Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Atchison Senior Village Rehabilitation And Nursing during CMS and state inspections, most recent first.
RN coverage was not provided for eight consecutive hours daily as required. PBJ staffing records showed missed RN coverage on multiple days, and an Administrative Nurse verified the gaps during survey review. The facility’s policy stated that adequate RN coverage must be maintained, including an RN on duty for at least eight consecutive hours each day unless a state-approved waiver applies.
Food service staff failed to follow basic food safety practices in the kitchen and nutrition center. Surveyors found multiple unlabeled and undated food items in refrigerators, missing refrigerator/freezer temperature log entries, and observed a dietary staff member touch surfaces with ungloved, unwashed hands before handling and buttering a resident's roll.
Undated tuberculin serum was found in a med room refrigerator, and staff stated opened serum should have been dated after opening. Surveyors also found two residents’ medications prepped in cups and left unlabeled in a med cart. The DON/designee stated meds should not be prepared ahead of time until the resident is ready to take them, and facility policy required meds to be labeled and not set up in advance.
Failure to administer a consented PCV20 vaccine: A resident had signed consent for pneumococcal vaccination, but the EMR showed no documentation that the vaccine was given. Staff stated the floor nurse and DON/ADON were responsible for ensuring immunizations were administered, and the facility policy required offering and administering influenza, pneumococcal, and COVID-19 vaccines to eligible residents after education and consent.
A cognitively impaired resident at high risk for elopement exited a facility unsupervised due to inadequate supervision and ineffective alarm systems. Despite wearing a WanderGuard bracelet, the resident was able to ambulate past staff and exit through a locked door that alarmed, but staff were too far away to hear it. The resident was found outside only after staff noticed the alarm and brought them back inside.
The facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, placing residents at risk of decreased quality of care. The PBJ report indicated 139 days without the required RN coverage, and timeclock data confirmed RN coverage was missing on four specific days. The facility's policy required RN services for the mandated hours, but this was not met.
The facility failed to conduct annual performance reviews for four CNAs and one CMA, as required by their policy, placing residents at risk for inadequate care. Staff interviews and record reviews confirmed the absence of these reviews, despite the facility's policy mandating annual competency assessments.
The facility failed to submit complete and accurate staffing information to CMS through PBJ, leading to discrepancies in reported licensed nurse and RN coverage. Administrative Staff A attributed the errors to confusion from previous staff responsible for reporting.
The facility failed to provide consistent bathing and dressing assistance for several residents who were dependent on staff for ADLs. Multiple residents did not receive documented baths or showers over a 46-day period, and staff cited hectic staffing conditions as a reason for the inconsistency. This failure placed residents at risk for complications related to poor hygiene and impaired dignity.
The facility failed to secure hazardous materials out of reach of five cognitively impaired, independently mobile residents, and did not implement fall interventions for a resident with severe cognitive impairment and a history of falls. Hazardous chemicals were found unsecured in laundry rooms, and a resident was left alone in the dining room before her meal was served, attempting to stand up multiple times without staff intervention.
The facility failed to follow guidelines for enhanced barrier precautions (EBP) by not having PPE readily available outside residents' rooms and not sanitizing equipment that fell on the floor. An LN dropped a continuous glucose monitor and did not sanitize it before use on a resident. Administrative staff confirmed that PPE should be available in hallways and equipment should be sanitized immediately after use.
A resident with multiple health conditions and intact cognition reported that a CNA did not allow her to wear an incontinence brief at night, causing discomfort and embarrassment. Staff interviews confirmed the incident, and the facility's policy on resident rights was not upheld, placing the resident at risk for negative psychosocial outcomes and decreased autonomy and dignity.
A resident reported feeling pressured by the facility to switch pharmacy services during an ownership changeover, leading to a two-day delay in receiving necessary medication. Despite the facility's policy requiring clear communication and a 30-day notice for service changes, the resident's right to choose her healthcare providers was not supported, resulting in negative psychosocial outcomes.
