Medicalodges Atchison
Inspection history, citations, penalties and survey trends for this long-term care facility in Atchison, Kansas.
- Location
- 1637 Riley Street, Atchison, Kansas 66002
- CMS Provider Number
- 175141
- Inspections on file
- 17
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Medicalodges Atchison during CMS and state inspections, most recent first.
Surveyors found multiple unsanitary food storage and kitchen practices, including numerous opened dry goods such as cocoa powder, baking mixes, pudding mix, cereal, and pretzels that lacked open-on dates and were loosely closed, as well as unlabeled, dirty bulk bins with a ladle stored inside one. Additional observations included crumbs in a drawer with measuring utensils, a gritty and dirty backsplash and windowsill with spilled spices, uncovered cake pieces on pans near a toaster, and a moist, grimy floor under the clean dish counter. A dietary staff member reported not being trained to date opened items and confirmed the unclean and unlabeled conditions, while policy review showed sanitation and sanitizing policies were in place but no policy for food storage was provided.
Surveyors found that residents with Foley catheters and a PEG tube lacked required Enhanced Barrier Precautions (EBP) signage, and a resident on EBP for wound care received a dressing change from two LNs who did not wear gowns despite posted EBP signage. During perineal care, two CNAs changed gloves without performing hand hygiene between soiled and clean tasks. Review of the water management records showed no documentation of flushing stagnant water areas for Legionella prevention, and the maintenance supervisor acknowledged he had not recorded these activities. The facility could not provide EBP or Legionella policies, although its infection control policy referenced staff education on hand hygiene and infection prevention.
A resident with dementia, anxiety, repeated falls, and dependence on staff for ADLs did not have dentures and glasses addressed in the comprehensive care plan, despite documentation of very impaired cognition, communication difficulties, poor intake with chewing problems, and inconsistent eye contact. Existing nutrition and ADL care plans directed staff to assist with eating, dressing, personal care, and grooming but omitted any mention of dentures, glasses, or the resident’s preferences and responses to using them. Observations found the resident seated in a Broda chair without dentures or glasses, while staff reported these items were in the room and that the resident’s willingness to use them varied, and nursing leadership acknowledged the care plan should have reflected their use and refusals.
Two residents were placed at risk when a nurse signed out controlled medications on the count sheet without documenting administration in the EMAR, and falsified witness signatures for medication destruction. The nurse signed out medications for a resident who was not present and used another nurse's initials without permission, violating facility policy and resulting in missing medications and inaccurate records.
A facility with 37 residents was found to have deficiencies in food storage and cleanliness. Observations revealed improperly labeled and stored food, such as an open box of waffles and a bag of French fries without dates. There was significant calcium buildup on the dishwasher and dirt on the ice machine. Bowls and cups were not stored inverted as required. Dietary staff acknowledged these issues, which posed a risk of foodborne illness.
The facility failed to secure hazardous materials and equipment, exposing nine cognitively impaired residents to potential harm. Unsecured utility rooms and closets contained hazardous chemicals, and a resident was observed attempting to access disinfectant wipes from a Hoyer lift. Staff acknowledged the expectation to lock away such materials, but this was not adhered to, and no policy was provided upon request.
The facility failed to follow infection control standards, with soiled laundry found on the floor and improper hand hygiene during peri care. Used towels and dirty clothing were improperly handled, and a CNA did not change gloves or perform hand hygiene when transitioning from dirty to clean areas during resident care.
A resident was observed to have multiple flies in their room over several days, including on their bed and body, indicating a failure to maintain a clean and homelike environment. Despite the presence of flies, the issue was not promptly reported to maintenance, and the facility lacked a documented policy for ensuring a homelike environment.
The facility failed to update care plans for two residents, one with Alzheimer's and another with obesity, to reflect current needs for bed rail use and weight monitoring. The absence of updated care plans led to uncommunicated care needs, as staff were unclear about the use and assessment of bed canes and weight monitoring procedures.
