Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Caritas Center, Inc during CMS and state inspections, most recent first.
A resident with dementia and anxiety had an MDS coded to show antipsychotic use and no antidepressant use during the look-back period, despite EMR diagnoses, CAA documentation, care plan entries, physician orders, and MARs all showing that an antipsychotic had been discontinued and Sertraline, an antidepressant, was being administered daily for anxiety. An administrative nurse later acknowledged the MDS was marked in error, resulting in inaccurate assessment and coding of the resident’s psychotropic medication use.
The facility failed to maintain sanitary conditions in the food preparation and serving areas. Observations included dust and dried-on food in the microwave, unsanitizable surfaces on carts, food debris in cabinets and drawers, and a cereal container without a lid. These issues were acknowledged by dietary staff.
A resident with osteoarthritis and bilateral knee replacements did not receive the accurate dose of prescribed Voltaren gel due to a CMA's lack of knowledge about the dosing card, leading to incorrect medication administration.
A facility failed to ensure timely reevaluation of PRN lorazepam for a resident with end-stage renal disease, chronic pain, and osteoarthritis. The resident's use of lorazepam exceeded the 14-day reevaluation limit without documented physician review, contrary to facility policy.
The facility failed to ensure housekeeping staff maintained proper isolation standards for transmission-based precautions. Housekeeping staff were observed inside a resident's room without gowns, and the housekeeping cart was placed inside the room, contrary to the facility's policy.
The facility failed to verify that residents or their responsible parties were provided with vaccine information and risk versus benefit information to document informed choices for COVID-19 vaccinations. Specifically, two residents' electronic medical records lacked documentation of a COVID-19 vaccination or a declination for 2023. The facility did not have a policy for vaccination declination, and there was no documentation that residents or their responsible parties received vaccine information sheets to make informed decisions.
Inaccurate MDS Coding of Psychotropic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to complete an accurate MDS assessment for a resident’s medication regimen. The resident’s EMR diagnosis list included dementia and anxiety. A Quarterly MDS documented a BIMS score of 15, indicating intact cognition, and recorded that the resident received an antipsychotic medication and did not receive an antidepressant during the observation period. However, the Psychotropic Drug Use CAA noted that the resident had received Seroquel during a past hospitalization, that the physician had decreased the Seroquel, and that an antidepressant had been ordered for anxiety. The resident’s care plan documented use of Sertraline, an antidepressant, with associated risk of suicidal thoughts and behaviors. Further record review showed a signed physician order discontinuing the antipsychotic during the previous observation period and a subsequent order for Sertraline 100 mg daily for anxiety. The MAR from early December through mid-February showed the resident received Sertraline 50 mg daily, and from mid-February through early March the resident received Sertraline 100 mg daily. During an interview, the Administrative Nurse acknowledged that the MDS had been marked in error, indicating antipsychotic use instead of antidepressant use during the observation period. This inaccurate documentation conflicted with the EMR, physician orders, MAR, and care plan, and did not align with the facility’s policy requiring accurate resident assessments by qualified staff knowledgeable about the resident and correctly documenting the resident’s status.
Sanitation Deficiencies in Food Preparation and Serving Areas
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions, as observed during an initial tour of the resident kitchenette. Specific issues included a layer of dust on the top of the microwave, a heavy build-up of dried-on food inside the microwave, and unsanitizable surfaces on a beige, plastic, rolling two-tier cart due to three large, melted areas. Additionally, a black, plastic, rolling three-tier cart had ground-in food substances and food debris in all four corners of the top tier. The front of a covered, silver trash can by the hand washing sink contained dried-on food and liquid. A large plastic cereal container beneath the steam table lacked a lid, and the bottom of a cabinet containing plastic serving trays had food debris. The cabinet holding the plate warmer also had a large build-up of food debris, and two drawers holding silverware, scoops, tongs, and ladles had food debris on the bottom. These observations were acknowledged by dietary staff BB.