The facility failed to assist a resident with maintaining her amplified hearing device, leading to periods where the device was non-functional due to dead batteries. This resulted in the resident experiencing difficulty in communication and a potential decline in her psychosocial well-being.
The facility failed to ensure a pressure-reducing device was in place for a resident while seated in her recliner, as specified in her care plan. The resident, who has severe cognitive impairment and multiple medical diagnoses, was observed without the cushion in her recliner on two occasions. Staff acknowledged the oversight, which placed the resident at risk for skin breakdown and pressure ulcers.
A resident with COPD and severely impaired cognition was observed with an undated and unbagged nebulizer mask placed directly on surfaces, contrary to the facility's practice of storing masks in plastic bags. Staff confirmed the proper storage practice, but the facility lacked a policy on sanitary storage of respiratory equipment.
A facility failed to ensure nursing staff demonstrated appropriate competencies in administering diclofenac gel, leading to a CMA applying an unmeasured amount of the medication to a resident without reviewing the dosage order. This placed the resident at risk of adverse side effects.
A resident missed several doses of critical medications during a transition to a new pharmacy provider due to disorganized delivery and failure to follow procedures for handling medication shortages. Staff were unaware of the missed doses, indicating lapses in communication and protocol adherence.
The facility failed to document multiple unsuccessful attempts for non-pharmacological symptom management and risk versus benefits for the continued use of an antipsychotic medication for a resident with dementia. The resident's electronic medical record lacked evidence of non-drug behavioral interventions before starting the antipsychotic medication, and staff were unsure of the specific reasons for its use.
The facility failed to ensure proper communication with the hospice provider for two residents, leading to a lack of essential documentation and a risk of missed or delayed services. Staff interviews and observations revealed that the hospice provider was unable to document visits in the facility's EMR, and there was uncertainty about the services provided by hospice staff.
RN Coverage Deficiency
Penalty
Summary
The facility failed to provide RN coverage for eight consecutive hours a day, seven days a week for a census of 45 residents. Survey review of the Payroll Based Journal staffing data showed that RN eight-hour coverage was not provided on September 27, 2025, September 28, 2025, and December 20, 2025. On 02/12/26 at 08:58 AM, Administrative Nurse D verified that the two September dates and one December date lacked eight consecutive RN hours. The facility’s Consistent RN Coverage policy, dated 03/2025, stated that the facility’s policy was to ensure adequate RN coverage, and that the facility must provide licensed nurse coverage 24 hours a day and an RN on duty for at least eight consecutive hours daily, seven days a week, unless a state-approved waiver applies.
Food Storage, Temperature Log, and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to store, distribute, and serve food in accordance with professional standards in the kitchen and nutrition center. On 02/10/26, surveyors observed an unlabeled, undated crab salad sandwich, an unlabeled and undated bag with 6 cookie dough batters, an unlabeled and undated bag of onion rings, and an unlabeled, undated, uncovered cup of ice cream in the nutrition center two-door refrigerator/freezer. The February 2026 refrigerator/freezer temperature log also had missing documentation for morning and evening shifts on February 2, 3, 4, 7, and 8. Dietary staff and an LPN verified the findings, and the LPN discarded the items. In the kitchen, surveyors observed two unlabeled and undated packages of sliced yellow cheese in the walk-in refrigerator. The two-door refrigerator/freezer and the walk-in refrigerator/freezer temperature logs had missing evening shift documentation for 02/08/26 and 02/09/26. The Certified Dietary Manager verified these observations and stated staff should label and date food before placing it in the refrigerator or freezer and document refrigerator and freezer temperatures twice a day. Later that day, a dietary staff member was observed touching the refrigerator counter and dining tables with ungloved hands and without washing hands, then handling a resident's roll and buttering it.
