Inspection Reports for
Medicalodges Atchison
1637 RILEY STREET, ATCHISON, KS, 66002-1514
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
87% occupied
Based on a May 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Date: May 19, 2025
Visit Reason
The inspection was conducted following concerns about misappropriation of medications discovered during a random controlled substance audit.
Complaint Details
The investigation was complaint-driven, triggered by a random controlled substance audit revealing discrepancies in medication documentation and destruction. The complaint was substantiated with findings of falsified medication records and unauthorized use of initials by a licensed nurse.
Findings
The facility failed to ensure residents remained free from misappropriation of medications when a nurse signed out medications without proper documentation and used unauthorized initials to document medication destruction. The nurse was terminated and law enforcement was notified.
Deficiencies (1)
F 0602: The facility failed to protect residents from wrongful use of their belongings or money by allowing a nurse to sign out controlled medications without proper documentation and to falsify medication destruction records using unauthorized initials. This placed residents at risk for missed medications and further misappropriation.
Report Facts
Residents affected: 3
Census: 39
Medication entries missing documentation: 6
Oxycodone tablets received: 15
Corrective actions completion date: Mar 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in medication misappropriation and falsification of medication destruction documentation |
| LN H | Licensed Nurse | Involved as alleged second nurse whose initials were forged; denied witnessing medication destruction |
| Administrative Nurse D | Administrative Nurse | Conducted audits, interviews, and investigation; informed LN G of findings and termination |
| Administrative Staff A | Administrative Staff | Reported concerns to State Agency and law enforcement; described facility monitoring and corrective actions |
| Consultant GG | Consultant | Conducted monthly on-site medication documentation review and controlled substance audit |
Inspection Report
Routine
Census: 37
Deficiencies: 9
Date: Jun 27, 2024
Visit Reason
Routine inspection of Medicalodges Atchison nursing home to assess compliance with regulatory standards related to resident care, safety, infection control, medication management, and facility environment.
Findings
The facility had multiple deficiencies including failure to maintain a clean and home-like environment, incomplete care plan revisions, unsafe discharge procedures, unsafe storage of hazardous materials, improper catheter care, lack of bed rail assessments and consents, unsecured medication carts, improper food storage and labeling, and inadequate infection control practices.
Deficiencies (9)
F 0584: The facility failed to provide a clean and home-like environment for Resident 11, with multiple observations of flies in the resident's room over several days.
F 0657: The facility failed to revise Resident 25's care plan to reflect bed rail evaluation and Resident 11's care plan to reflect weight monitoring, placing residents at risk for uncommunicated care needs.
F 0661: The facility failed to ensure Resident 38's discharge summary included a recapitulation of stay and medication reconciliation, risking inappropriate post-discharge care.
F 0689: The facility failed to secure hazardous chemicals and equipment, leaving nine cognitively impaired residents at risk for accidents and injuries.
F 0690: The facility failed to provide appropriate peri care and catheter care for Resident 1, including improper hand hygiene, risking catheter-related complications and UTIs.
F 0700: The facility failed to document safety assessments, consents, and risk/benefit discussions for the use of side rails for Resident 7, risking uninformed decisions and impaired safety.
F 0761: The facility failed to properly secure medication carts, leaving medications accessible and risking adverse outcomes or ineffective treatment.
F 0812: The facility failed to properly label and store food and failed to store clean dishes inverted, risking foodborne illness.
F 0880: The facility failed to follow sanitary infection control standards related to handling soiled laundry and hand hygiene during care, placing residents at risk for infectious diseases.
