Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Center At Waterfront Llc during CMS and state inspections, most recent first.
Annual performance reviews were not completed for five CNA/CMA staff members reviewed. Personnel file review showed each of the five staff members lacked an annual evaluation, and the DON-level nurse stated she expected full compliance with annual reviews. The facility policy stated in-service training would be based on the results of those reviews and address identified weaknesses.
Unsanitary food handling and improper storage in the kitchen. Staff were observed with trash on the floor behind the ice machine and open bags of pork chops and hamburger patties left exposed in the refrigerator and freezer. During meal service, a Dietary staff member handled plated holders, bread, trash, lettuce, tomatoes, cheese, hamburger patties, ground meat, and bowls with the same gloves without washing hands or changing gloves, and an RN stated staff were expected to wash hands and replace gloves.
Missing Bed Hold Notices and Incomplete Discharge Summary: The facility failed to provide written bed hold notices and transfer notifications for three residents who were sent to the hospital, and failed to complete a discharge recapitulation for another resident discharged home. EMRs lacked evidence of the required written notices or a completed discharge summary, while staff interviews showed inconsistent understanding of who completed bed holds and how discharge paperwork was handled.
Medication Administration Errors Exceeded Allowed Rate: The facility had a 79.62% med error rate after 30 errors were identified during observation of 39 med administrations. An LPN administered multiple residents’ scheduled oral meds late, and another LPN gave both oral and IV meds late, all outside the one-hour before-or-after protocol. The ADNS verified the meds were scheduled for 08:00 AM and confirmed there was no liberalized med pass time.
Failure to Use EBP PPE for Residents With Devices and Wounds: The facility identified multiple residents who met EBP criteria, including residents with urinary catheters, PICC lines, and a pressure ulcer, but there was no visible signage or readily accessible PPE setup for staff. A CNA and an LPN provided direct care to a resident with a PICC line without wearing gowns, and the LPN confirmed the proper EBP PPE was not used. The facility’s Infection Control policy did not address EBP.
A resident with dementia and C-diff had a baseline care plan that failed to include contact enteric precautions, even though PPE and an isolation sign were present and the IP later confirmed the precaution should have been documented. Another resident with dementia and diabetes had a baseline care plan that identified fall risk but lacked fall interventions after repeated falls, including being found on the floor near a recliner and later on a mattress beside the bed with the urinary catheter pulled out.
Failure to provide shaving assistance for a resident who could not shave himself. The resident had metabolic encephalopathy, bacteremia, and muscle weakness, and his MDS showed intact cognition with need for touch supervision for personal hygiene. He was observed with unkempt facial hair and said he wanted staff to offer him a shave, while an electric razor was present in his room but out of reach. Staff gave differing accounts about who was responsible for grooming assistance, and the care plan directed staff to assist with grooming and personal hygiene per the resident’s preferences.
Failure to Investigate Falls and Document Immediate Interventions: Two residents with significant fall risk factors, including prior falls, cognitive impairment, weakness, and cardiac/vascular diagnoses, experienced falls with injury or head impact. One resident was transferred to the hospital after a fall with a head laceration and skin tear, and the other was found on the floor next to a recliner after an unwitnessed fall. In both cases, the EHR lacked a thorough fall investigation, root cause analysis, and documentation of immediate interventions to prevent further falls.
Improper Disposal of Kitchen Garbage and Refuse: During a kitchen tour, surveyors observed the outside shred bin and trash bin with lids up while the Dietary Manager was present. He stated he was not sure why the bins were open and said they are usually closed. The facility did not provide a waste disposal policy.
A cognitively impaired resident with moderate elopement risk left the facility unsupervised after staff failed to implement care plan interventions addressing elopement, and the incident was only discovered when the resident's representative was alerted by a community member. Staff interviews and records confirmed that the resident's risk was known but not addressed in the care plan prior to the event.
The facility failed to maintain sanitary conditions in food preparation areas, with issues such as food debris in the refrigerator, stained shelf covers, and deeply grooved cutting boards. Dietary staff confirmed these concerns needed attention, and the cleaning schedule was not being adequately followed.
The facility failed to maintain a sanitary kitchen environment, with food debris and dirt observed around the kitchen floor perimeter, beneath equipment, and in floor drains. Dietary staff acknowledged the need for cleaning, but the facility lacked a specific policy for kitchen floor cleaning.
The facility failed to notify the State Ombudsman of the transfer or discharge of four residents, including those with acute kidney failure, pancytopenia, peripheral vascular disease, and metabolic encephalopathy. Administrative staff were unaware of the requirement, and the facility lacked a policy for such notifications.
The facility failed to develop comprehensive assessments by not completing the Care Area Assessments (CAAs) for further investigation and development of the comprehensive care plan for seven residents. These residents had various medical conditions and required specific care plans that were not adequately addressed, leaving them without proper care plans to address their complex medical needs.