Undated tuberculin serum and prepped unlabeled medications
Penalty
Summary
The facility failed to appropriately store medications and biologicals when staff did not ensure an opened vial of tuberculin test serum in the medication room refrigerator was dated after opening. During observation on 02/10/26 at 08:34 AM, surveyors found one vial of tuberculin test serum that had been opened but was undated. At 08:37 AM, LN H stated that all opened tuberculin test serum should be dated, that it is good for 30 days after opening, and that the person who opened it should have dated the vial. The facility also failed to ensure safe medication administration when staff prepped medications in advance for two residents and left the medication cups unlabeled in the medication cart. During the initial tour on 02/10/26 at 07:34 AM, surveyors observed two medication cups containing multiple medications in clear plastic containers in the top drawer of the 100 hall medication cart, and LN H identified the medications as belonging to two residents. At 04:00 PM, Administrative Nurse D stated medications should not be prepared ahead of time until the resident is ready to take them. The facility’s medication policies stated medications must be labeled in accordance with facility requirements and federal laws, and that medications may not be set up in advance.
Failure to Administer Consented PCV20 Vaccine
Penalty
Summary
The facility failed to administer Resident 2’s pneumococcal conjugate vaccine (PCV20) even though the resident had signed consent to receive it. Review of the clinical record showed no documented PCV20 administration, and the resident’s last documented influenza vaccine was 10/29/25. The resident’s PCV20 consent form was dated 08/30/25, but the electronic medical record lacked documentation that the vaccine was ever given. During interviews, Administrative Nurse F stated that immunization consent forms were signed as refused or consented at admission and that it was the floor nurse’s responsibility to give the vaccination if possible. She stated that Resident 2 signed consent for PCV20, but the vaccine was not given, and that it was her responsibility to give the vaccine if it was not given on admission. Administrative Nurse D stated the assistant director of nursing was responsible for immunization auditing, that immunization forms were included in the admission packet, and that the floor nurse would ensure a consent was signed or a vaccination was refused. She stated the assistant director of nursing was to ensure the vaccine was given. The facility’s revised Immunizations policy stated it was the facility’s policy to offer and administer influenza, pneumococcal, and COVID-19 immunizations to eligible residents after providing education and obtaining consent.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for a cognitively impaired resident who was at high risk for elopement and had a recent history of exit-seeking. The resident, who had a WanderGuard bracelet due to exit-seeking behaviors, wandered the halls and into other residents' rooms almost daily. On one occasion, the resident ambulated past staff from the dining room to the great room, where they pushed on a locked door, causing it to release after 15 seconds. Although the door alarmed, staff were too far away to hear it, allowing the resident to exit the facility unsupervised. The resident's medical records indicated severe cognitive impairment, requiring supervision or assistance with walking and transfers. The resident exhibited wandering behaviors, was disoriented, and had a history of attempting to exit the facility. Despite these known risks, staff failed to adequately monitor and redirect the resident, resulting in the resident exiting the building and being found outside by staff only after the door alarm was acknowledged. Interviews with staff revealed that the door alarms were not audible in certain areas of the facility, such as the dining room, which contributed to the failure to respond promptly to the alarm. Staff were aware of the resident's tendency to trigger door alarms and attempted to redirect the resident, but these measures were insufficient to prevent the elopement. The facility's policy required appropriate assessment, interventions, and supervision to prevent such incidents, but these were not effectively implemented in this case.
Removal Plan
- R1 was assessed and placed under one-to-one staff supervision.
- R1's physician and family were notified.
- R1's plan of care was updated with interventions to address R1's desire to go outside and experience the weather.
- The facility implemented behavioral audits in the clinical meeting to review and follow up on any new behaviors from the report.
