Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avita Health And Rehab At Reeds Cove during CMS and state inspections, most recent first.
Improper Food Storage and Incomplete Temperature Logs: Surveyors observed multiple food items stored open, unlabeled, undated, or unsealed in kitchen refrigerators, freezers, and pantry areas, including meats, condiments, and dry goods. Temperature logs were also incomplete, with missing food temps and sanitation documentation on several entries. The DM and Administrative Staff acknowledged that food should be sealed, dated, and properly temped for safe distribution.
A nurse failed to perform hand hygiene during a G-tube dressing change and before medication administration, repeatedly removing gloves and re-gloving without washing hands. In a separate event, a CNA transported a basket of uncovered clean personal laundry from the clean/laundry room down the hallway to a resident’s room, despite staff expectations that laundry be covered during transport.
A resident with major depressive disorder and anxiety filed a grievance after a CNA did not respond to his concern that another resident may have needed help while eating. The grievance form marked the issue as resolved but did not document the resolution, was unsigned by date, and the resident reported that management never spoke with him about the grievance or its status within the required timeframe.
A facility failed to include a 14-day stop date or documented physician rationale for a PRN lorazepam order for a resident with anxiety and severe cognitive impairment. The facility also failed to document monitoring for Abilify in another resident with MDD and anxiety; the care plan and EMAR lacked documentation of target behaviors, side effects, interventions, and effectiveness, despite policy requiring monitoring of psychoactive meds every shift.
A resident with dementia, DM, severe cognitive impairment, and a feeding tube had medications and enteral nutrition administered without the nurse checking tube placement or residuals first. The care plan directed staff to verify placement and residuals, but the nurse stated she did not know she had to check placement for that type of tube, and an admin nurse said placement should be verified before use.
A resident with multiple risk factors developed facility-acquired Stage 3 pressure ulcers after staff failed to implement timely repositioning, monitor wounds adequately, and provide standard interventions such as a low air loss mattress. Wound assessments and documentation were inconsistent, and physician orders for wound care were not always followed. Nutritional support for wound healing was delayed, and the resident's wounds worsened, leading to hospitalization for suspected sepsis.
A significant medication error occurred when a CMA mistakenly administered medications intended for another resident to a cognitively impaired resident with a J-tube. Despite instructions not to give oral medications, the CMA gave clopidogrel, morphine ER, and acetaminophen to the resident, who had a complex medical history and was dependent on tube feeding. The error was discovered when the resident was found coughing with tablets in their mouth, leading to immediate medical intervention.
The facility failed to maintain sanitary conditions in its food service operations, with issues such as missing thermometers, unlabeled and improperly stored food items, and a refrigerator operating above the recommended temperature. These deficiencies were observed in two kitchen areas, placing residents at risk for food-borne illness.
The facility failed to secure a maintenance shop containing hazardous chemicals and did not maintain a functional alarm on an exit door, posing risks to residents. Additionally, the facility did not address a tripping hazard in a resident's room, despite the resident's history of falls and mobility issues. Staff acknowledged these hazards but did not take corrective actions, leading to deficiencies in maintaining a safe environment.
A facility failed to uphold resident dignity when a CNA referred to residents needing feeding assistance as 'feeders' in front of others. This practice was confirmed by the CNA and recognized as a dignity issue by other staff, violating the facility's Right to Dignity policy.
The facility failed to provide written bed-hold notices to four residents or their representatives during hospital transfers, as required by policy. This deficiency was identified through observations, interviews, and record reviews, revealing that verbal consent was obtained without completing necessary forms. The lack of documentation placed residents at risk of not returning to their former rooms.
A licensed nurse from a nursing agency failed to administer medications to 12 residents during a night shift, citing unavailability or unnecessary use, despite medications being available. The nurse also did not complete required assessments or document narcotic administration properly. Interviews revealed the nurse's unusual behavior and failure to notify the physician about held medications.
A resident with multiple medical conditions experienced a 48% medication error rate during administration. A CMA spilled medications, failed to replace them, and administered them without proper hygiene or gloves, violating infection control standards. The facility's policy requires safe and sanitary medication administration, which was not followed, leading to deficiencies.
A licensed nurse from an agency failed to maintain complete and accurate medical records for several residents during a shift, resulting in undocumented and unadministered medications and treatments. The nurse did not follow standard procedures, leading to discrepancies in medication counts and incomplete resident assessments. Facility staff reported the nurse's disregard for communication and documentation protocols.
A certified medication aide failed to maintain infection control standards during medication administration by using contaminated pills and neglecting hand hygiene. The aide also administered a nasal spray without gloves, causing the resident to cough. These actions were against the facility's policies, as confirmed by administrative staff.
A resident with intact cognition was not included in their care plan meetings, despite facility policy requiring their participation. The resident, who needed assistance with daily activities due to diabetes and osteoarthritis, reported never being invited to these meetings. Social service staff failed to document the resident's involvement, assuming it was implied, leading to a risk of inadequate care and uncommunicated needs.
