident council meetings.
Report Facts
Resident census: 86
Water temperature readings: 77.9
Water temperature readings: 129.2
Resident sample size: 14
Resident sample size: 13
Menu week: 4
Date of survey completion: Mar 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Wound Nurse/LPN | Named in wound care deficiency and delayed treatment of resident's infected toe |
| LPN D | Licensed Practical Nurse | Named in wound care deficiency and resident toe infection reporting |
| Maintenance Director (MD) | Maintenance Director | Named in water temperature monitoring and repair |
| Administrator B | Administrator | Named in water temperature and wound care interviews |
| Administrator A | Administrator | Named in water temperature and dietary interviews |
| Nurse A | Nurse | Named in dialysis care interview |
| Nurse B | Nurse | Named in dialysis care interview |
| Dietary Supervisor | Dietary Supervisor | Named in dietary and food service deficiencies |
| CNA E | Certified Nursing Assistant | Named in food quality complaints |
| CNA F | Certified Nursing Assistant | Named in food quality complaints |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 2
Date: Jan 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's transfer and discharge procedures, specifically focusing on medical advice against discharge (AMA) and related documentation and notification requirements.
Complaint Details
The complaint investigation focused on the facility's handling of a resident who signed an AMA discharge. The investigation found the facility did not contact the resident's physician or family prior to the AMA discharge, did not inform the hospital, and failed to document circumstances leading to the AMA discharge. The complaint was substantiated by these findings.
Findings
The facility failed to follow its policy against medical advice discharges by not contacting the resident's physician or representative prior to signing an AMA discharge and failed to inform the hospital that the resident signed an AMA discharge. Documentation and notification requirements related to transfers and discharges were not met.
Deficiencies (2)
F622 Transfer and Discharge Requirements: The facility failed to follow policy for against medical advice discharges by not contacting the physician or resident representative prior to resident signing an AMA discharge and failed to inform hospital that resident signed AMA discharge.
A8015 19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge: No resident shall be transferred or discharged except in case of emergency discharge unless proper notification and arrangements are made. This regulation is not met as evidenced by the deficiency cited at F622.
Report Facts
Census: 71
Sample size: 13
Date of survey: Jan 12, 2023
Inspection Report
Follow-Up
Census: 64
Deficiencies: 1
Date: Nov 23, 2022
Visit Reason
Follow-up visit to verify correction of previous deficiencies related to administration and timely payments to vendors.
Findings
The facility failed to ensure timely payments to multiple vendors including pharmacy, dietician, medical director, and others, resulting in outstanding balances. Interviews and invoice reviews confirmed ongoing payment delays and lack of response from the management company.
Deficiencies (1)
F835 Administration. The facility management company failed to ensure payments were issued or issued timely to necessary vendors providing services for residents, including medical director and dietician. The census was 64.
Report Facts
Outstanding balance: 103374.47
Invoice amounts: 4174.62
Invoice amounts: 6115.45
Invoice amounts: 10579.35
Invoice amounts: 11665.06
Invoice amounts: 13261.5
Invoice amounts: 1212.59
Invoice amounts: 18123.17
Invoice amounts: 30170.96
Invoice amounts: 21462.86
Invoice amounts: 428.87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Conner | Administrator | Signed the statement of deficiencies and plan of correction. |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 8
Date: Jul 21, 2022
Visit Reason
The inspection was conducted in response to allegations of resident-to-resident verbal abuse and concerns about resident rights, safe environment, abuse prevention, accuracy of assessments, and food safety.
Complaint Details
The complaint investigation was triggered by allegations of resident-to-resident verbal abuse involving Residents #14 and #55. The facility failed to conduct a complete investigation and implement protective interventions. The allegation was substantiated as evidenced by interviews, record reviews, and observations.
Findings
The facility failed to schedule and organize resident council meetings, maintain a safe and homelike environment, prevent resident-to-resident verbal abuse, accurately complete resident assessments, provide adequate supervision and safety measures, and ensure food safety standards. Multiple deficiencies were cited related to resident rights, environment, abuse prevention, assessments, activity programs, and food safety.