Report Facts
Residents present: 37
Residents sampled: 12
Medication carts inspected: 3
Medication rooms inspected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statements regarding fly control, care plan revisions, bed rail assessments, and catheter care |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding pest control, care plan updates, discharge procedures, chemical storage, medication cart security, and infection control |
| Certified Nurse Aide M | Certified Nurse Aide | Observed providing peri care and catheter care with noted hand hygiene deficiencies |
| Certified Nurse Aide P | Certified Nurse Aide | Provided statements regarding bed cane use and chemical storage |
| Certified Medication Aide R | Certified Medication Aide | Observed medication cart unsecured and locked it |
| Maintenance Staff U | Maintenance Staff | Responded to fly infestation and pest control issues |
| Dietary BB | Dietary Staff | Provided statements regarding kitchen cleanliness and food storage |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
The inspection was conducted to investigate allegations that a Certified Nurse Aide (CNA M) recorded videos of residents and sent them to an individual outside the facility, potentially violating resident privacy and abuse protections.
Complaint Details
The complaint investigation was triggered by law enforcement discovering videos of residents on an inmate communication app. The videos were sent by CNA M, who was subsequently suspended and terminated. The investigation confirmed multiple unauthorized recordings and sharing of resident videos.
Findings
The facility failed to ensure that residents R1, R2, R3, and R4 remained free from abuse when CNA M recorded and shared videos of them without consent. This practice placed residents at risk for further abuse and a decline in psychosocial well-being.
Deficiencies (1)
F 0600: The facility failed to protect residents from abuse when CNA M recorded videos of residents and sent them to an outside individual without authorization. This violated residents' rights to privacy and placed them at risk for harm.
Report Facts
Resident census: 33
Number of videos reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in abuse finding for recording and sharing resident videos without consent |
| Administrative Staff A | Involved in investigation and communication with law enforcement | |
| Administrative Nurse D | Administrative Nurse | Involved in investigation and communication with law enforcement |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Jun 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow up with a resident's physician after a change in condition.
Complaint Details
The investigation found the facility did not follow up with Resident 1's physician after a change in condition on 06/01/23. The complaint was substantiated with evidence of lack of physician notification and follow-up.
Findings
The facility failed to follow up with Resident 1's physician after he experienced a change in condition on 06/01/23, which posed a risk for delayed treatment and unwarranted physical complications. The facility lacked a policy on change in condition or physician notification.
Deficiencies (1)
F0684: The facility failed to follow up with Resident 1's physician after a change in condition on 06/01/23, risking delayed treatment and physical complications.
Report Facts
Resident census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Notified about Resident 1's condition and stated facility should have followed up on the fax about the urinalysis. |
| Licensed Nurse G | Licensed Nurse | Provided information on physician notification procedures during the investigation. |
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 4
Date: Sep 15, 2022
Visit Reason
Annual inspection survey conducted to assess compliance with healthcare regulations and standards at Medicalodges Atchison nursing home.
Findings
The facility was found deficient in multiple areas including ineffective topical medication administration, failure of the consultant pharmacist to identify inappropriate antipsychotic medication use, and unsafe food handling practices during meal distribution. These deficiencies placed residents at risk for delayed healing, inappropriate medication use, and communicable illnesses.
Deficiencies (4)
F 0684: The facility failed to administer topical medication effectively for Resident 27, placing the resident at risk for delayed healing of a rash on the right axillary area.
F 0756: The consultant pharmacist failed to identify and report an inappropriate diagnosis for antipsychotic medication use for Resident 22, placing the resident at risk for inappropriate medication use and side effects.
F 0758: The facility failed to ensure appropriate diagnosis and clinical justification for Resident 22's antipsychotic medication, increasing risk for adverse side effects and unnecessary medication use.
F 0812: The facility failed to follow sanitary food handling practices during meal service, including staff touching the lip surfaces of cups, placing residents at risk for communicable illnesses.