The facility failed to verify and document advanced directives for a resident with chronic conditions, leading to a discrepancy between a DNR order and the resident's stated preference for full code. Additionally, the facility improperly allowed a guardian to consent to a DNR for another resident with schizophrenia and bipolar disorder, contrary to policy. These deficiencies risked uncommunicated end-of-life care needs.
A facility failed to develop a person-centered baseline care plan for a newly admitted resident with acute pancreatitis, CKD, and DM2 within 48 hours, as required by policy. The resident's EHR lacked a complete Admission MDS and CAA, and the baseline care plan was missing essential information and signatures. The resident had not participated in a care plan meeting, leading to potential uncommunicated needs.
A facility failed to document a resident's oxygen and nebulized medication use in their care plan, despite physician orders and staff confirmation of these treatments. The resident had diagnoses of obstructive sleep apnea and COPD, requiring careful respiratory management. Staff interviews revealed inconsistencies in care plan documentation, with some staff unaware of the resident's specific respiratory care needs.
The facility failed to update the care plans for two residents after they experienced falls, leading to uncommunicated care needs. One resident, with bipolar disorder and dementia, reported falls that were not reflected in her care plan. Another resident, with a right hip fracture, had changes in her weight-bearing status that were not updated in her care plan. This failure violated the facility's Care Plan Revision Policy and risked the residents' well-being.
A CMA in a facility administered medications in an unsanitary manner by picking up spilled pills from the floor and medication cart and giving them to a resident. The CMA acknowledged the error, and administrative staff confirmed the violation of medication administration and infection control policies.
Two residents with severe cognitive impairment in a LTC facility did not receive adequate personal and oral care. One resident had facial whiskers despite needing assistance with ADLs, and another had poor oral hygiene with dried substances on her teeth and lips. Staff were unaware of grooming responsibilities, and the facility's policy on dignity was not followed, risking residents' psychosocial well-being.
A resident with a pressure ulcer and multiple medical conditions received inadequate infection control during wound care. The resident required substantial assistance and had a urinary catheter. During care, a nurse failed to change gloves between cleaning the resident's rectal area and continuing wound care, despite the resident being incontinent. This was against the facility's infection control policy, and the nurse admitted to forgetting to change gloves due to frequent use.
A resident with an indwelling urinary catheter was not provided proper care to prevent urinary tract infections. The resident's catheter collection bag was improperly placed on their lap and held above the bladder during a transfer, contrary to the facility's policy requiring the bag to be below the bladder. Staff were unaware of the correct protocol, posing a risk of urine backflow and infection.
The facility failed to manage respiratory care for two residents, leading to deficiencies. A resident did not have a physician's order for oxygen administration, and their oxygen cannula was contaminated and not replaced promptly. Another resident's nebulizer equipment was not properly cleaned or stored, and the equipment was not dated as required. These issues highlighted gaps in the facility's management of respiratory needs.
The facility failed to properly store medications for three residents, leading to a deficiency in medication management. Medications were found in residents' rooms without physician orders or self-administration assessments. Staff were unaware of the policy regarding medication storage, and the facility lacked a policy for medication storage in resident rooms.
Improper Food Storage and Incomplete Temperature Logs
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions to prevent potential for food borne bacteria. During the initial kitchen tour, surveyors observed multiple food items in refrigerators, freezers, and pantry areas that were open, unlabeled, undated, or improperly stored, including a plate of food with no date, ketchup and mustard without open dates, half-used liquid eggs with no open date, open hotdogs with crystals on them, and a molasses container with syrup running down the bottle and making the shelf sticky. In another kitchen area, surveyors found open hamburgers and/or sausage patties in the freezer that were not labeled or dated, and a jar of peanut butter on top of the refrigerator with peanut butter on the outside of the container. Additional observations showed similar storage and documentation problems in another house, including open hotdogs and brussels sprouts left exposed in the freezer with no date, a bag of honey oats without a date, and an unsealed caramel dip. Temperature logs were incomplete, with missing refrigerator and freezer documentation on some days and missing food temperature entries for lunch, breakfast, and dinner on multiple dates, as well as a missing sanitation log sheet. The Dietary Manager stated that all items should be kept in clean, sealed containers with dates and that all food items should be temped for safe food distribution, while Administrative Staff stated that food in refrigerators should be closed or sealed and properly dated to maintain regulatory compliance.