Deficiencies (8)
F565 Resident/Family Group and Response: The facility failed to schedule and organize resident council meetings for residents who wished to participate, affecting all residents.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to provide a safe, clean, comfortable, and homelike environment, including maintenance issues in resident bathrooms and air conditioning units.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to conduct a complete investigation and implement interventions after allegations of resident-to-resident verbal abuse involving two residents.
F641 Accuracy of Assessments: The facility failed to ensure resident assessments accurately reflected resident status by omitting required sections and documentation.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive person-centered care plans for residents, including smoking needs and transfer status.
F679 Activities Meet Interest/Needs Each Resident: The facility failed to provide an ongoing program to support residents' choice of activities, including evening and weekend activities.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the resident environment was free of accident hazards and provide adequate supervision and assistive devices to prevent accidents related to smoking.
F812 Food Procurement, Store, Prepare, Serve, Sanitary: The facility failed to ensure food safety requirements, including proper hand hygiene, hair restraints, and sanitary food handling practices.
Report Facts
Census: 73
Resident sample size: 18
Resident smokers identified: 11
Resident weight: 417.3
Resident weight: 432
Inspection Report
Routine
Census: 73
Deficiencies: 8
Date: Jul 21, 2022
Visit Reason
Routine inspection of Atrium Place Health and Rehabilitation to assess compliance with resident rights, environment safety, abuse investigation, resident assessments, care planning, activities, smoking safety, and food service standards.
Findings
The facility failed to schedule resident council meetings, maintain a safe and homelike environment, conduct timely abuse investigations, complete accurate resident assessments, develop comprehensive care plans, provide meaningful activities including evenings and weekends, ensure smoking safety and supervision, and maintain proper food service hygiene and sanitation.
Deficiencies (8)
F 0565: Facility failed to schedule and organize resident council meetings for residents wishing to participate, affecting all residents.
F 0584: Facility failed to provide a safe, clean, comfortable environment; issues included broken furniture, water damage, exposed toilet bolts, and uncomfortable water temperatures for residents.
F 0610: Facility failed to follow policy to immediately investigate and protect residents after an allegation of resident-to-resident verbal abuse involving two residents.
F 0641: Facility failed to ensure resident assessments accurately reflected status; multiple residents had incomplete or blank Minimum Data Set (MDS) interviews and activity preference assessments.
F 0656: Facility failed to develop and implement comprehensive person-centered care plans for four residents, including smoking needs and transfer status.
F 0679: Facility failed to provide ongoing meaningful activities including evenings and weekends; resident activity preferences were not assessed or documented for some residents.
F 0689: Facility failed to maintain a safe environment free from accident hazards; smoking supervision was inadequate, smoking apron not used as required, fire blanket missing, and dry storage and kitchen areas were unsanitary with pest presence.
F 0812: Facility failed to ensure food service safety; staff did not fully cover hair or facial hair, failed hand hygiene after touching contaminated surfaces, blew into gloves before wearing, and kitchen floors and trashcans were not properly cleaned or covered.
Report Facts
Residents affected: 73
Residents who smoke: 11
Weight: 417.3
Cleaning schedule dates: 3
Inspection Report
Life Safety
Census: 73
Capacity: 120
Deficiencies: 10
Date: Jul 21, 2022
Visit Reason
The inspection was conducted as a result of an emergency preparedness investigation and life safety code survey.
Findings
The facility failed to develop a comprehensive emergency power plan and did not maintain proper signage and functionality for delayed-egress doors. Multiple deficiencies were found related to fire safety systems, sprinkler maintenance, electrical systems, and smoking regulations, potentially affecting all residents and staff.
Deficiencies (10)
E041 Emergency preparedness: The facility failed to develop an emergency plan including procedures for emergency power system operation and fuel supply. The plan lacked details on generator make, model, location, and fuel procurement.
K222 Delayed-egress locking: The facility failed to ensure delayed-egress exit doors had proper signage and maintained required locking mechanisms, affecting all occupants in smoke compartments.
K223 Self-closing doors: The facility failed to ensure self-closing doors to corridor and hazardous areas fully closed, affecting residents and staff in multiple smoke compartments.
