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Deficiency Records for Athene Nursing and Rehabilitation
A list of the most recent deficiencies for Athene Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Athene Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2024-08-02 | 2024-07-31 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-06-04 | 2024-06-04 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-24 | 2024-05-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-24 | 2024-05-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-15 | 2024-04-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-15 | 2024-04-11 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-24 | 2024-04-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-24 | 2024-04-10 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2024-02-15 | 2024-03-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-15 | 2024-03-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-02-15 | 2024-03-19 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2024-02-15 | 2024-03-19 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-02-15 | 2024-03-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-15 | 2024-03-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-02-15 | 2024-03-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-15 | 2024-03-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-15 | 2024-03-19 | N |
| Provide activities to meet all resident's needs. | Health | 2024-02-15 | 2024-03-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-15 | 2024-03-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-15 | 2024-03-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-15 | 2024-03-19 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-02-15 | 2024-03-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-02-15 | 2024-03-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-02-15 | 2024-03-19 | 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 | 2024-02-15 | 2024-03-19 | N |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-02-15 | 2024-03-19 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-02-15 | 2024-03-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-02-15 | 2024-03-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-15 | 2024-03-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-15 | 2024-03-19 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-02-15 | 2024-03-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-15 | 2024-03-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-15 | 2024-03-19 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-02-15 | 2024-03-19 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-02-15 | 2024-03-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-15 | 2024-03-19 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-24 | 2024-03-19 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-02-24 | 2024-03-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-24 | 2024-03-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-24 | 2024-03-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-02 | 2024-02-02 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-11-16 | 2023-12-08 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-11-16 | 2023-12-08 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-11-16 | 2023-12-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-16 | 2023-12-08 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-09-28 | 2023-11-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-28 | 2023-11-08 | Y |
| 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 | 2023-07-25 | 2023-08-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-25 | 2023-08-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-25 | 2023-08-18 | Y |
| 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 | 2023-06-08 | 2023-08-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-08 | 2023-08-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-08 | 2023-08-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-08-18 | Y |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-06-08 | 2023-06-30 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-08 | 2023-06-10 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-08 | 2023-06-10 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-08 | 2023-06-10 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-08 | 2023-06-10 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-05-19 | 2023-06-04 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-30 | 2023-06-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-30 | 2023-05-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-30 | 2023-05-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-30 | 2023-05-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-30 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-30 | 2023-05-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-30 | 2023-05-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-30 | 2023-05-12 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-30 | 2023-05-12 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-02 | 2023-03-01 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-31 | 2022-04-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-08-31 | 2021-10-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-08-31 | 2021-10-15 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-08-31 | 2021-10-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-08-31 | 2021-10-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-31 | 2021-10-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-31 | 2021-10-15 | 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 | 2021-08-31 | 2021-10-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-31 | 2021-10-15 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-08-31 | 2021-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-31 | 2021-10-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-31 | 2021-10-15 | N |
| Provide activities to meet all resident's needs. | Health | 2021-08-31 | 2021-10-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-31 | 2021-10-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-31 | 2021-10-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-31 | 2021-10-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-31 | 2021-10-15 | 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 | 2021-08-31 | 2021-10-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-31 | 2021-10-15 | 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 | 2021-08-31 | 2021-10-15 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-08-31 | 2021-10-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-31 | 2021-10-15 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-08-31 | 2021-10-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-31 | 2021-10-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-31 | 2021-10-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-08-31 | 2021-10-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-31 | 2021-10-15 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-08-31 | 2021-10-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Meet other general requirements. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-31 | 2021-10-15 | 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 | 2021-08-31 | 2021-10-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-31 | 2021-10-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-29 | 2019-06-07 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-04-29 | 2019-06-07 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-04-29 | 2019-06-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-04-29 | 2019-06-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-29 | 2019-06-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-04-29 | 2019-06-07 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-04-29 | 2019-06-07 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-04-29 | 2019-06-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-29 | 2019-06-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-29 | 2019-06-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-29 | 2019-06-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-29 | 2019-06-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-29 | 2019-06-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-29 | 2019-06-07 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-04-29 | 2019-06-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-29 | 2019-06-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-29 | 2019-06-07 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-04-29 | 2019-06-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-29 | 2019-06-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-29 | 2019-06-07 | 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 | 2019-04-29 | 2019-06-07 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-04-29 | 2019-06-07 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-04-29 | 2019-06-07 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-04-29 | 2019-06-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-29 | 2019-06-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-04-29 | 2019-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-29 | 2019-06-07 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2019-04-29 | 2019-06-07 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-04-29 | 2019-06-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-29 | 2019-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-29 | 2019-06-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-29 | 2019-06-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-29 | 2019-06-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-29 | 2019-06-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-29 | 2019-06-07 | N |
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