Hand Hygiene and Linen Transport Deficiencies
Penalty
Summary
The facility failed to ensure adequate hand hygiene during dressing change and medication administration for a resident with a gastrostomy tube (G-tube). During the dressing change, the licensed nurse removed the soiled dressing from the resident’s G-tube site, discarded it, opened a new dressing, and removed gloves without performing hand hygiene before applying a new pair of gloves. The nurse cleansed the G-tube site, again removed gloves without hand hygiene, reapplied gloves, placed a new dressing, and then removed gloves without hand hygiene before administering medications through the feeding tube. The facility also failed to properly transport clean personal linens. A certified nurse aide exited the clean/laundry work room with a full basket of uncovered, clean personal laundry and transported it down the hallway to a resident’s room. The aide reported the linen had just been taken out of the dryer and said he generally covered the linen with a bag, but it was uncovered during transport. Facility staff stated that laundry moving in and out of the soiled/clean laundry areas was required to be covered, and administrative staff also stated that hand hygiene was expected before applying gloves and after gloves were removed.
Grievance Not Resolved or Communicated to Resident
Penalty
Summary
The facility failed to address and resolve a grievance submitted by a resident with a diagnosis of major depressive disorder and anxiety, and failed to notify the resident of any actions or the status of the grievance. The resident had intact cognition with a BIMS score of 15 and no behaviors noted on the MDS. The resident’s care plan directed staff to provide opportunities for expression of feelings related to situational stressors, and the psychotropic medication CAA indicated nursing monitoring for side effects and physician notification for abnormal findings. The resident filed a grievance after a concern at the dinner table involving another resident who may have needed assistance with swallowing food. The resident reported that the CNA did not check on the other resident or notify the nurse. The grievance form indicated the issue was resolved, but it did not document what the resolution was and was signed by an administrative nurse without a date. The resident later stated that no one from management had spoken with him about the grievance, although the CNA had apologized the next day. A copy of the grievance later documented that the resident was okay at that time and would notify administration if concerns continued, but this was not provided to the resident within the required timeframe described in the facility grievance policy.
PRN psychotropic order lacked stop date and antipsychotic monitoring was not documented
Penalty
Summary
The facility failed to obtain a 14-day stop date or a documented physician rationale for extending an as-needed lorazepam order for R66. R66 had diagnoses of cerebral palsy and anxiety, and the MDS documented severely impaired cognition with behaviors toward others during the look-back period. The care area assessment noted yelling out and throwing cups and personal items, with risk factors including injury to self and increased anxiety. The care plan stated that medications would be overseen and managed by nursing and the physician and that staff would observe for psychosocial changes and report mental status changes caused by situational stressors to the physician. R66’s physician orders included lorazepam 0.5 mg by mouth every eight hours as needed for anxiety, but the order did not include a stop date. A licensed nurse stated the PRN lorazepam had been started and verified that the order did not have a stop date. An administrative nurse stated that psychotropic medication use should be monitored for side effects and that PRN orders should have a 14-day stop date when obtained. The facility policy stated PRN psychotropic medication orders are limited to 14 days upon initial orders, and at 14 days providers may extend the order with a documented rationale. The facility also failed to monitor antipsychotic medication for R18. R18 had diagnoses of major depressive disorder and anxiety, with intact cognition and no behaviors noted on the MDS. The psychotropic drug use care area assessment directed nursing to monitor side effects every shift and notify the physician for abnormal findings, and the care plan instructed staff to administer medications as ordered and monitor/document side effects and effectiveness. However, the care plan lacked documentation for Abilify, and the EMAR lacked documentation of the number of episodes of identified target behaviors and/or side effects, actions taken, and effectiveness of interventions for Abilify. Staff stated they were monitoring Abilify like an antidepressant, while the administrative nurse stated staff were expected to monitor every psychoactive medication every shift.
Failure to Verify Feeding Tube Placement Before Use
Penalty
Summary
The facility failed to ensure Resident 48’s feeding tube was monitored for placement before medications and enteral nutrition were administered. Resident 48 had diagnoses including dementia and diabetes mellitus, and the admission MDS documented a BIMS score of two, indicating severely impaired cognition. The resident required total assistance with all activities of daily living and had a feeding tube. The feeding tube CAA identified risks related to tube use, including aspiration, weight changes, and fluid imbalance, and the care plan instructed staff to check tube placement and gastric contents/residual volume per facility protocol and record it. Physician orders directed water flushes before and after feeds and medications, but the 05/06/26 physician orders lacked documentation to check feeding tube placement or residual. During observation, an LN flushed the tube and administered medications without checking placement, and later connected a syringe to the tube, administered water and enteral feed, and flushed again without checking placement. The LN stated she did not know she had to check placement on that type of feeding tube and verified she did not check residual either. An administrative nurse stated she expected the nurse to verify placement of all feeding tubes prior to use. The facility’s Enteral Tube Feeding Policy lacked documentation to check for placement of a feeding tube.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of facility-acquired pressure ulcers for a resident with multiple risk factors, including osteoarthritis, weakness, and incontinence. Despite being identified as at risk for pressure injuries, the resident was not placed on a turn and reposition schedule, and the electronic health record lacked documentation of such a program. The care plan directed staff to assist with repositioning as needed, but routine repositioning was not implemented until after the wounds had progressed. Additionally, the facility did not provide a low air loss mattress or other standard interventions until the pressure ulcers had worsened. Wound monitoring and documentation were inadequate following the initial development of skin issues. Weekly skin assessments failed to identify or document the presence of wounds until after the resident and their representative reported concerns. When wounds were identified, staff did not consistently measure or assess the wounds for infection, drainage, or peri-wound condition, and there was a lack of evidence that physician orders for wound care were carried out as documented in the medication and treatment administration records. Communication among staff regarding wound status and interventions was inconsistent, and there was a gap in wound assessments due to improper training of the responsible nurse. Nutritional interventions to support wound healing were not implemented promptly, and the resident's wounds progressed to Stage 3 pressure injuries with exposed adipose tissue and signs of infection. The wounds increased in size and severity before appropriate interventions, such as frequent repositioning and specialized mattresses, were put in place. The resident ultimately developed a fever and was transferred to the hospital with suspected sepsis secondary to wound infection.