A resident with severe cognitive impairment and a diagnosis of rhabdomyolysis left the facility against medical advice. The facility failed to provide a recapitulation of the resident's stay and medication reconciliation, as required for discharge. Despite educating the family about the risks of leaving AMA, the facility did not document a discharge summary or ensure continuity of care, placing the resident at risk.
A resident with a history of UTIs and a suprapubic catheter did not receive proper peri-care due to a CNA's failure to follow hand hygiene protocols. The CNA washed the resident's buttocks and front peri area without changing gloves or performing hand hygiene, contrary to the facility's process. The resident's medical history included cerebral palsy and kidney failure, and they were dependent on assistance for daily activities. The facility lacked a policy for peri-care or catheter care, contributing to the deficiency.
A facility failed to document a safety assessment and obtain consent for the use of bed rails for a resident with severe cognitive impairment and a history of falls. The resident's care plan lacked documentation regarding bed canes, and staff were unsure about safety assessments. The facility could not provide documentation or a policy on bed rail management.
A medication cart was found unlocked and unattended in a common area, containing various medications while residents were nearby. A CMA confirmed the cart should be locked when unattended, and an Administrative Nurse stated that all carts must be locked when not in use, as per facility policy.
Unsanitary Food Storage and Kitchen Practices
Penalty
Summary
Surveyors identified a deficiency in the sanitary storage, preparation, and service of food in the facility kitchen based on observations, interviews, and record review. During a kitchen tour, multiple opened dry goods, including cocoa powder, buttermilk pancake mix, brownie mix, chocolate instant pudding mix, and a bag of crispy cereal, were found partially used, closed with clips, and lacking open-on dates. A plastic container without a lid contained loose pretzels and an open sandwich bag of pretzels with a prior date. Three large bins stored under a counter near the toaster were not labeled in a readable manner, and their lids had visible particles and crumbs and appeared dirty; one bin had a ladle hanging in it. The drawer holding measuring cups and spoons had crumbs along one side, the backsplash behind the counter was gritty with visible particles, and the windowsill above the counter, which held spices, had spilled spices scattered across it. Two pans on a rack near the toaster held a total of 27 pieces of cake that were left uncovered. Additional unsanitary conditions were observed under the clean dish counter, where the floor had black and gray residue and was moist and grimy. When interviewed, a dietary staff member stated she had not been trained to place open dates on food items and confirmed that the bin lids, identified by her as containing flour, sugar, and chicken batter, were not clean or labeled. She also confirmed the presence of crumbs in the measuring utensil drawer, the dirty and gritty condition of the backsplash and windowsill, and acknowledged that the uncovered cake pieces should have been covered and that the area beneath the dish counter should not be grimy. Review of facility policies showed existing policies for sanitation of dining and food service areas and for sanitizing equipment and food contact surfaces, but the facility was unable to provide a requested policy for food storage.
Inadequate Infection Control Practices and Missing Water Management Documentation
Penalty
Summary
Surveyors identified multiple failures in the facility’s infection prevention and control practices. Residents with devices that require Enhanced Barrier Precautions (EBP) did not have appropriate signage posted at their room doors, including a resident with a PEG tube and two residents with Foley catheters. Another resident on EBP for wound care had EBP signage on the door frame, but two licensed nurses entered without donning gowns and performed a buttock wound dressing change using only gloves. One of these nurses later stated she did not know if the resident was on EBP and acknowledged that the signage meant the resident was on EBP and that a gown should have been worn during the wound care. Surveyors also observed hand hygiene failures during perineal care when two CNAs removed soiled gloves and donned clean gloves without performing hand hygiene between cleaning the resident and applying a clean brief. Both CNAs confirmed they did not sanitize or wash their hands at that point, and one stated they had never really washed or sanitized their hands in between. Additionally, review of the facility’s water management documentation revealed no recorded dates or times for flushing stagnant water areas as part of Legionella prevention. The maintenance supervisor confirmed he was responsible for this documentation, had not recorded when flushing occurred, and was unaware that he was required to do so. Upon request, the facility was unable to provide an EBP policy or a Legionella policy, despite having an infection control policy stating staff would be educated on hand hygiene and other infection prevention practices.