K345 Fire alarm system: The facility failed to conduct semi-annual inspections and testing of the fire alarm system as required, potentially affecting all residents.
K353 Sprinkler system: The facility failed to maintain sprinkler heads and conduct required quarterly and annual inspections, affecting all building occupants.
K372 Smoke barrier walls: The facility failed to maintain smoke barrier walls with required fire resistance rating, affecting residents in three smoke compartments.
K511 Electrical systems: The facility failed to maintain electrical wiring and conduct annual testing of hospital-grade receptacles in patient sleeping areas, affecting all residents.
K914 Electrical receptacle testing: The facility failed to document testing of non-hospital grade electrical receptacles in sleeping areas, affecting 73 residents.
K918 Generator maintenance: The facility failed to maintain generator fuel levels, conduct proper servicing, and maintain emergency preparedness documentation, affecting all occupants during emergencies.
K741 Smoking regulations: The facility failed to properly dispose of ashtray contents and maintain smoking areas, potentially affecting staff and residents.
Report Facts
Facility capacity: 120
Resident census: 73
Deficiency counts: 10
Inspection Report
Plan of Correction
Census: 58
Deficiencies: 1
Date: Mar 28, 2022
Visit Reason
The inspection was conducted to investigate a deficiency related to discharge appeal rights at St Louis Place Health & Rehabilitation.
Findings
The facility failed to permit a resident to remain while an appeal for discharge was pending and refused to accept the resident back after an immediate discharge during hospitalization. The facility census was 58 at the time of inspection.
Deficiencies (1)
19 CSR 30-88.010(17) Discharge Appeal Rights: The facility did not provide full and adequate notice or permit a resident to remain during a discharge appeal, violating discharge appeal rights. The facility refused to accept the resident back after an immediate discharge during hospitalization.
Report Facts
Facility census: 58
Sampled residents: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karey Conner | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 2
Date: Feb 15, 2022
Visit Reason
Annual survey conducted to assess compliance with quality of care regulations at St Louis Place Health & Rehabilitation.
Findings
The facility failed to ensure proper wound care for a resident, including weekly skin assessments, notification of wound care nurse, documentation of physician-ordered ointment, and informing next of kin. The resident was discharged with a wound and readmitted to hospital for infection.
Deficiencies (2)
F684 Quality of care: The facility failed to perform and document weekly skin assessments and notify the wound care nurse when an open wound was observed. The physician-ordered ointment was not documented on the treatment administration record, and the next of kin was not informed of wound care treatments upon discharge.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiency cited at F684.
Report Facts
Resident census: 69
Sample size: 3
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Date: Jan 20, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding the care of a resident with multiple pressure ulcers and medication administration errors.
Complaint Details
The complaint investigation was substantiated. The resident admitted with multiple pressure ulcers experienced worsening wounds and significant medication errors, including missed antibiotic doses. The resident died following complications related to infection and sepsis.
Findings
The facility failed to provide adequate care to a resident admitted with multiple pressure ulcers, including failure to perform timely skin assessments and wound treatments. The facility also failed to ensure the resident was free from significant medication errors, resulting in worsening infection and the resident's death.
Deficiencies (2)
F686 Treatment/Services to Prevent/Heal Pressure Ulcers: The facility failed to ensure a resident with multiple pressure ulcers received weekly skin assessments, ordered wound treatments, and timely wound care, resulting in worsening wounds. This affected one of two sampled residents (Resident #1).
F760 Residents are Free of Significant Medication Errors: The facility failed to ensure a resident was free from significant medication errors, including missed doses of antibiotics and pain medication, contributing to worsening infection and death. This affected one of two sampled residents (Resident #1).
Report Facts
Resident census: 66
Wound treatments missed: 13
Medication administration opportunities missed: 12
Medication administration opportunities missed: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 4, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 12/20/2020 through 01/04/2021 as a complaint investigation.
Complaint Details
This complaint investigation found no deficiencies and confirmed compliance with COVID-19 infection control and emergency preparedness regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and emergency preparedness. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 16, 2020
Visit Reason
A COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey were conducted from 12/14/2020 through 12/16/2020 as a complaint investigation.
