Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at 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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Atchison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atchison Senior Village Rehabilitation And Nursing | 1 mi | ★★★★★ | 6 | 0 |
| Dooley Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Nortonville Health Care Center | 14.4 mi | ★★★★★ | 49 | 4 |
| Easton Health Care Center | 15.4 mi | ★★★★★ | 14 | 0 |
| Wathena Healthcare & Rehabilitation Center | 16.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.