Failure to Include Dentures and Glasses in Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, individualized care plan addressing a resident’s dentures and glasses. The resident had dementia with severely impaired cognition, anxiety disorder, repeated falls, and required staff assistance with oral care, toileting, bathing, dressing, footwear, and personal hygiene. The MDS and CAAs documented that the resident was very cognitively impaired, needed staff to anticipate his needs, and had communication difficulties, including missing or not understanding what was said. Existing care plans for nutrition and ADLs directed staff to provide verbal cues and assistance with eating, dressing, personal care, and grooming, but did not identify that the resident used dentures or glasses, nor did they include his preferences or responses to using these items. Facility records showed that the resident’s bottom dentures had previously broken after he placed them in his overall pocket and they fell out when staff removed his overalls. A dietitian note documented that the resident had dentures and reported difficulty chewing tougher meats, and a social services note documented that he did not always exhibit good eye contact during conversation. During observation, the resident was seated in a Broda chair near the television without his dentures or glasses and appeared restless and fidgeting. Social services staff confirmed that the dentures and glasses were in the resident’s room and that whether he wore them depended on his mood. Administrative nursing staff acknowledged that the care plan should have reflected that the resident had dentures and glasses and that he sometimes refused to wear them, but this information was not included in the care plan despite the facility’s use of the RAI process to develop individualized care plans.
Misappropriation and Falsification of Controlled Medication Records
Penalty
Summary
The facility failed to protect two residents from misappropriation of their controlled medications. During a random controlled substance audit, discrepancies were found in the documentation of medication administration for two residents. Specifically, several entries for controlled medications were signed out on the count sheet by a licensed nurse but were not documented on the Electronic Medication Administration Record (EMAR). Further review revealed that medications were signed out as being destroyed using another nurse's initials, as well as initials that did not belong to any licensed staff at the facility. The investigation found that on multiple occasions, controlled medications such as hydrocodone-acetaminophen, tramadol, and oxycodone were signed out and either not documented as administered or were documented as destroyed with falsified witness signatures. In one instance, a medication was signed out for a resident who was not present in the facility, having been admitted to the hospital at the time. Interviews with the nurse whose initials were used as a witness confirmed that she did not participate in the destruction of the medications and had not given permission for her initials to be used. Other licensed staff also denied witnessing or participating in the destruction of these medications. The nurse responsible for the discrepancies was unable to provide a consistent explanation for the documentation issues and admitted to signing another nurse's initials, claiming permission had been given, which was denied by the other nurse. The facility's policies required two licensed nurses to be present for the destruction of controlled substances and for accurate documentation of medication administration, which was not followed in these instances. The events led to the identification of missing medications and falsified records, placing the residents at risk for missed medications and further misappropriation.
Deficiencies in Food Storage and Cleanliness
Penalty
Summary
The facility, with a census of 37 residents, was found to have several deficiencies related to food storage and cleanliness during a survey. Observations revealed that the freezer contained an open box of waffles and an open bag of French fries, both of which were not sealed or labeled with a resident's name or the date they were opened. Additionally, there was a significant amount of calcium buildup on the top of the dishwasher, and the ice machine's catch tray had calcium buildup and dirt around the opening of the door and water drain bin. Furthermore, bowls, soup cups, and dessert bowls were stored on open shelving in the kitchen without being covered or stored inverted, contrary to the facility's policy. Interviews with Dietary staff indicated a lack of adherence to the facility's cleaning and storage policies. Dietary BB acknowledged that all dishes should be covered or stored inverted and that deliming the dishwasher was on the cleaning list, although it was not being performed. The facility's policies from 2016 stated that food should be stored in a clean, dry area, free from contaminants, and that glass and cups should be stored inverted. The failure to properly label and store food, along with improper storage of clean dishes, posed a risk of spreading foodborne illness to the residents.