A resident with Parkinson's disease could not access the mirror in his bathroom to shave, leading to unshaven facial hair despite his preference to be clean-shaven. Staff interviews and observations confirmed that the resident required assistance with shaving, but the facility failed to provide reasonable accommodations to his physical environment, resulting in inadequate grooming care.
The facility failed to notify a resident with a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare covered Part A stay. The Social Service Designee responsible for completing the NOMNCs had quit six weeks prior, leading to the deficiency.
The facility failed to provide two residents and/or their representatives with a written notice specifying the duration and cost of the bed hold policy at the time of the residents' transfer to the hospital. Staff interviews revealed that bed holds were not completed for residents when they transferred to the hospital, and administrative staff were unaware of the need for such documentation.
The facility failed to develop baseline care plans within 48 hours of admission for three residents, including one with multiple diagnoses, one on antipsychotic medication, and one requiring dialysis. This led to deficiencies in their care, as confirmed by staff interviews and record reviews.
The facility failed to assist a resident with Parkinson's disease in shaving, despite his need for supervision and expressed preference to be clean-shaven. Observations and staff interviews confirmed that the resident had several days' growth of facial hair and had difficulty seeing the mirror to shave while seated in his wheelchair.
The facility failed to provide appropriate treatment for a resident with skin injuries and did not follow sanitary procedures during dressing changes. The resident, who had multiple diagnoses and was at risk for pressure ulcers, did not receive proper wound care, and the facility did not adhere to its policy for pressure ulcers. Observations revealed undated dressings, improper hand hygiene, and unsanitary bed linens, indicating significant deficiencies in treatment protocols and infection control.
A resident with a stage III pressure ulcer on the coccyx did not have the wound cleansed before a new dressing was applied. The resident was at high risk for pressure ulcers due to obesity, decreased mobility, and incontinence. Despite facility policies and staff expectations to cleanse wounds before dressing changes, the nurse did not follow this procedure, leading to a deficiency in care.
The facility failed to ensure proper communication with the dialysis facility for a resident with end-stage renal disease (ESRD). The baseline care plan lacked dialysis instructions, and the Dialysis Communication Form was incomplete, missing critical information. Staff confirmed that the form should be filled out and sent with the resident, but this protocol was not followed.
The facility failed to follow physician-ordered parameters for administering medications to two residents. One resident received Midodrine Hydrochloride outside the prescribed blood pressure parameters, and another resident did not receive the ordered sliding scale insulin for elevated blood glucose levels. These deficiencies were confirmed through interviews and record reviews.
The facility failed to monitor a resident for the use of antipsychotic medications. Despite the resident's diagnosis of dementia with psychotic disturbance and a policy requiring an AIMS assessment, no such assessment was completed when the medication was ordered. This oversight was confirmed by staff interviews and a review of the resident's medical record.
Failure to Complete Annual Performance Reviews for CNA/CMA Staff
Penalty
Summary
The facility failed to complete annual performance reviews at least once every 12 months for five CNA/CMA staff members reviewed, despite reporting a census of 54 residents and identifying five CNAs employed for more than 12 months. Review of personnel files showed that CNA O, CNA P, CNA Q, CNA S, and CMA R each lacked an annual performance evaluation. During an interview, the Administrative Nurse stated she expected 100 percent compliance with completing annual performance evaluations annually. The facility policy, Inservice Training Program, Nurse Aide, dated 04/02/24, stated that in-service training would be based on the outcome of annual performance reviews and address weaknesses identified in those reviews.
Unsanitary food handling and improper storage in kitchen
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions to prevent potential for food borne bacteria. During the initial tour of the main kitchen, trash was observed on the floor behind the ice machine, one bag of pork chops was left open in the refrigerator, and one bag of hamburger patties was left open to air in the freezer. During meal service, Dietary Staff CC was observed preparing food while wearing gloves and repeatedly touching multiple items without changing gloves or washing hands, including plated holders, bread, trash on the counter, lettuce, tomatoes, cheese, a hamburger patty, ground meat, and bowls used for corn. When asked about the food service process, Dietary Staff CC refused to answer. Dietary Staff BB stated that staff were expected to wash their hands and replace their gloves. The facility policy stated that food products delivered to the facility are to be inspected for safety and quality, dated upon receipt, labeled with use-by dates when opened or in use, and raw meat must be properly sealed and separated from other foods during storage.