- Staff received education on elopement policies and procedures.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, which placed the residents at risk of decreased quality of care. The Payroll Based Journaling (PBJ) report from CMS for Fiscal Year 2023 Quarters 3 and 4 indicated that there were 139 days when the facility did not have an RN for the required hours. A review of timeclock and payroll data showed that the facility had RN coverage for eight consecutive hours on all but four specific days. Administrative Staff A was unable to confirm the previous system used to track RN hours before March 1, 2024. The facility's Nursing Administrative- Nursing Services policy, last revised in February 2024, stated that the facility would ensure RN services for at least eight consecutive hours a day, seven days a week, as required by regulation. However, the facility did not meet this requirement, leading to the identified deficiency.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete the required nurse aide performance reviews at least once every 12 months, placing residents at risk for inadequate care. The report identified that four CNAs and one CMA had not received performance reviews within the last 12 months, despite being employed for varying lengths of time. Interviews with staff members confirmed that they could not recall having performance reviews since their hire dates. The facility's policy mandated annual competency assessments, but there was no evidence that these were conducted as required. The deficiency was further corroborated by statements from the Administrative Nurse, who acknowledged the lack of performance reviews by prior management. The facility's Nursing Staff Competency policy, last updated in March 2024, required annual or bi-annual skills fairs or equivalent evaluations to ensure staff competency. However, the absence of documented performance reviews indicated non-compliance with this policy, thereby compromising the quality of care provided to the residents.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information to the Centers for Medicare & Medicaid Services (CMS) through Payroll Based Journaling (PBJ). Specifically, the facility did not report staffing data for all direct care personnel for one quarter and submitted inaccurate data for others. This discrepancy was identified through a PBJ report for Fiscal Year (FY) 2023 Quarter 2 and 2024 Quarter 1, which indicated suppressed data due to inaccurate reporting or failure to report. The report also highlighted that the facility did not have licensed nurse coverage for 23 days and registered nurse (RN) coverage for eight consecutive hours each 24-hour period for 139 days in FY 2023 Quarters 3 and 4. However, a review of timeclock and payroll data revealed that the facility did have the required coverage on most of these days, except for four days without eight consecutive hours of RN coverage. Administrative Staff A acknowledged the errors in the PBJ submission, attributing them to confusion related to the previous staff responsible for reporting and entering payroll information. The facility's Payroll-Based Journal policy, dated 03/01/24, mandates the submission of detailed staffing hours every quarter to CMS. The failure to submit accurate information placed the residents at risk for impaired care due to unidentified staffing issues.
Inconsistent Bathing and Dressing Assistance for Dependent Residents
Penalty
Summary
The facility failed to ensure consistent bathing and dressing assistance for several residents who were dependent on staff for activities of daily living (ADLs). Resident 30, who had severe cognitive impairment and required substantial to maximal assistance with bathing, received only one shower, one full bath, and two sponge baths over a 46-day period. Despite the facility's policy to provide necessary services for personal hygiene, the documentation revealed multiple instances where bathing was marked as 'Not Applicable' or 'Resident Refused,' although staff interviews indicated that refusals were not always documented accurately. Staffing issues in March 2024 were cited as a reason for the inconsistency in providing baths and showers. Resident 22, who required substantial assistance with bathing, did not receive any documented baths or showers over the same 46-day period. The resident stated she would never refuse a bath unless ill, contradicting the records that showed refusals. Staff interviews confirmed that some residents did not receive their baths due to hectic staffing conditions. Similarly, Resident 18, who also required substantial assistance, received only three showers and had multiple days marked as 'Not Applicable' or 'Resident Refused,' despite the resident stating she never refused a bath. Resident 7, who was dependent on staff for all bathing, did not receive any documented baths or showers for the entire month of March 2024. The resident reported that she usually refused showers but never refused a bed bath, and staff confirmed that she likely did not receive any baths during that period. Resident 16, who required substantial assistance for bathing and dressing, also experienced inconsistent care. The resident reported missing baths and not receiving timely assistance with dressing, which was corroborated by staff interviews. The facility's failure to provide consistent bathing and dressing assistance placed these residents at risk for complications related to poor hygiene and impaired dignity.