Failure to Secure Hazardous Materials and Equipment
Penalty
Summary
The facility failed to maintain a safe environment free from hazardous materials and equipment, particularly for nine cognitively impaired and independently mobile residents. During a walkthrough, unsecured soiled utility rooms and closets were found to contain hazardous cleaning chemicals and aerosol deodorizers, all of which were accessible to residents. These items were labeled with warnings indicating they were harmful if swallowed and could cause eye irritation. Additionally, the service hallway was found to be unsecured, with doors propped open and keys left in locks, allowing potential resident access to hazardous areas. A specific incident involved a severely cognitively impaired resident who was observed attempting to access disinfectant wipes from a Hoyer lift placed in an egress. The wipes were not secured, and the resident was able to reach them, posing a risk of harm. Staff interviews revealed that hazardous chemicals were expected to be locked away, but this protocol was not followed. The facility was unable to provide a policy related to safe chemical storage or accident prevention when requested, further highlighting the deficiency in ensuring a safe environment for residents.
Infection Control Deficiencies in Laundry Handling and Hand Hygiene
Penalty
Summary
The facility failed to adhere to sanitary infection control standards, particularly in the handling of soiled laundry and hand hygiene during resident care. During an inspection, used towels were found placed directly on the floor of the shower room, and dirty clothing was observed on the floor next to a resident's bed. These practices are contrary to the facility's infection control policy, which mandates that soiled items should be taken directly to the soiled utility room and not placed on the floor. Additionally, there was a failure in proper hand hygiene practices during peri care. A Certified Nurse's Aide (CNA) was observed performing peri care on a resident without changing gloves and performing hand hygiene when transitioning from a dirty area to a clean area. This lapse in protocol was acknowledged by the CNA, who stated that all nursing staff had been educated on proper peri care and catheter care procedures. The facility's policy requires staff to perform hand hygiene to prevent cross-contamination, which was not followed in this instance.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident, identified as R11, which placed the resident at risk for impaired comfort and decreased psychosocial well-being. Over several days, surveyors observed multiple flies in R11's room, including on the bed, bedside table, transfer pole, and even on the resident's body. These observations were made on consecutive days, indicating a persistent issue with flies in the resident's room. Licensed Nurse G acknowledged the presence of flies and mentioned that she would either provide a fly swatter to the resident or personally swat the flies. However, the process for reporting such issues involved notifying maintenance staff with a work order, which was not initially done. Maintenance Staff U was only informed about the issue after several days and stated he would investigate the source of the flies and ensure the resident had a fly swatter. The facility did not have a documented policy for maintaining a homelike environment, contributing to the deficiency.
Care Plan Deficiencies for Bed Rail and Weight Monitoring
Penalty
Summary
The facility failed to revise the care plan for Resident 25 to reflect her bed rail evaluation and current use. Resident 25, diagnosed with Alzheimer's disease, insomnia, hypertension, and a history of repeated falls, was noted to have severe cognitive impairment and required assistance with activities of daily living. Despite the care plan indicating the use of bilateral bed canes for mobility, an inspection revealed the absence of these canes. Staff interviews indicated confusion about the installation and assessment of the bed canes, and the facility could not provide documentation on the assessment or consent for their use. Additionally, the facility did not update Resident 11's care plan to reflect his weight monitoring needs. Resident 11, with diagnoses including lymphedema, cellulitis, obesity, and muscle weakness, was dependent on staff for activities of daily living. Although the care plan required daily weight monitoring, the electronic medical record lacked specific orders or directions for obtaining weights. Interviews with staff revealed reliance on informal tools like the Kardex and a notebook to track weight monitoring, but the care plan did not accurately reflect these practices. The facility's policy required the MDS coordinator to initiate and review care plans, with the interdisciplinary team responsible for revisions. However, the care plans for both residents were not updated to reflect their current care needs, placing them at risk for uncommunicated care needs.
