Inspection visit
Inspection
Citations
36 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F584 - Safe Environment
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.
F661 - Quality of life
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F882 - Infection preventionist
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F727 - Except when waived under paragraph (f) or (g) of this section, the
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.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F838 - Facility assessment
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F865 - Quality assurance and performance improvement (QAPI) program
Have a plan that describes the process for conducting QAPI and QAA activities.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0163GeneralS&S Epotential for harm
Install noncombustible or limited-combustible interior walls.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0291GeneralS&S Epotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
- 0901GeneralS&S Fpotential for harm
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the November 2, 2022 survey of ATCHISON SENIOR VILLAGE REHABILITATION AND NURSING?
This was a inspection survey of ATCHISON SENIOR VILLAGE REHABILITATION AND NURSING on November 2, 2022. The surveyor cited 36 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ATCHISON SENIOR VILLAGE REHABILITATION AND NURSING on November 2, 2022?
Yes, 36 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to and the facility must promote and facilitate resident self-determination through support o..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.