A list of the most recent deficiencies for Atherton Park Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-12-15 | 2024-01-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-15 | 2024-01-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-15 | 2024-01-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-15 | 2024-01-14 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-15 | 2024-01-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-12-15 | 2024-01-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-12-15 | 2024-01-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-12-15 | 2024-01-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-12-15 | 2024-01-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-15 | 2024-01-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-15 | 2024-01-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-15 | 2024-01-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-15 | 2024-01-14 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-12-15 | 2024-01-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-15 | 2024-01-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-15 | 2024-01-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-20 | 2024-01-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-20 | 2024-01-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-20 | 2024-01-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-20 | 2024-01-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-20 | 2024-01-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-12-20 | 2024-01-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-20 | 2024-01-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-20 | 2024-01-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-11 | 2023-11-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-29 | 2023-09-18 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-14 | 2023-09-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-14 | 2023-09-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-14 | 2023-09-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-14 | 2023-09-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-29 | 2023-09-07 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-29 | 2023-09-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-13 | 2023-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-03 | 2022-06-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-04-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-08 | 2021-09-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-08 | 2021-09-22 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-06-08 | 2021-09-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-06-08 | 2021-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-08 | 2021-09-22 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-06-08 | 2021-09-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-08 | 2021-09-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-08 | 2021-09-22 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-06-08 | 2021-08-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-08 | 2021-08-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-08 | 2021-08-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-06-08 | 2021-08-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-08 | 2021-08-26 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-06-07 | 2021-07-09 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-07 | 2021-07-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-07 | 2021-07-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-07 | 2021-07-09 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-06-07 | 2021-07-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-07 | 2021-07-09 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-03-12 | 2019-07-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-12 | 2019-07-09 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-03-12 | 2019-07-09 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Establish methods for sharing information. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Use approved construction type or materials. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-15 | 2019-06-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-12 | 2019-05-10 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-03-12 | 2019-05-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-12 | 2019-05-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-03-12 | 2019-05-10 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-03-12 | 2019-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-12 | 2019-05-10 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-03-12 | 2019-05-10 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-03-12 | 2019-05-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-12 | 2019-05-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-03-12 | 2019-05-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-03-12 | 2019-05-10 | N |
| Provide or obtain dental services for each resident. | Health | 2019-03-12 | 2019-05-10 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-03-12 | 2019-05-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-03-12 | 2019-05-10 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-03-12 | 2019-05-10 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-03-12 | 2019-05-10 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-03-12 | 2019-05-10 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2019-03-12 | 2019-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-12 | 2019-05-10 | N |
| Keep all essential equipment working safely. | Health | 2019-03-12 | 2019-05-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-03-12 | 2019-05-10 | N |