Significant Medication Error Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent a significant medication error involving a cognitively impaired resident, identified as R1, who was incorrectly administered medications intended for another resident, R2. On the morning of 10/11/24, a Certified Medication Aide (CMA) mistakenly gave R2's medications, which included clopidogrel, morphine extended release, and acetaminophen, to R1. This error occurred despite the Licensed Nurse (LN) G having previously instructed the CMA that R1 had a jejunostomy tube and could not receive medications orally. The CMA had documented not to give medications to R1, but still proceeded to administer the wrong medications. R1 had a complex medical history, including hereditary ataxia, multiple system atrophy, quadriplegia, basal ganglia dysfunction, dysphagia, and aphagia, and was dependent on a jejunostomy tube for nutrition and medication administration. The resident was also noted to have short-term and long-term memory problems and was dependent on nursing staff for activities of daily living. The error was discovered when LN G heard R1 coughing and found four tablets in R1's mouth, which were removed to prevent further risk of aspiration, given R1's history of aspiration pneumonia. The incident was reported to the administrative staff and the healthcare provider, who ordered a chest x-ray and prescribed an antibiotic as a precautionary measure. The x-ray showed increased airspace disease in the right lung base, which could indicate atelectasis, infection, or aspiration. The CMA involved in the error was asked to leave the facility and placed on a do-not-return list. The facility's failure to prevent this medication error placed R1 in immediate jeopardy, as the resident was NPO and had a J-tube for medication administration.
Removal Plan
- The facility asked the CMA R to complete a witness statement, was escorted out of the facility, and placed the CMA on the Do Not Return (DNR) list.
- Licensed Nurses (LN) and Certified Medications Aides (CMA) were provided education related to medications administration.
- Licensed Nurses (LN) and Certified Medications Aides (CMA) completed a medication administration checkoff, observed by the Unit Managers.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service operations, as observed in two kitchen areas. In the [NAME] House kitchen, several issues were noted, including the absence of thermometers in the refrigerator and freezer, a large bag of macaroni salad without a preparation or expiration date, and open containers of breadsticks and sausage patties in the freezer. Additionally, a bag containing an unknown frozen liquid lacked labeling. In the corridor between [NAME] House and the dry storage area, a large bin of pasta, egg noodles, and tortilla chips were found without open or expiration dates. In the Saghbene Kitchen, the refrigerator was observed to have a temperature of 46 degrees Fahrenheit, above the recommended 41 degrees. The freezer contained a plastic bag with an unknown meat product and open boxes of hamburger patties and breakfast biscuits, all lacking proper labeling. A discolored loaf of luncheon meat in the refrigerator also lacked labeling. These deficiencies were acknowledged by the facility's staff, including the Administrative Nurse and Dietary Staff, who were made aware of the concerns.
Facility Fails to Secure Hazardous Areas and Address Fall Risks
Penalty
Summary
The facility failed to ensure a secure environment free from accident hazards, as evidenced by the unsecured maintenance shop door and the non-functional alarm on an exit door. The maintenance shop, located in the main hallway leading to resident units, contained hazardous chemicals labeled as harmful or fatal if ingested. Observations revealed that the maintenance shop door was often left open, and the chemicals were stored on an open shelf, accessible to residents. Maintenance Staff O admitted to setting the door to close slowly for convenience, and the Environmental Supervisor N confirmed the concern. Additionally, the exit door leading outside had a non-functional alarm system, posing a risk to residents who might wander outside unsupervised. The report also highlights the facility's failure to maintain a safe environment for Resident 9, who had a history of falls and a recent hip fracture. Despite being aware that Resident 9 engaged in 'furniture surfing' for mobility, the facility did not address the tripping hazard posed by an electric cord in the resident's room. The cord extended across the floor between the recliner and the dresser, creating a potential fall risk. Staff members, including a CNA and a Licensed Nurse, acknowledged the hazard but did not take action to mitigate it. Resident 9's medical history included dementia, a right hip fracture, and muscle weakness, requiring assistance with activities of daily living. The resident had experienced a fall resulting in a hip fracture, which was initially undiagnosed. Despite interventions in place to prevent further falls, the facility's inaction regarding the electric cord contributed to an unsafe environment. The facility's policies on chemical storage and fall prevention were not adhered to, leading to these deficiencies.
