Atchison Senior Village Rehabilitation and Nursing

Inspectors wroteThe facility had a census of 45 residents. Based on observation, interview, and record review, the facility failed to provide Registered Nurse (RN) coverage eight hours a day, seven days a week.

Inspectors wroteThe facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, distribute, and serve food by professional standards for food service safety in the facility's kitchen.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents with two medication rooms and three medication carts. Based on observation, record review, and interviews, the facility failed to appropriately store medications and biologicals when staff failed to ensure the tuberculin (a sterile liquid used to diagnose tuberculosis) test serum was dated after opened, and further failed to ensure safe medication administration when staff prepped two residents' medications in medication cups, unlabeled in the medication cart.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 12 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to administer Resident (R)2's Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) vaccination that R2 consented to receive.

Inspectors wroteThe facility identified a census of 41 residents. The sample included three residents reviewed for elopement (when a cognitively impaired resident with little or poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an elopement for Resident (R) 1, who was cognitively impaired, at high risk for elopement, and had a recent history of exit-seeking. The facility placed a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) on R1 on 10/04/24 due to R1's exit-seeking behaviors and setting off door alarms. R1 wandered the halls and into other residents' rooms almost daily from 10/06/24 through, and including, 10/11/24. On 10/12/24 R1 ambulated past staff, from the dining room to the great room. [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents. Based on record review and interview, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours a day seven days a week. This placed the residents at risk of decreased quality of care.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents. Four Certified Nurse Aides (CNA) and one Certified Medication [NAME] (CMA) were sampled for performance reviews. Based on record review and interview, the facility failed to complete the required nurse aide performance review at least once every 12 months. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility had a census of 32 residents. Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing data for all direct care personnel as required one quarter and failed to submit accurate data on others. This placed the residents at risk for impaired care due to unidentified staffing issues.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents with seven residents reviewed for activities of daily living (ADL) for dependent residents. Based on observation, record review, and interviews, the facility failed to ensure a shower/bath was consistently provided for Resident (R) 30, R22, R18, R7, and R16 who were dependent on staff assistance with ADLs. The facility also failed to ensure R16 was assisted with dressing. This deficient practice had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 32 residents. The sample included 13 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure hazardous materials out of reach of five cognitively impaired, independently mobile residents. The facility also failed to ensure Resident (R)25's fall interventions were implemented per her plan of care at mealtime. This deficient practice placed the affected residents at risk for preventable injuries and accidents. Findings Included: - On 04/18/2024 at 07:11 AM a walkthrough of the facility was completed. An inspection of the facility's 100 and 200 unsecured laundry rooms revealed accessible containers of sanitary bleach wipes. The wipes contained a Keep out of reach from children warning. [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure guidelines for enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) were followed when the facility failed to have personal protective equipment (PPE) readily available for staff use, stored outside the room. The facility failed to ensure staff sanitized resident equipment when it fell on the floor. This placed the residents at risk of infection development.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents with eight residents reviewed for resident rights. Based on observation, interview, and record review, the facility failed to ensure Resident (R)7 was treated with respect and dignity during incontinence care. This deficient practice placed the resident at risk for negative psychosocial outcomes and decreased autonomy and dignity.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents with eight residents reviewed for resident rights. Based on observation, interview and record review, the facility failed to ensure Resident (R)22 was allowed to exercise her right for self-determination without intimidation. This deficient practice placed the resident at risk for negative psychosocial outcomes related to decreased autonomy and impaired rights. Findings Included: - On 04/17/24 at 11:00 AM R22 stated she felt pressured by the facility to switch pharmacy services during the facility's ownership changeover. She stated R21 (her spouse) and she were told by the facility their medications may be difficult to obtain by their previous pharmacy once the facility switched to the new one. She stated she was afraid of not receiving her medications due to her existing medical problems. [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents with seven reviewed for maintaining activities of daily living. Based on observation, record review, and interviews, the facility failed to assist Resident (R)16 with maintaining her amplified hearing device. This deficient practice placed R16 at risk for a decline in communication and psychosocial well-being. Findings Included: - The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of an anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (difficulty sleeping), and gastro-esophageal reflux disorder (GERD-backflow of stomach contents to the esophagus). R16's Annual Minimum Data Set (MDS) completed 03/04/24 noted a Brief Interview for Mental Status score of 14 indicating intact cognition. [...]