Failure to Secure Hazardous Materials and Implement Fall Interventions
Penalty
Summary
The facility failed to secure hazardous materials out of reach of five cognitively impaired, independently mobile residents. During a walkthrough, it was observed that unsecured laundry rooms contained accessible containers of sanitary bleach wipes and tuberculocidal disinfectant spray, both of which had warnings to keep out of reach of children. Staff interviews confirmed that hazardous chemicals were supposed to be locked away from residents, and the facility's policy indicated that all potentially hazardous materials should be stored in secured areas. This failure placed the affected residents at risk for preventable injuries and accidents. Additionally, the facility failed to implement fall interventions for a resident (R25) with severe cognitive impairment and a history of falls. R25's care plan instructed staff to bring her to the dining room only once her meal was ready and to stay with her during mealtimes. However, observations revealed that R25 was left alone in the dining room before her meal was served, during which she attempted to stand up multiple times without staff intervention. Staff interviews confirmed that R25 was at high risk for falls and that staff were expected to stay with her during mealtimes. This failure to follow the care plan placed R25 at risk for preventable falls and related injuries.
Failure to Follow Enhanced Barrier Precautions and Sanitize Equipment
Penalty
Summary
The facility failed to ensure guidelines for enhanced barrier precautions (EBP) were followed, as personal protective equipment (PPE) was not readily available for staff use outside the residents' rooms. During an inspection, it was observed that PPE was stored inside the resident's room rather than in a covered cart or storage area outside the room. Additionally, a licensed nurse (LN) was observed dropping a continuous glucose monitor (CGM) on the floor and failing to sanitize the equipment or her hands before using it on a resident. The nurse later acknowledged the oversight but stated that she usually would have sanitized the equipment after it fell. The facility's administrative staff confirmed that PPE should be available in the hallways and that equipment should be sanitized immediately after use, especially if it had fallen on the floor. The facility's infection control policies, last revised in 2007 and 2024, respectively, documented the need for immediate cleaning and disinfection of shared equipment and the use of EBP in conjunction with standard precautions. The failure to have PPE readily available and to sanitize equipment properly placed residents at risk of infection development.
Failure to Respect Resident's Dignity During Incontinence Care
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity during incontinence care. The resident, who had diagnoses including hypertension, obesity, congestive heart failure, candidiasis, and muscle weakness, was dependent on staff for toileting and frequently incontinent. Despite having intact cognition and a care plan that directed staff to provide good peri-care and brief changes as needed, the resident reported that a CNA did not allow her to wear an incontinence brief throughout the night, causing her discomfort and embarrassment. Interviews with staff confirmed the resident's report. A licensed nurse admitted forgetting to report the resident's complaint, and another CNA suggested the brief was left off to allow the resident's skin to be open to air. The administrative nurse was unaware of the situation but agreed that the resident should be allowed to wear a brief if she wished. The facility's policy on resident rights emphasized treating all residents with kindness, dignity, and respect, which was not upheld in this case, placing the resident at risk for negative psychosocial outcomes and decreased autonomy and dignity.
Failure to Support Resident's Right to Self-Determination
Penalty
Summary
The facility failed to ensure that a resident, R22, was allowed to exercise her right to self-determination without intimidation. R22 reported feeling pressured by the facility to switch pharmacy services during an ownership changeover. She and her spouse, R21, were informed by the facility that their medications might be difficult to obtain from their previous pharmacy once the facility switched to a new one. This led R22 to switch pharmacies, resulting in a two-day delay in receiving her clotrimazole cream, which she needed for a fungal infection. R22 stated that she and R21 would not have changed pharmacies if not for the facility's warning about potential difficulties in obtaining medications from their previous pharmacy. The facility's new Admission Agreement required residents to communicate their preference for a different vendor at the time of admission or during a care plan meeting, with a 30-day notice to ensure services could be arranged. The agreement also stated that services and charges from non-contracted providers would need to be managed by the resident or their representative. Despite a letter being sent to all residents two weeks in advance with the new pharmacy information and a meeting with the resident council where no concerns were raised, R22's medications were delayed. The facility's Resident Rights policy indicated that information should be provided to residents in a clear and understandable manner. The facility's failure to support R22's right to choose her healthcare providers and services, including pharmacy services, placed her at risk for negative psychosocial outcomes related to decreased autonomy and impaired rights.