Violation of Resident Dignity Due to Labeling
Penalty
Summary
The facility failed to protect the privacy and dignity of residents who were dependent on staff assistance for eating. This deficiency was identified when a Certified Nurse Aide (CNA) was observed referring to these residents as 'feeders' in the presence of other residents. The CNA confirmed the use of this label, acknowledging that it violated the dignity of the residents. Further interviews with a Licensed Nurse and two Administrative Nurses corroborated that referring to residents by labels instead of their names is a dignity issue. The facility's Right to Dignity policy, dated December 7, 2023, explicitly states that residents should be cared for in a manner that maintains and enhances their dignity and respect, and that staff should never use terms or labels to refer to residents.
Failure to Provide Written Bed-Hold Notices
Penalty
Summary
The facility failed to provide written bed-hold notices to four residents, R22, R3, R8, and R32, or their representatives, at the time of their transfers to the hospital. This deficiency was identified through observations, interviews, and record reviews. The facility's policy, dated 09/01/23, mandates that written information regarding the bed-hold policy, including duration and cost, must be provided to the resident or their representative and included in the transfer packet. However, this procedure was not followed, placing the residents at risk of not being allowed to return to their former rooms. For Resident R8, the Electronic Health Record (EHR) documented a hospitalization from [DATE] to 08/09/24, but there was no evidence of a written bed-hold notice being provided. Administrative Staff CC confirmed that she only obtained verbal consent for the bed-hold and did not complete any form. Similarly, for Resident R32, the EHR documented a hospitalization from [DATE] to 02/17/24, but the documentation lacked evidence of verbal or written contact with the resident or their representative regarding the bed-hold. Resident R3's EHR revealed a hospitalization on 05/15/24, but the progress notes lacked documentation for a bed-hold. Administrative staff and social services personnel acknowledged the absence of a bed-hold form in the EHR or progress notes. For Resident R22, the EHR documented a hospitalization on 03/28/24, but again, there was no documentation of a bed-hold notice. The facility's failure to provide written bed-hold notices for these residents could lead to uncommunicated needs, potentially impacting their physical, mental, and psychosocial well-being.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that 12 out of 20 residents received their prescribed medications during a specific shift. This occurred when a licensed nurse from a nursing agency, who was employed to work the night shift, did not administer medications as ordered by the physician. The investigation revealed that the nurse exhibited unusual behavior and failed to administer medications for various reasons, including documenting that medications were unavailable or not needed, despite them being available in the medication cart. Several residents, including those with intact cognition and those with moderate to severe cognitive impairments, were affected by this deficiency. The nurse failed to administer critical medications such as antibiotics, inhalers, cholesterol medications, and pain relief medications. Additionally, the nurse did not complete necessary assessments for conditions like anxiety, depression, and respiratory issues, and failed to document the administration of narcotics properly. Interviews with staff and residents indicated that the nurse did not follow proper procedures, often claiming that medications were unnecessary or unavailable. The nurse also failed to notify the physician about holding medications and did not complete vital sign assessments. Despite the nurse's actions, the physician assistant determined that no significant harm was done to the residents due to the omission of medications.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 48% error rate during a medication administration pass for a resident. The resident, who had medical diagnoses including diabetes mellitus, hypertension, and heart failure, was observed during a medication pass where 25 medication opportunities resulted in 12 errors. This significant error rate placed the resident at risk for adverse reactions from the medications. During the medication administration, a Certified Medication Aide (CMA) spilled a medication cup containing the resident's oral medications, with some pills landing on the floor and others on the medication cart. Despite this, the CMA proceeded to administer the medications to the resident without replacing them. Additionally, the CMA administered a nasal spray without wearing gloves and failed to perform hand hygiene before and after administering medications, which violated infection control standards. The facility's Medication Administration Policy requires that all medications be administered safely and sanitarily as ordered by a physician. However, the CMA's actions did not adhere to these standards, as confirmed by both the CMA and administrative nurses. The failure to administer medications in a sanitary manner and maintain a medication error rate below 5% were identified as deficiencies that could negatively impact the residents' overall physical and psychosocial well-being.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for seven residents during a shift from 06:00 PM on 07/21/24 to 06:00 AM on 07/22/24. A licensed nurse from a nursing agency, referred to as LN I, was responsible for medication administration and documentation during this period. However, multiple medications and treatments were not documented or administered as required. For instance, vital signs were not recorded for a resident with intact cognition, and orders for medications and treatments such as ASV, melatonin, and skin tear care were not documented or completed. Several residents with varying levels of cognitive impairment were affected by the nurse's failure to document and administer medications. One resident with moderate cognitive impairment reported uncertainty about receiving medications, while another with severe cognitive impairment did not receive ordered treatments for skin care. Additionally, a resident with intact cognition did not receive insulin or have their fluid restriction documented, and there was no follow-up on the reasons for these omissions. The nurse also failed to document the administration of narcotics and other medications, leading to discrepancies in the medication count. Interviews with facility staff revealed that the nurse disregarded standard procedures and failed to communicate effectively with other staff members. A certified medication aide noted discrepancies in the narcotic count, and a licensed nurse reported that the nurse dismissed her attempts to provide a resident report. The administrative nurse confirmed the lack of documentation and attempts to contact the nurse were unsuccessful. The facility's policy on medication administration emphasizes the importance of administering medications as ordered, but this was not adhered to during the shift in question.