Complaint Details
This complaint investigation focused on COVID-19 infection control and emergency preparedness. The facility was found compliant and no deficiencies were cited.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and emergency preparedness. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 6, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted from 07/31/2020 through 08/06/2020 to assess compliance with relevant CMS and CDC COVID-19 guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 28, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and 42 CFR 483.73 related regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 7
Date: Oct 23, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to meet professional standards in comprehensive care plans and quality of care, including issues with following physician orders, obtaining blood pressures on dialysis days, and pressure ulcer prevention.
Complaint Details
Complaint investigation related to failure to meet professional standards in care plans, quality of care, pressure ulcer treatment, medication errors, and infection control.
Findings
The facility failed to follow physician orders and facility policy for blood pressure monitoring on dialysis days, failed to ensure timely and adequate nutritional supplementation, and did not properly assess and document residents' wandering risks. Additionally, the facility failed to notify physicians of abnormal lab results, provide adequate treatment for pressure ulcers, and maintain proper medication administration and storage.
Deficiencies (7)
F658 Services Provided Meet Professional Standards: The facility failed to follow physician orders and facility policy by not obtaining blood pressures on dialysis days for residents, not ensuring timely nutritional supplementation, and not completing wandering risk assessments.
F684 Quality of Care: The facility failed to promptly notify physicians of abnormal lab results, failed to assess and document vital signs before hospitalization, and did not adequately document bowel movements or hospitalizations.
F686 Treatment/Services to Prevent/Heal Pressure Ulcers: The facility failed to provide adequate treatment and documentation for residents with pressure ulcers and did not ensure proper wound care and assessment.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to ensure proper catheter care and maintenance, and did not provide appropriate treatment and documentation for urinary tract infections.
F759 Free of Medication Error Rates 5 Percent or More: The facility failed to ensure medication error rates were below 5 percent, with documented errors in medication administration.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure proper storage of medications, including insulin pens, and did not maintain medication carts according to policy.
F880 Infection Prevention & Control: The facility failed to maintain an effective infection prevention program, including failure to ensure proper isolation precautions and staff compliance.
Report Facts
Resident census: 63
Medication error rate: 6.45
Pressure ulcer count: 6
Wound measurements: 6
Wound measurements: 7.5
Wound measurements: 0.1
Inspection Report
Life Safety
Census: 63
Capacity: 120
Deficiencies: 8
Date: Oct 23, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility failed to meet several fire safety requirements including incomplete fire alarm system documentation, unlocked fire alarm panel, inadequate sprinkler system maintenance, failure to conduct fire drills quarterly on each shift, improper smoking area maintenance, failure to maintain smoke barrier doors, and inadequate electrical system maintenance. These deficiencies had the potential to affect all building occupants.
Deficiencies (8)
K345 Fire Alarm System - The facility failed to provide and maintain complete documentation of the fire alarm system and left the fire alarm panel unlocked, allowing unauthorized access.
K353 Sprinkler System - The facility failed to inspect, test, and maintain sprinkler systems weekly and quarterly, and failed to keep sprinkler heads free of debris and properly installed.
K712 Fire Drills - The facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times and under varying conditions.
K741 Smoking Regulations - The facility failed to maintain smoking areas in accordance with NFPA regulations, with cigarette butts and ashes found in multiple locations and improper ash can usage.
K761 Maintenance, Inspection & Testing - Doors - The facility failed to maintain smoke barrier doors in five of seven smoke zones, including failure to repair damage and missing fire resistant ratings.
K914 Electrical Systems - The facility failed to assess and maintain electrical receptacles at patient bed locations and failed to maintain required testing and records.
K918 Electrical Systems - The facility failed to ensure weekly visual inspections of the emergency power supply system and maintain documentation.
K923 Gas Equipment - The facility failed to maintain oxygen cylinder storage in accordance with NFPA code, including improper storage of combustibles and lack of proper signage.