Report Facts
Residents present: 34
Residents in sample: 12
Residents reviewed for unnecessary medications: 5
Medication days look back period: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified topical medication administration issues and inappropriate diagnosis for antipsychotic medication |
| Licensed Nurse G | Licensed Nurse | Observed applying topical medication ineffectively |
| Certified Nurse Aide M | Certified Nurse Aide | Assisted with resident positioning during topical medication application |
| Certified Medication Aid S | Certified Medication Aid | Observed administering medications to Resident 22 |
| Dietary Staff BB | Dietary Staff | Observed unsafe food handling practices during meal service |
Inspection Report
Routine
Census: 31
Deficiencies: 5
Date: Apr 26, 2021
Visit Reason
Routine inspection of Medicalodges Atchison nursing home to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to prevent pressure ulcers, failure to ensure pharmacist review and physician notification of abnormal blood glucose levels, lack of certified dietary manager, and unsanitary food preparation and storage conditions.
Deficiencies (5)
F 0686: The facility failed to implement timely interventions to prevent the development of an unstageable pressure ulcer to Resident 12's right heel after staff discovered the heel was boggy.
F 0756: The facility failed to ensure the consultant pharmacist identified and reported Resident 25's blood glucose readings greater than 400 mg/dl and lack of physician notification.
F 0757: The facility failed to consistently notify the physician when Resident 25's blood glucose was greater than 400 mg/dl as ordered.
F 0801: The facility failed to employ a certified dietary manager to carry out the functions of food and nutrition services for 31 residents.
F 0812: The facility failed to prepare, store, and serve meals under sanitary conditions, including missing temperature and sanitizer logs for refrigerators, freezers, and dishwashers.
Report Facts
Residents census: 31
Residents reviewed: 12
Blood glucose readings >400 mg/dl: 9
Days missing PPM sanitizer logs: 53
Days missing refrigerator/freezer temperature logs: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Performed wound care and provided statements regarding Resident 12 and Resident 25 |
| CNA M | Certified Nurse Aide | Provided information on repositioning Resident 12 |
| Consultant GG | Consultant | Provided statement on Resident 12's skin condition |
| Administrative Nurse D | Administrative Nurse | Verified wound care procedures, dietary manager certification, and expectations for notification and logs |
| CP HH | Consultant Pharmacist | Reviewed pharmacy records and provided statements regarding Resident 25's blood glucose monitoring |
| DM GG | Dietary Manager | Stated she was not a certified dietary manager |
| DS CC | Dietary Staff | Observed not knowing how to check dishwasher sanitizer PPM |
| DS DD | Dietary Staff | Demonstrated how to check dishwasher sanitizer PPM |
| DS BB | Dietary Staff | Verified missing PPM and temperature logs |
| Maintenance Staff U | Maintenance Staff | Verified dishwasher type and sanitizing requirements |
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Jan 5, 2014
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Atchison in response to deficiencies identified during a prior inspection.
Findings
The plan outlines corrective actions for multiple deficiencies including care plan updates, staff education on resident preferences, anxiety interventions, pressure offloading, water temperature control, nutritional interventions, behavioral monitoring, dining room monitoring, food handling, and emergency preparedness training.
Deficiencies (14)
F242-D Resident #36 was added to the bathing schedule and care plans will be reviewed and updated for accuracy. Direct care staff will receive education on obtaining resident preferences through the Wellness process.
F279-D Resident #47's care plan was updated to include non pharmacological interventions for anxiety. Ongoing compliance will be achieved through Risk Committee monitoring and routine review of orders.
F280-D Resident #36's care plan was reviewed and updated. Licensed staff will receive additional training on care plan interventions and revisions.
F314-G Direct care staff will receive education on proper repositioning and equipment use to offload pressure. Residents with new skin issues will be referred to the Registered Dietician.
F323-K The kitchenette sink was taken out of service and a temperature reducing valve was applied to prevent water temperatures exceeding 120 degrees. Water temperatures will be monitored weekly.
F325-D Risk Committee will review Resident #15 and update nutritional interventions. Other residents at nutritional risk will be reviewed by the Registered Dietician.
F329-E Behavioral monitoring of residents will be reviewed and updated. Acetaminophen limits will be monitored and physician contacted if limits are exceeded.
F362-E A Dining Room Monitor program was implemented to ensure meals are palatable, timely, and honor resident choices. Supervisory staff will rotate monitoring duties.