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection control program during medication administration, as observed with a certified medication aide (CMA) who did not adhere to sanitary practices. During the administration of morning medications to a resident, the CMA spilled the medication cup, causing several pills to fall on the floor and the medication cart. Instead of discarding the contaminated medications, the CMA placed them back into the cup and proceeded to administer them to the resident. Additionally, the CMA administered a nasal spray without wearing gloves, which caused the resident to cough, and failed to perform hand hygiene before and after administering medications. The facility's policies on medication administration and infection control were not followed, as confirmed by administrative nurses. The CMA acknowledged the errors, including the failure to use gloves and perform hand hygiene. The facility's policies clearly state that medications should be administered in a safe and sanitary manner, and hand hygiene should be performed before and after contact with a resident. These deficiencies were confirmed by administrative staff, who expected adherence to infection control standards.
Resident Excluded from Care Plan Meetings
Penalty
Summary
The facility failed to include a resident in the development and continued planning of their care plan, which was supposed to occur quarterly. The resident, who had intact cognition and a good memory, was not invited to any care plan meetings despite being documented as such in the care plan. The resident's medical conditions included diabetes mellitus and osteoarthritis, and they required varying levels of assistance with activities of daily living. Despite the facility's policy requiring residents to be invited to care plan meetings, the resident reported never being invited, and there was no documentation to confirm their attendance. The facility's policy stated that care plan conferences should be scheduled at least every 90 days and include the resident, family, or healthcare representative, along with the interdisciplinary team. However, the social service staff failed to document the resident's involvement in these meetings, assuming it was implied. The lack of documentation and failure to invite the resident to participate in their care planning placed them at risk for inadequate care and services, with potential negative psychosocial effects related to safety and uncommunicated needs.
Failure to Verify and Authorize Advanced Directives
Penalty
Summary
The facility failed to verify and document the advanced directives for Resident 8, who had a history of chronic obstructive pulmonary disease, diabetes mellitus type 2, and chronic respiratory failure with hypoxia. Despite the resident's intact cognition and a stated preference to be a full code, the facility's records contained an un-rescinded DNR order signed by the resident. The facility's staff, including a Certified Medication Aide and a Certified Nurse Aide, were unable to locate the resident's advance directive wishes in the care plan book or on the lanyards meant to document code status. This discrepancy between the DNR order and the full code order was not addressed, leading to potential uncommunicated needs regarding end-of-life care. The facility also failed to obtain proper authorization for a DNR order for Resident 3, who had diagnoses of schizophrenia and bipolar disorder. Although the resident had a BIMS score indicating moderately impaired cognition, the facility allowed the resident's guardian to consent to a DNR order, which was not permissible according to the facility's policy. The care plan did not document the presence of a guardian, and the uploaded guardianship document lacked direction for advanced directives. Administrative Nurse D was unaware that a guardian could not sign a DNR, leading to a failure in obtaining proper authorization. Both cases highlight the facility's failure to adhere to its policy for advanced directives, which required assessment and documentation of each resident's directives in the EHR. The lack of verification and proper authorization for advanced directives had the potential to lead to uncommunicated needs specifically related to end-of-life care for the residents involved.
Failure to Develop Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop a person-centered baseline care plan for Resident 153 within 48 hours of admission, as required by their care planning policy. Resident 153, who was admitted with acute pancreatitis, chronic kidney disease, and diabetes mellitus type 2, did not have a completed Admission Minimum Data Set (MDS) or Care Area Assessment (CAA) in their Electronic Health Record (EHR). The baseline care plan was incomplete and lacked essential information such as the resident's initial goals, communication risks, dietary preferences, therapy services, and other critical care instructions. Additionally, the care plan was neither signed nor dated by the interdisciplinary team (IDT) or the resident's representative. Interviews and observations revealed that Resident 153 had not participated in a care plan meeting with the staff, nor had any staff inquired about her needs or wishes regarding her care since her arrival. The facility's policy mandates that a summary of the baseline care plan be provided to residents and their representatives within 48 hours of admission, but this was not adhered to in the case of Resident 153. The lack of a complete and signed baseline care plan had the potential to lead to uncommunicated needs for the resident.
