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Deficiency Records for Atchison Senior Village Rehabilitation and Nursing
A list of the most recent deficiencies for Atchison Senior Village Rehabilitation and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Atchison Senior Village Rehabilitation and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-08 | 2024-06-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-05-08 | 2024-06-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-05-08 | 2024-06-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-08 | 2024-06-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-08 | 2024-06-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-08 | 2024-06-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-08 | 2024-06-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-08 | 2024-06-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-08 | 2024-06-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-08 | 2024-06-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-17 | 2024-05-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-04-17 | 2024-05-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-04-17 | 2024-05-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-17 | 2024-05-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-17 | 2024-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-17 | 2024-05-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-17 | 2024-05-17 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-04-17 | 2024-05-17 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-04-17 | 2024-05-17 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-04-17 | 2024-05-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-17 | 2024-05-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-04-17 | 2024-05-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-04-17 | 2024-05-17 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-04-17 | 2024-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-17 | 2024-05-17 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-08 | 2023-01-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-02 | 2022-12-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-11-02 | 2022-12-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-11-02 | 2022-12-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-02 | 2022-12-16 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-11-02 | 2022-12-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-02 | 2022-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-02 | 2022-12-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-11-02 | 2022-12-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-11-02 | 2022-12-16 | N |
| Post nurse staffing information every day. | Health | 2022-11-02 | 2022-12-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-02 | 2022-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-02 | 2022-12-16 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-11-02 | 2022-12-16 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-11-02 | 2022-12-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-02 | 2022-12-16 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-02 | 2022-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-02 | 2022-12-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-02 | 2022-12-16 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-11-02 | 2022-12-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Use approved construction type or materials. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-08 | 2021-08-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-03 | 2021-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-03 | 2021-06-30 | N |
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