ATHENE NURSING AND REHABILITATION

Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.

Administration Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Have a plan that describes the process for conducting QAPI and QAA activities.

Administration Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Administration Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 13, 2025

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 13, 2025

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 5, 2025

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 30, 2024

Implement a program that monitors antibiotic use.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

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.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

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.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 27, 2026

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 13, 2025

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 2, 2025

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 27, 2026

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 27, 2026

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 27, 2026

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 27, 2026

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 2, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 5, 2025

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 5, 2025

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 2, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Past Non-Compliance, corrected July 1, 2025

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 11, 2024

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 27, 2026

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 5, 2025

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 27, 2026

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 27, 2026

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 27, 2026

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 27, 2026

Give residents a notice of rights, rules, services and charges.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 19, 2024

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

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.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Past Non-Compliance, corrected June 30, 2024

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Past Non-Compliance, corrected June 3, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 29, 2025

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 29, 2025

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 1, 2024

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

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.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Past Non-Compliance, corrected July 31, 2024

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 1, 2024

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 1, 2024

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2025

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Assure the security of all personal funds of residents deposited with the facility.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 15, 2021

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies — Deficient, Provider has date of correction, corrected June 10, 2023

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Administration Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

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.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 8, 2023

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2023

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

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.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

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.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Past Non-Compliance, corrected January 12, 2024

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 8, 2023

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2023

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2023

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2023

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2023

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Assure that each resident’s assessment is updated at least once every 3 months.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 8, 2023

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 8, 2023

Assure the security of all personal funds of residents deposited with the facility.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 8, 2023

Give residents a notice of rights, rules, services and charges.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 8, 2023

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2023

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 18, 2023

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 4, 2023

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 7, 2019