Failure to Document Respiratory Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R30, regarding the use of oxygen and nebulized medication. R30's electronic health record included diagnoses of obstructive sleep apnea and chronic obstructive pulmonary disease, conditions that necessitate careful management of respiratory support. Despite physician orders for nebulized medication and supplemental oxygen, the care plan lacked documentation related to these treatments. Interviews with staff revealed inconsistencies in care plan documentation, with some staff unaware of the specific respiratory care needs of R30. The deficiency was identified through interviews, observations, and record reviews. Certified Nurse Aide LL confirmed that R30 used oxygen, and the tubing and nebulizers were changed weekly. However, the care plan did not reflect these practices. Licensed Nurse K and Administrative Nurse D acknowledged that the care plan should accurately reflect the care administered, but it did not include the necessary information for R30's oxygen and nebulized medication use. This oversight had the potential to lead to uncommunicated needs, negatively impacting R30's physical well-being.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to accurately revise the care plans for two residents, R22 and R9, after they experienced falls, which placed them at risk for uncommunicated care needs. Resident R22, who had diagnoses of bipolar disorder and dementia, reported falling out of bed and later out of her wheelchair, but her care plan was not updated to reflect these incidents. Despite having a history of falls and being on medications that increased her fall risk, the care plan did not include new interventions to prevent further falls after these incidents were reported by the resident and her family. Resident R9, who had a history of dementia and a right hip fracture, also experienced a fall that resulted in a major injury. Although her care plan should have included guidance on her weight-bearing status following her hospital discharge, it lacked any instructions regarding hip fracture precautions. Despite therapy communication forms indicating changes in her weight-bearing status, these updates were not reflected in her care plan, leaving staff without crucial information to provide appropriate care. The facility's failure to update the care plans for R22 and R9 after their falls and changes in their medical conditions was a violation of their Care Plan Revision Policy. This policy requires that care plans be revised by a licensed nurse in collaboration with the interdisciplinary team and communicated to all staff. The lack of updates in the care plans for these residents had the potential to negatively affect their physical and psychosocial well-being.
Unsanitary Medication Administration
Penalty
Summary
The facility failed to meet professional standards of care when a Certified Medication Aide (CMA) administered medications in an unsanitary manner. During the morning medication administration, the CMA accidentally spilled a medication cup containing oral pills for a resident, with some pills landing on the floor and others on the medication cart. Instead of discarding the contaminated medications, the CMA picked them up and placed them back into the medication cup, then proceeded to administer them to the resident along with an Oxycodone tablet. The incident was confirmed by the CMA shortly after, acknowledging that she should have replaced the dropped medications with new ones. Administrative staff, including two nurses, also confirmed that the medications should not have been administered after falling on the floor and cart, as it violated the facility's medication administration and infection control policies. These policies require that all medications be administered in a safe and sanitary manner, ensuring a safe and comfortable environment for residents.
Deficient Personal and Oral Care for Residents
Penalty
Summary
The facility failed to provide adequate personal care for Resident 19, who was dependent on staff for activities of daily living (ADLs) due to severe cognitive impairment and physical limitations. Despite requiring maximal assistance with personal hygiene, the care plan lacked documentation for facial hair removal, and observations over several days revealed that the resident had noticeable facial whiskers. A family member expressed concern about the resident's appearance, and staff interviews indicated a lack of awareness and adherence to the facility's policy on grooming, which emphasized maintaining residents' dignity. Similarly, Resident 40, who also had severe cognitive impairment and required total assistance with ADLs, did not receive proper personal hygiene and oral care. Observations showed the resident had facial whiskers and poor oral hygiene, with dried substances on her teeth and lips. Despite having oral care supplies available, there was a lack of documentation and consistent care provided. Staff interviews revealed confusion about responsibilities for facial hair removal and oral care, with some staff unaware of the resident's personal care items. The facility's policy on dignity and grooming was not followed, as both residents did not receive the necessary care to maintain their dignity and well-being. The lack of proper grooming and oral care placed the residents at risk for decreased psychosocial well-being, as noted in the report. The facility's failure to ensure these dependent residents received appropriate care highlights deficiencies in staff training and adherence to care policies.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to adhere to effective infection control practices during wound care for a resident with a pressure ulcer. The resident, who was admitted with a pressure ulcer on the coccyx, had multiple medical conditions including muscle weakness, diabetes mellitus type two, chronic kidney disease, and disseminated intravascular coagulation. The resident required substantial assistance for daily care and had a urinary catheter due to neurogenic bladder. The care plan included the use of a pressure-reducing mattress and wheelchair cushion, assistance with repositioning, and specific wound care orders. However, during an observation, a licensed nurse failed to change gloves between cleaning the resident's rectal area and continuing wound care, despite the resident being incontinent of bowel movement. The incident was observed when the licensed nurse, after removing the resident's brief and exposing the wound, cleansed the rectal area with wet wipes, removed gloves, used hand sanitizer, and replaced gloves. However, after the resident continued to have a bowel movement, the nurse wiped the bowel movement and continued wound care without changing gloves. This action was contrary to the facility's wound management policy, which required maintaining general infection control practices during wound care. The nurse later admitted to forgetting to change gloves due to frequent glove use, and the administrative nurse confirmed that failing to change gloves appropriately presented an infection control problem.