Failure to Administer Accurate Dose of Topical Pain Medication
Penalty
Summary
The facility failed to ensure staff administered an accurate dose of a topical pain medication for one resident. The resident, who had diagnoses including osteoarthritis of both knees and aftercare of bilateral knee joint replacement, was prescribed Voltaren gel to be applied topically to both knees three times a day. On the observed date, a Certified Medication Aide (CMA) was seen applying the medication without using the provided dosing card, instead using a quarter-sized dollop of the gel, which did not ensure the accurate dosage as prescribed by the physician. The CMA admitted to not knowing about the dosing card, which was found in the medication box. This lack of knowledge led to the incorrect administration of the medication, potentially affecting its effectiveness for pain relief. The facility's policy required medications to be administered following the prescribed dosage, but this was not adhered to in this instance, resulting in the deficiency noted by the surveyors.
Failure to Timely Reevaluate PRN Lorazepam Use
Penalty
Summary
The facility failed to ensure that a physician reevaluated the use of as-needed (PRN) lorazepam for a resident beyond the 14-day reevaluation limit. The resident, who had diagnoses including end-stage renal disease, chronic pain, and osteoarthritis, was assessed with a normal cognitive status and was receiving lorazepam for anxiety. The facility's policy required that PRN psychotropic drugs be limited to 14 days unless the attending physician documented a rationale for extending the order. However, the medical record lacked evidence of a physician reevaluation within the required timeframe. The deficiency was identified when the Administrative Nurse sent a Medication Regimen Review Communication to the physician 55 days after the initial 14-day period had lapsed. The physician subsequently changed the lorazepam dosage, but this action occurred well beyond the required reevaluation period. The facility's failure to ensure timely reevaluation of the PRN lorazepam order resulted in the resident potentially receiving unnecessary antianxiety medication, contrary to the facility's policy and regulatory requirements.
Failure to Maintain Proper Isolation Standards
Penalty
Summary
The facility failed to ensure housekeeping staff maintained proper isolation standards for transmission-based precautions. Four residents were on transmission-based precautions due to COVID-19 infections. During an observation, housekeeping staff were seen inside a resident's room without gowns, and the housekeeping cart was placed inside the room. The cart contained items that would require extended time for vaporized chemical to effectively sanitize. Interviews with administrative nurses revealed that the resident had tested negative for COVID-19 earlier in the morning, but the expectation was for housekeeping staff to follow transmission-based precautions and not place the cart directly in the room. The facility's policy instructed staff to adhere to transmission-based precautions and dedicate disposable equipment when possible, which was not followed in this instance.
Failure to Document COVID-19 Vaccination Informed Choices
Penalty
Summary
The facility failed to verify that residents or their responsible parties were provided with vaccine information and risk versus benefit information to document informed choices for COVID-19 vaccinations. Specifically, Resident 5's electronic medical record lacked documentation of a COVID-19 vaccination or a declination for the 2023 vaccination, despite the resident currently having a COVID-19 infection. Administrative Nurse E confirmed the lack of declination and mentioned that the responsible party may have declined the vaccination because the resident rarely left the building. Similarly, Resident 1's electronic medical record also lacked documentation of a COVID-19 vaccination or declination for 2023. The facility did not have a policy for vaccination declination, and there was no documentation that residents or their responsible parties received vaccine information sheets to make informed decisions regarding their acceptance or declination of the vaccines.
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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.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchard Gardens | 3.4 mi | ★★★★★ | 7 | 0 |
| Regent Park Rehabilitation And Healthcare | 3.7 mi | ★★★★★ | 21 | 0 |
| Center At Waterfront Llc | 3.9 mi | ★★★★★ | 19 | 0 |
| Avita Health And Rehab At Reeds Cove | 4.6 mi | ★★★★★ | 11 | 0 |
| Life Care Center Of Wichita | 4.7 mi | ★★★★★ | 0 | 0 |
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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.