Atchison Senior Village Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Atchison, Kansas.
- Location
- 1419 N 6th Street, Atchison, Kansas 66002
- CMS Provider Number
- 175531
- Inspections on file
- 17
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Atchison Senior Village Rehabilitation And Nursing during CMS and state inspections, most recent first.
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.
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.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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