Improper Handling of Urinary Catheter Collection Bag
Penalty
Summary
The facility failed to provide proper care to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who had a history of hydronephrosis, diabetes mellitus type two, and neuromuscular dysfunction of the bladder, required substantial assistance for daily care. The care plan specified that the urinary catheter collection bag should be positioned below the level of the bladder to prevent urine backflow. However, during an observation, it was noted that the catheter collection bag was placed on the resident's lap and later held above the resident's bladder during a transfer, contrary to the facility's policy. Staff members involved in the incident were not aware of the requirement to keep the urinary collection bag below the bladder. A Certified Nursing Assistant (CNA) reported being unaware of this protocol, and a Licensed Nurse confirmed that all CNAs should be trained in the proper placement of the catheter. The facility's policy, dated December 2023, clearly stated that the catheter and drainage bag should be kept lower than the bladder to allow drainage by gravity. The failure to adhere to this policy posed a risk of urine backflow and potential urinary tract infection for the resident.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to properly manage respiratory care for two residents, leading to deficiencies in their care. For Resident 1, the facility did not obtain a physician's order for the administration of oxygen, despite the resident's diagnoses of chronic obstructive pulmonary disease, obstructive sleep apnea, and chronic respiratory failure with hypoxia. The care plan and physician's orders lacked documentation related to oxygen use, and the Medication Administration Record and Treatment Administration Record did not include information on oxygen administration. Additionally, the resident's oxygen cannula was contaminated and not replaced promptly, and the staff failed to date the new cannula as required by the facility's policy. For Resident 30, the facility did not properly clean and store the nebulizer equipment. The resident, who had diagnoses of obstructive sleep apnea and chronic obstructive pulmonary disease, had a nebulizer mask that was not dated, and the equipment was not stored according to the facility's policy. The nebulizer was observed on the resident's bedside table and in the resident's lap without proper cleaning or storage. Staff interviews revealed that the nebulizer and oxygen tubing were supposed to be changed and dated weekly, but this was not consistently done. These deficiencies in respiratory care practices had the potential to negatively impact the residents' physical and psychosocial well-being. The facility's failure to adhere to its own policies regarding the administration of oxygen and the maintenance of nebulizer equipment contributed to these issues. The lack of proper documentation and adherence to protocols for respiratory care highlighted significant gaps in the facility's management of residents' respiratory needs.
Improper Medication Storage for Residents
Penalty
Summary
The facility failed to properly store medications for three residents, leading to a deficiency in medication management. Resident 153 had miconazole powder stored on her bedside table without a physician's order or a completed self-administration assessment. The facility's records lacked documentation allowing medications to be left at the bedside, and staff were unaware of the policy regarding medication storage in resident rooms. This oversight had the potential to negatively impact the resident's well-being. Resident 8 had multiple over-the-counter medications, including Voltaren Gel, Flonase, and a petroleum-based salve, stored on her over-the-bed table without specific physician orders or a self-administration assessment. The resident was unable to specify the dosage or frequency of use for these medications. The facility's records did not document permission for these medications to be left at the bedside, and staff were not informed about the policy for medication storage in resident rooms. Resident 22 had Fluticasone Propionate Suspension and Saline Nasal Spray stored in plain view on her overbed table without a physician's order or a self-administration assessment. The facility's records lacked documentation allowing these medications to be left at the bedside. Staff were unaware of the policy regarding medication storage in resident rooms, and there was concern that removing the medications could lead to behavioral issues. The facility did not have a policy for medication storage in resident rooms, contributing to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 358 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wichita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regent Park Rehabilitation And Healthcare | 1.8 mi | ★★★★★ | 21 | 0 |
| Center At Waterfront Llc | 1.9 mi | ★★★★★ | 19 | 0 |
| Life Care Center Of Andover | 2.6 mi | ★★★★★ | 4 | 4 |
| Great Plains Post Acute | 3.7 mi | ★★★★★ | 17 | 0 |
| Larksfield Place | 3.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.