Failure to Provide Discharge Summary and Medication Reconciliation
Penalty
Summary
The facility failed to ensure that a resident, identified as R38, had a recapitulation of their stay, including medication reconciliation, at the time of discharge. R38, who had a diagnosis of rhabdomyolysis and severe cognitive impairment, left the facility against medical advice (AMA) with family. The facility's records showed that R38's family was educated about the implications and risks of leaving AMA, and they voiced understanding. However, the clinical record lacked evidence of a completed recapitulation of R38's stay and medication reconciliation, which are essential for ensuring continuity of care. Administrative Nurse D stated that the charge nurse was responsible for sending medications and setting up necessary services for residents discharged to home settings. However, when a resident leaves AMA, no external services can be arranged, but the charge nurse is still expected to document a discharge summary with a recapitulation of the stay and details of medications sent with the resident. The facility did not provide a policy and procedure for discharge, which contributed to the oversight in R38's discharge process, placing the resident at risk for not receiving timely and appropriate care.
Failure in Catheter Care and Hand Hygiene
Penalty
Summary
The facility failed to provide the standard of care for a resident with a history of urinary tract infections and a suprapubic catheter. The resident's care plan required catheter care every shift, including washing the peri-area with soap and water and drying it well. However, during an observation, a Certified Nurse's Aide (CNA) did not follow proper hand hygiene protocols while performing peri-care. The CNA washed the resident's buttocks and then the front peri area without changing gloves or performing hand hygiene, which is against the facility's process to avoid cross-contamination. The resident's medical record documented diagnoses including cerebral palsy, kidney failure, anemia, anxiety, and urine retention. The resident was dependent on two-member assistance for activities of daily living and had moderately impaired cognition. Despite being inserviced on peri-care and catheter care, the CNA admitted to not following the correct procedure. The facility did not provide a policy for peri-care or catheter care, which contributed to the failure in maintaining the standard of care, placing the resident at risk of catheter-related complications and further UTIs.
Failure to Document Safety Assessment and Consent for Bed Rails
Penalty
Summary
The facility failed to ensure that a resident, identified as R7, had a documented safety assessment for the use of side rails, consent for their use, and that the resident or their responsible party was informed of the risks and benefits associated with side rails. R7 had a medical history including Alzheimer's disease, cerebrovascular accident, dysphagia, repeated falls, and depression, with a severe cognitive impairment indicated by a BIMS score of six. The resident required maximal assistance for daily activities and had a history of falls, yet the care plan lacked documentation regarding the use of bed canes, which were installed to assist with bed mobility and positioning. Observations and interviews revealed that the facility did not have a clear process for assessing the safety of bed canes or obtaining consent for their use. Staff members, including a CNA and a licensed nurse, were unsure about who was responsible for assessing the bed canes for safety or checking for gaps. The administrative nurse indicated that the bed canes were used company-wide and did not believe they needed to be assessed as bed rails. The facility was unable to provide documentation of assessments, potential risks, or consent related to the bed canes, nor could they provide a policy on the management or assessment of bed rails.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications in one of the three medication carts, which placed residents at risk for adverse outcomes or ineffective medication regimens. During an observation, a medication cart located in the common area between halls 300 and 400 was found unlocked and unattended. The cart contained eye drops, nasal spray, stock medications, and numerous cards of medication, while three residents in wheelchairs were nearby. A Certified Medication Aide (CMA) acknowledged that the cart contained overflow medications and confirmed that it should be locked at all times when unattended. An Administrative Nurse reiterated that all medication carts must be locked when not in use. The facility's policy on Medication Storage, dated 2007, mandates that only authorized personnel have access to medication carts and that these should remain locked when not attended.
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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