F371-E Dietary staff will receive education on proper food serving temperatures and dishware handling. The Registered Dietician will provide ongoing education.
F428-D Pharmacist will identify inconsistencies in behavior monitoring during monthly consultant visits. Monitoring will be done by DON or designee.
F441-F Housekeepers will receive education on facility requirements and participate in skills assessments for proper chemical use. Monitoring by Environmental Director and Administrator.
F456-E Labels were placed on semi-private room towel bars for personal towel identification. Housekeeping staff will be educated on label purpose and monitoring will continue.
F497-F CNA employees will complete a minimum of 12 hours of annual education meeting Federal and State requirements. Education will be assigned through Health Care Academy and live in-services.
F518-F All employees will participate in disaster and emergency preparedness training upon orientation and annually. Ongoing compliance will be monitored by Administrator and Environmental Director.
Inspection Report
Census: 42
Deficiencies: 14
Date: Dec 24, 2013
Visit Reason
Health Resurvey, Extended Health Resurvey and investigation of complaints #69945 and #61299.
Complaint Details
The inspection included investigation of complaints #69945 and #61299.
Findings
The facility had multiple deficiencies including failure to assist residents with bathing, develop and revise comprehensive care plans, provide adequate nutritional support, monitor medication regimens, maintain safe environment, and provide sufficient staff training and emergency preparedness.
Deficiencies (14)
F242: The facility failed to ensure a resident requiring staff assistance received a bath/shower according to preference.
F279: The facility failed to develop a comprehensive care plan for a resident with anxiety.
F280: The facility failed to revise care plans for residents after changes in medical condition or development of pressure ulcers.
F314: The facility failed to provide adequate services to prevent and promote healing of pressure ulcers for 2 residents.
F323: The facility failed to monitor hot water temperatures in common areas accessible to residents, exposing them to scalding hazard.
F325: The facility failed to administer and monitor nutritional interventions and failed to prevent weight loss for a resident.
F329: The facility failed to provide consistent and accurate behavior monitoring for residents on antipsychotic and antianxiety medications and failed to monitor total Tylenol intake for a resident.
F362: The facility failed to provide adequate staff for timely dining assistance.
F371: The facility failed to hold cooked food at safe temperatures and properly handle dishes.
F428: The consultant pharmacist failed to identify and report inconsistent behavior monitoring for residents on psychotropic medications.
F441: The facility failed to follow manufacturer's instructions when cleaning a resident's room.
F456: The facility failed to label towel bars in semi-private rooms to identify resident ownership.
F497: The facility failed to provide at least 12 hours of annual education for certified nursing assistants.
F518: The facility failed to provide regular disaster and emergency preparedness training for all employees.
Report Facts
Resident census: 42
Water temperature: 159.4
Water temperature: 158.7
Weight loss: 13
Braden score: 15
Braden score: 16
Tylenol dosage: 2950
Education hours missing: 12
Staff employed: 58
Staff trained on disaster plan: 25
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 27, 2012
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously identified deficiency with regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by the revisit date of 09/27/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 27, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the plan of correction.
Findings
All previously reported deficiencies identified by regulation numbers F0226, F0279, F0280, F0323, F0329, and F0428 were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 27, 2012
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously identified deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency previously cited under ID prefix S0600 was corrected by the revisit date of 09/27/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 27, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
All previously reported deficiencies identified by regulation numbers F0226, F0279, F0280, F0323, F0329, and F0428 were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 1
Date: Aug 29, 2012
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements.
Findings
The facility failed to have a full-time certified dietary manager on 4 of 4 days of the survey. The dietary services did not meet the staffing requirement for a certified dietary manager.
Deficiencies (1)
28-39-158(a) Dietary services. The facility failed to have a full-time certified dietary manager on 4 of 4 days of the survey. Observation and interview confirmed the dietary manager was not certified.
Report Facts
Resident census: 45
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