F 0577
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Level of Harm - Potential for
minimal harm
Based on observation, interview, and record review, the facility failed to maintain the availability of the most
recent survey results for 1 of 1 facility reviewed for rights to survey results, in that:
Residents Affected - Many
The facility failed to retain the previous survey results within the survey binder for residents to review.
This failure could affect residents who resided in the facility and could result in a lack of awareness for
visitors, family and residents regarding the survey results and the plan of corrections submitted by the
facility.
The findings included:
Observation on 07/05/2023 at 10:06 AM revealed the state survey book did not contain information related
to the annual certification on 03/09/2023.
Interview on 07/05/2023 at 11:20 AM, the Administrator stated he was aware of the most recent state
survey results not being in the state survey binder and stated he forget to add the results to the binder after
the inspection was completed. The Administrator stated he was the staff member responsible for facility
postings and updating the state survey binder. The Administrator stated he understood the risk to residents
was that the residents, their families, or visitors would not know of historic inspection results for the facility.
Record review of ASPEN Central Office reflected the most recent annual recertification and re-licensure
inspection took place on 03/09/2023.
Record review of facility policy, titled Resident Rights, undated, reflected in part that residents had the right
to be informed of his or her rights. The facility must not prohibit or in any way discourage a resident from
communicating with federal, state or local officials.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
675205
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675205
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Atrium Rehabilitation Center
7602 Louis Pasteur St
San Antonio, TX 78229
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure, in accordance with State and Federal
laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and
permitted only authorized personnel to have access in 2 of 3 medication rooms.
The facility failed to separate expired medications from the remaining medications in 2 of 3 medication
rooms.
This failure could place residents at risk of receiving expired medications resulting in diminished clinical
results.
The findings included:
Observation on 07/05/2023 at 12:54 PM revealed: four bottles of sixty-count vitamin D3 supplements
expired on 05/23; two bottles of one hundred-count acetaminophen expiring on 06/23; and one bottle of one
hundred-count [NAME]-Vite dietary supplement expired on 04/23 within the over-the-counter storage
closet.
Observation on 07/05/2023 at 12:59 PM revealed six units of influenza vaccination with a disposal date of
06/29/2023 within the cold storage refrigerator.
Interview on 07/05/2023 at 1:09 PM, the Assistant Director of Nursing stated she was not aware of the
expired medications in the over-the-counter storage room or the cold storage refrigerator and stated the
storage room or refrigerator were not audited on a recurring basis. The Assistant Director of Nursing stated
the over-the-counter and cold storage medications were to be checked by any staff member who opened
the storage closet or refrigerator. The Assistant Director of Nursing stated she was not sure who the last
person was that opened the over-the-counter storage closet or cold storage refrigerator and stated access
to the room and refrigerator was not tracked. The Assistant Director of Nursing stated herself, the Director
of Nursing, and any charge nurses had keys to the over-the-counter storage closet and cold storage
refrigerator. The Assistant Director of Nursing stated the facility policy regarding storage of medications was
to separate and dispose of expired medications immediately upon inspection and stated a risk associated
with not separating and destroying expired medications would be that residents may be administered
expired medications and receive insufficient results.
Interview on 07/06/2023 at 10:42 AM, the Administrator stated it was his expectation that medications be
routinely evaluated and inspected to remove expired medications as it could be accidentally provided to
residents and not provide intended results.
Record Review of the facility medication storage policy, titled Medication Administration, undated, reflected
a purpose statement of medications are stored and administered in an accurate, safe, timely and sanitary
manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675205
If continuation sheet
Page 2 of 2