Inspectors wroteThe facility reported a census of 32 residents. The sample included 13 residents with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) care. Based on record review, interviews, and observations, the facility failed to ensure Resident (R)25's pressure-reducing device was in her recliner as care planned. This deficient practice placed the resident at risk for complications related to skin breakdown and pressure ulcers. Findings Included: [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure the nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask was stored in a sanitary manner to decrease exposure and contamination for Resident (R) 30. This placed R30 at increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 32 residents. Based on observation, record review, and interview, the facility failed to ensure nursing staff demonstrated the appropriate competencies and skill sets to provide nursing services to care for resident's needs when staff lacked knowledge related to dosing and administering diclofenac gel (a topical ointment used to relieve arthritis pain) for Resident (R) 17. This deficient practice placed R17 at risk of adverse side effects.

Inspectors wroteThe facility identified a census of 32 residents. There were 13 residents in the sample. Based on observation, record review, and interview, the facility failed to ensure Resident (R)4's medications were available for administration without missed doses during the facility's change-over to a new pharmacy provider. This deficient practice placed R4 at risk of unnecessary complications and an ineffective medication regimen.

Inspectors wroteThe facility had a census of 32 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the multiple unsuccessful attempts for nonpharmacological symptom management were documented including risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) for Resident (R) 29, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion) and received Risperdal (antipsychotic). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 13 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, for Resident (R) 2 and R30. This deficient practice created a risk for missed or delayed services and impaired physical, and psychosocial care for R2 and R30.

Inspectors wroteThe facility had a census of 35 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of lack of assessment and inappropriate care.

Inspectors wroteThe facility had a census of 35 residents. Based on interview and record review, the facility failed to provide no less than 12 hours of in-service education per year for 5 of 5 reviewed certified nurse aides.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI), placing the 35 residents who reside in the facility at risk for lack of quality improved services.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview, the facility's (QAA) Quality Assessment and Assurance program failed to indeitfy efforts to imporve multiple issues of concern. This placed the residents at risk for decreased quality of care and life.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to maintain a Quality Assessment and Assurance Committee (QAA) that had the required QAA members and met quarterly, placing the residents at risk for lack of quality improved services.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to have an infection control program which included tracking, education and prevention of infections. The facility further failed to ensure appropriate hand hygiene and handling of soiled linens for Resident (R) 17, who had a draining wound. This placed the residents in the facility at increased risk for infections and communicable disease.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to maintain an ongoing infection surveillance program which included antibiotic stewardship. This placed the 35 residents who resided in the facility at increased risk for receiving an infection and /or negative effects of antibiotic use.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure the facility employed a designated staff person for the Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) and who completed the specialized training in infection prevention and control.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to provide a clean, sanitary and comfortable environment for residents who resided in the facility. This placed the residents at risk for impaired comfort.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure an accurate reconciliation of controlled drugs at the end of daily worked shifts for Hall 300. This practice placed residents at risk for misappropriation of medications by staff and unmet therapeutic medication regimen.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to store food in accordance with professional standards for food service safety for the residents who received their food from the facility kitchen, when staff failed to label and date two open food items in the kitchen freezer. This placed the residents at risk for food borne illness.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide a dignified dining experience for Resident (R) 23, who received an insulin (a hormone to regulate glucose) injection in the dining room. This placed the resident at risk for impaired dignity

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents with four reviewed for activities of daily living (ADLs). Based on observation, record review, and interview the facility failed to ensure staff honored Resident (R) 30's personal choices for days and times of bathing per his request. This placed the resident at risk for poor hygiene and impaired autonomy.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to develop a comprehensive care plan to include potential risk for elopement for Resident (R) 36 and R5.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on record review and interview, the facility failed to develop a discharge summary for one of the residents reviewed for discharge that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post-discharge plan for Resident (R) 40. This placed the resident at risk for receiving inadequate care.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents with four reviewed for activities of daily living (ADLs). Based on observation, record review, and interview the facility failed to provide bathing on a regular basis for one of four reviewed for acgtivities of daily living (ADLs), Resident (R) 30. This placed the resident at risk for poor hygiene.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to assess and identify potential risk for elopement for Resident (R) 36 and R5 placing them at increased potential for injury.

Inspectors wroteThe facility had a census of 35 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the daily staff nursing schedule was posted two of four days during the onsite survey. This placed the residents at risk for decreased knowledge regarding their care.

Inspectors wroteThe facility had a census of 35 residents. Based on interview and record review. the facility failed to complete a facility assessment that included a competency-based approach to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. This placed the residents at risk for inappropriate care.