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
- 18
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 8
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 identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
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