Report Facts
Facility capacity: 120
Resident census: 63
Inspection Report
Routine
Census: 63
Deficiencies: 7
Date: Oct 23, 2019
Visit Reason
Routine inspection to assess compliance with professional standards of quality and regulatory requirements at Atrium Place Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to follow physician orders for dialysis residents, delayed notification of abnormal lab results, inadequate pressure ulcer care, improper catheter care, medication errors, improper medication storage, and lapses in infection control practices.
Deficiencies (7)
F 0658: The facility failed to follow physician orders by not obtaining blood pressures on dialysis days for one resident, delayed ordering a protein supplement for another, and failed to properly manage wander guard assessments for two residents.
F 0684: The facility failed to promptly notify the physician of abnormal lab results and failed to track bowel movements and assess vital signs preceding hospitalization for two residents.
F 0686: The facility failed to provide adequate treatment and documentation for pressure ulcers for two residents, including failure to replace soiled or removed dressings.
F 0690: The facility failed to maintain proper placement of an indwelling urinary catheter and failed to ensure the resident received the correct catheter size as ordered.
F 0759: The facility failed to ensure medication error rates were below 5%, with two errors observed in 31 opportunities, including incorrect dosing and failure to administer medication with food.
F 0761: The facility failed to store three unopened insulin pens in the refrigerator as required until use.
F 0880: The facility failed to ensure a resident on reverse isolation had a sign on the door alerting staff and visitors to inquire before entering, and failed to follow infection control policies during perineal care and blood glucose monitoring.
Report Facts
Medication error rate: 6.45
Resident census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Named in findings related to blood pressure documentation, wander guard assessments, catheter care, and infection control. | |
| Assistant Director of Nurses (ADON) | Interviewed regarding wound care, catheter care, and infection control. | |
| Nurse A | Named in findings related to vital signs assessment and blood glucose machine cleaning. | |
| Certified Medication Technician (CMT) N | Named in medication administration error involving clonidine dosing. | |
| Certified Medication Technician (CMT) O | Named in medication administration error involving meloxicam and medication storage. | |
| Nurse H | Named in wound care findings. | |
| Nurse C | Named in catheter care and infection control observations. | |
| Administrator | Interviewed regarding multiple findings including blood pressure documentation, wound care, medication errors, and infection control. | |
| Regional Nurse | Interviewed regarding medication storage and wound care. |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Date: Apr 12, 2019
Visit Reason
The inspection was conducted due to a complaint investigation related to failure to provide necessary behavioral health care services for residents with substance abuse and alcohol use issues.
Complaint Details
The complaint investigation substantiated that the facility failed to provide adequate behavioral health services and social services oversight for residents with substance abuse issues, leading to multiple incidents including overdoses and hospitalizations.
Findings
The facility failed to provide necessary behavioral health care services addressing alcohol and illegal substance use for residents, resulting in incidents including hospitalization and overdose. The facility also lacked a policy addressing substance use and failed to ensure person-centered care reflecting residents' safety and well-being needs.
Deficiencies (2)
CFR 483.40 Behavioral health services. The facility failed to provide necessary behavioral health care services for residents with substance abuse and alcohol use, affecting two of three sampled residents. The facility lacked a policy addressing alcohol and illegal substance use.
19 CSR 30-85.042(92) Social Service Program. The facility failed to designate a qualified staff member responsible for the social services program to meet residents' social and emotional needs, as related to the deficiency at F740.
Report Facts
Census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Klyndo Wilbert | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Life Safety
Census: 60
Deficiencies: 9
Date: Aug 30, 2018
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations at St Louis Place Health & Rehabilitation.
Findings
The facility failed to maintain fire safety compliance in multiple areas including fire-resistant construction, means of egress, emergency lighting, fire extinguishers, smoking regulations, combustible decorations, and electrical equipment. Several deficiencies were noted that affected all residents, staff, and occupants in the event of a fire.
Deficiencies (9)
K161: The facility failed to maintain ceilings free of penetrations to resist smoke passage, exposing wooden studs and sprinkler pipes without fire block.
K211: The facility failed to maintain exit pathways free of obstructions, including locked gates and uneven exit pathways.