Failure to Maintain Hearing Device for Resident
Penalty
Summary
The facility failed to assist Resident 16 with maintaining her amplified hearing device, which placed her at risk for a decline in communication and psychosocial well-being. Resident 16 had diagnoses of anxiety disorder, insomnia, and GERD, and her MDS indicated she had moderate difficulty hearing but did not use hearing aids. Despite having an amplifier that assisted with her hearing, staff did not regularly check or maintain the device, leading to periods where the device was non-functional due to dead batteries. This lack of assistance was observed during multiple visits, where Resident 16 struggled to hear and communicate effectively without her amplifier headphones. Interviews with staff revealed a lack of clarity and consistency in checking the functionality of Resident 16's hearing device. While the care plan indicated that staff should ensure the proper functioning of the amplifier, it was evident that this was not being consistently followed. Staff members admitted to not regularly checking the device, and it was only after several days that the batteries were finally replaced. This failure to maintain the hearing device as per the care plan resulted in Resident 16 experiencing difficulty in communication and a potential decline in her psychosocial well-being.
Failure to Utilize Pressure-Reducing Device for Resident
Penalty
Summary
The facility failed to ensure that a pressure-reducing device was in place for Resident 25 while she was seated in her recliner, as specified in her care plan. Resident 25, who has severe cognitive impairment and multiple medical diagnoses including repeated falls, muscle weakness, insomnia, dementia, and congestive heart failure, was observed on two separate occasions without the pressure-reducing cushion in her recliner. The cushion remained in her wheelchair instead. This oversight was confirmed by both a licensed nurse and a certified nurse aide, who acknowledged that the cushion should have been moved to the recliner during transfers. The resident's care plan indicated that she was at high risk for pressure injuries and required the use of pressure-relieving devices for both her wheelchair and recliner. Despite this, staff failed to follow the care plan interventions, placing the resident at risk for skin breakdown and pressure ulcers. The facility's policy on skin and wound monitoring, which was revised in March 2024, mandates the implementation of practices to prevent and promote healing of injuries, including the use of pressure-reducing devices. However, this policy was not adhered to in the case of Resident 25.
Failure to Store Nebulizer Mask in a Sanitary Manner
Penalty
Summary
The facility failed to ensure the nebulizer mask for a resident with chronic obstructive pulmonary disease (COPD) was stored in a sanitary manner, increasing the risk of respiratory infection and complications. The resident, who had severely impaired cognition and required assistance with personal care, was observed on multiple occasions with an undated and unbagged nebulizer mask placed directly on the nebulizer machine or dresser. This was contrary to the facility's practice of storing nebulizer masks in plastic bags when not in use, as confirmed by staff interviews. The resident's medical records documented a need for oxygen therapy and albuterol sulfate inhalation via nebulizer for COPD. Despite this, the nebulizer mask was not stored properly, as observed on three separate occasions. Staff members, including a Certified Medication Aide and a Licensed Nurse, acknowledged that the nebulizer mask should be dated and stored in a plastic bag. An Administrative Nurse also confirmed this practice and stated that all respiratory equipment had been replaced and provided with plastic bags for storage. However, the facility did not provide a policy related to the sanitary storage of respiratory equipment.
Failure to Ensure Proper Medication Administration Competency
Penalty
Summary
The facility failed to ensure nursing staff demonstrated the appropriate competencies and skill sets to provide nursing services to care for residents' needs when staff lacked knowledge related to dosing and administering diclofenac gel for Resident 17. On 04/16/24, a Certified Medication Aide (CMA) prepared and dispensed medications for Resident 17 without reviewing the diclofenac gel order for a dosage amount. The CMA squeezed an unmeasured amount of the gel onto her glove and applied it, unaware that the medication had a specific dosage requirement. The CMA admitted to not knowing about the dosage amount and the existence of a plastic measuring chart included with the medication until informed by the surveyor. On 04/17/24, the Administrative Nurse confirmed that CMA R and other nursing staff had been educated on the proper dosage and administration for diclofenac. The facility's Nursing Staff Competency policy, last revised in March 2024, stated that staff should demonstrate competency in medication management, including the ability to use tools and devices subject to training. Despite this policy, the facility failed to ensure that staff demonstrated the appropriate competencies and skill sets, placing residents at risk of adverse side effects due to improper medication administration.
Medication Availability Failure During Pharmacy Transition
Penalty
Summary
The facility failed to ensure that a resident's medications were available for administration without missed doses during a change-over to a new pharmacy provider. The resident, who had diagnoses including depressive disorder, dementia, anxiety, hypertension, diabetes mellitus, and bipolar disorder, missed several doses of critical medications such as Sertraline, Atorvastatin, Trazodone, Depakote, and Metformin on specific dates. The resident's care plan required these medications to be administered as ordered to manage their conditions effectively. The deficiency was identified through observations, record reviews, and interviews. Staff reported that the new pharmacy's medication delivery was disorganized, leading to confusion and missed doses. The facility's procedures for handling medication shortages, such as using the emergency medication kit and contacting the physician, were not followed. The administrative nurse and other staff members were unaware of the missed doses, indicating a lapse in communication and protocol adherence during the pharmacy transition.
Failure to Document Non-Pharmacological Interventions and Risk-Benefit Analysis for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that multiple unsuccessful attempts for non-pharmacological symptom management were documented, including risk versus benefits for the continued use of an antipsychotic medication for a resident with a diagnosis of dementia. The resident, who had severely impaired cognition and was dependent on staff for activities of daily living, was receiving Risperdal for restlessness, agitation, and paranoid personality disorder. The resident's electronic medical record lacked documentation of non-drug behavioral interventions that were tried and failed before starting the antipsychotic medication. Additionally, the facility did not attempt a gradual dose reduction as required. Observations and interviews revealed that staff were unsure of the specific reasons for the resident's Risperdal use. The facility's policy on psychotropic medication use required that residents who have not used psychotropic drugs should not be given these drugs unless necessary to treat a specific condition, and that residents using psychotropic drugs should receive a possible gradual dose reduction and behavior interventions unless clinically contraindicated. The facility's failure to document non-pharmacological interventions and risk versus benefits for the antipsychotic medication placed the resident at risk for unnecessary psychotropic medications and related complications.
Failure to Ensure Proper Communication with Hospice Provider
Penalty
Summary
The facility failed to ensure a proper communication process between the facility and the hospice provider for two residents, leading to a risk of missed or delayed services. For the first resident, who had diagnoses including diabetes mellitus, multiple sclerosis, and congestive heart failure, the facility's records lacked essential documentation such as physician orders, hospice care plans, and a list of medications covered by the hospice provider. Observations and staff interviews revealed that the hospice provider was not able to document their visits in the facility's electronic medical record (EMR), and there was no clear communication about the services provided by hospice staff. This lack of documentation and communication created a risk for the resident's physical and psychosocial well-being. Similarly, for the second resident, who had diagnoses including chronic obstructive pulmonary disease and Alzheimer's disease, the facility's records also lacked documentation of hospice visits and care provided since February 2024. The resident's care plan included various hospice-provided equipment and services, but there was no evidence of recent hospice visits in the communication book. Staff interviews confirmed that the hospice provider was unable to document their visits in the facility's EMR, and there was uncertainty among staff about the hospice services listed in the care plan. This deficiency placed the resident at risk for delayed services, potentially affecting their mental and psychosocial well-being. The facility's policy on end-of-life care emphasized the importance of interdisciplinary assessment and individualized plans to address the needs of terminally ill residents. However, the lack of collaboration and communication between the facility and the hospice provider for both residents indicated a failure to adhere to this policy. This deficiency in communication and documentation created a risk for missed or delayed services, impacting the residents' overall care and well-being.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 140 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Atchison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medicalodges Atchison | 1 mi | ★★★★★ | 8 | 0 |
| Dooley Center | 1.8 mi | ★★★★★ | 9 | 0 |
| Nortonville Health Care Center | 15.5 mi | ★★★★★ | 49 | 4 |
| Wathena Healthcare & Rehabilitation Center | 15.7 mi | ★★★★★ | 0 | 0 |
| Easton Health Care Center | 16.1 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.