K281: The facility failed to maintain emergency egress lighting and illumination of means of egress, with exit pathways lacking proper lighting.
K324: The facility failed to maintain the kitchen range hood wet chemical fire suppression system and perform monthly inspections.
K355: The facility failed to maintain portable fire extinguishers inspected monthly as required by NFPA code.
K741: The facility failed to maintain smoking areas in accordance with NFPA regulations, including ash cans with improper contents and trash cans with cigarette packs.
K753: The facility failed to prohibit combustible decorations, including candles with wicks, creating a fire hazard.
K920: The facility failed to maintain power cords and extension cords properly, with extension cords used improperly and surge protectors plugged into extension cords.
K923: The facility failed to maintain oxygen storage in accordance with NFPA code, with unsecured cylinders and lack of proper signage.
Report Facts
Facility census: 60
Inspection Report
Annual Inspection
Census: 60
Capacity: 60
Deficiencies: 17
Date: Aug 30, 2018
Visit Reason
Annual survey conducted to assess compliance with federal and state regulations for nursing home care and resident rights.
Findings
The facility was found to have multiple deficiencies related to resident self-determination, protection of personal funds, privacy, safety, care planning, abuse prevention, medication management, and infection control. Corrective actions and plans of correction were documented for each deficiency.
Deficiencies (17)
F561: The facility failed to ensure residents' rights to self-determination and choice were respected, including preferences for getting up and going to bed.
F567: The facility failed to protect residents' personal funds, including timely access and proper notification of changes in policy.
F576: The facility failed to ensure residents' right to privacy and access to telephone and mail services.
F578: The facility failed to comply with advance directives requirements and annual review of residents' code status.
F584: The facility failed to maintain a safe, clean, comfortable, and homelike environment, including maintenance of physical areas and temperature control.
F604: The facility failed to ensure residents' rights to be free from physical and chemical restraints and to be treated with respect and dignity.
F607: The facility failed to develop and implement policies to prevent abuse, neglect, and exploitation, and failed to investigate alleged incidents properly.
F608: The facility failed to report suspected crimes and failed to follow policies for abuse and neglect reporting.
F609: The facility failed to investigate and report allegations of abuse, neglect, and misappropriation of resident property.
F610: The facility failed to take appropriate corrective action for abuse, neglect, and misappropriation allegations and failed to protect residents.
F656: The facility failed to develop and implement comprehensive care plans addressing residents' needs and preferences.
F658: The facility failed to provide safe and effective medication management, including missed doses and improper storage.
F669: The facility failed to ensure residents' environment was free from accident hazards and provided adequate supervision and assistance.
F730: The facility failed to provide adequate in-service education and training for nursing staff.
F761: The facility failed to ensure proper labeling, storage, and administration of medications.
F804: The facility failed to maintain food safety standards, including proper storage and preparation of food.
F880: The facility failed to establish and maintain an effective infection prevention and control program.
Report Facts
Facility census: 60
Facility total capacity: 60
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Jul 16, 2018
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's transfer and discharge practices, specifically concerning residents given 30-day discharge notices to a homeless shelter.
Complaint Details
The complaint investigation substantiated that the facility failed to provide adequate discharge planning and documentation for residents discharged to a homeless shelter. Three residents received 30-day discharge notices without proper planning or communication.
Findings
The facility failed to properly assess and document residents' discharge planning, including goals, options for returning to the community, and communication with residents and physicians. Three residents were given 30-day discharge notices to a homeless shelter without adequate discharge planning or documentation.
Deficiencies (2)
F622 Transfer and discharge requirements were not met as the facility failed to assess and document residents' discharge goals and options, and did not provide adequate discharge planning or communication with residents and physicians.
A8015 Notice-Transfer/Discharge regulation was not met as no resident shall be transferred or discharged except under specific conditions, and the facility failed to provide proper notice and arrangements for residents being discharged.
Report Facts
Resident census: 54
Discharge notice period: 30
Discharge effective date: Jun 26, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Phyllis Wilbert | Administrator | Named in relation to discharge planning and interviews with residents |
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