Missing Bed Hold Notices and Incomplete Discharge Summary
Penalty
Summary
The facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for transfers involving R64, R7, and R97. The record for each of these residents showed they were transferred to the hospital, but their EMRs lacked evidence that the facility provided a bed hold notice or written notification of the transfer to the resident and/or representative. During interviews, staff gave differing accounts of who completed bed holds and whether a written form was provided, and Administrative Staff C stated she documented the bed hold in the EMR but did not provide a written/signed bed hold form for R64, R7, and R97. The facility also failed to complete a recapitulation of R66's stay after discharge to home. R66's EMR showed discharge to home, but the record lacked evidence of a completed discharge summary recapitulating the course of the resident's stay. Staff interviews indicated the discharge summary was still in progress, that therapy had not evaluated R66 because the resident was admitted for one day, and that the resident/family should have received a signed copy of the discharge summary. The facility's Bed Hold policy stated written information should be provided before transfer to a hospital and receipt of signature documentation maintained in the EMR, and the Discharge Policy and Procedures stated discharge instructions should be given to the patient.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent when 30 medication errors were identified during observation of 39 medication administrations, resulting in a 79.62 percent medication error rate. The report states that the facility had a census of 54 residents and that the observed errors involved medications being administered outside the one-hour before or after protocol. Resident 67’s January 2026 MAR/TAR showed six oral medications scheduled for 08:00 AM, but on 01/14/26 at 10:13 AM, LN L administered those medications late. Resident 56’s MAR/TAR showed seven oral medications scheduled for 08:00 AM, and LN L administered them at 10:29 AM, also late. Resident 98’s MAR/TAR showed five oral medications scheduled for 08:00 AM, and LN L administered them at 10:38 AM, late as well. Resident 38’s MAR/TAR showed 10 oral medications and two IV medications scheduled for 08:00 AM; LN G administered the 10 oral medications at 10:47 AM and the two IV medications at 11:13 AM, both outside the one-hour before or after protocol. During interviews, LN L stated the medications were over an hour late and said she did not have a certified medication aide on the schedule. LN G stated she knew she was late administering medications and would do the best she could with what staff she had. Administrative Nurse D verified the medications were scheduled for 08:00 AM and confirmed the facility did not have a liberalized medication pass time.
Failure to Use EBP PPE for Residents With Devices and Wounds
Penalty
Summary
The facility failed to ensure adequate infection control related to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices and wounds. The facility matrix identified 10 residents who met criteria for EBP, including residents with urinary catheters, PICC lines, and an unstageable pressure ulcer. During the initial tour, there was no visible signage to identify residents who required EBP and no readily accessible PPE setup for staff to use before entering resident rooms for direct care. Observed care showed staff entering the room of a resident with a PICC line and providing direct care without wearing a gown. A CNA entered the room, washed hands, put on gloves, and emptied the resident’s urinal without a gown. A nurse later administered daptomycin through the resident’s PICC line, cleaned the hub, and did not apply a gown. The nurse stated there were no signs to alert staff and visitors to EBP requirements and confirmed she did not use the proper PPE. A nurse and consultant later verified that staff should wear PPE for direct care of residents with surgical openings, PICC lines, indwelling catheters, and wounds. The facility policy titled Infection Control, dated 01/29/25, did not address EBP.
Baseline Care Plan Missing Isolation and Fall Interventions
Penalty
Summary
The facility failed to complete a thorough baseline care plan for a resident with dementia and C-diff, and the baseline care plan did not include contact isolation precautions. The resident’s EMR documented dementia and C-diff, and the admission MDS documented a BIMS score of seven, indicating severely impaired cognition, with total dependence for toileting hygiene. The resident also had CAA documentation showing a trigger related to assistance needed with ADLs. Although physician orders later documented contact enteric precautions for C-diff, the 01/09/26 baseline care plan marked transmission-based precautions as “no.” During observation, a contact precaution sign was on the resident’s door and PPE was outside the room, while the resident’s family member reported not knowing what the contact precautions were for. The IP later stated the baseline care plan was not completed and that isolation precautions should have been marked yes. The facility also failed to include fall interventions in the baseline care plan for another resident with dementia and diabetes mellitus. The resident’s baseline care plan identified fall risk related to impaired mobility, weakness, debility, and the current drug regimen, but it lacked interventions for falls that occurred after admission. Nursing notes documented the resident was found on the floor in front of a power recliner with the footrest still up and the indwelling catheter hooked to the recliner, and later attempted to get out of bed all night. After the falls, a mattress was placed beside the bed, and the resident was later found on the mattress on the floor with the urinary catheter pulled out. Observations showed the mattress remained beside the bed, and an administrative nurse stated staff discussed falls in morning risk management meetings but did not have investigation information to change the care plans.
Failure to Provide Shaving Assistance
Penalty
Summary
The facility failed to provide assistance with facial hair removal for a resident who was unable to shave himself. The resident had diagnoses of metabolic encephalopathy, bacteremia, and muscle weakness. His MDS documented a BIMS score of 13, indicating intact cognition, and also documented that he required touch supervision assistance with personal hygiene. His CAA identified that he triggered for assistance with ADLs due to generalized weakness and decreased safety awareness, with risk for further ADL decline. His care plan directed staff to provide assistance with grooming, bathing, and personal hygiene according to his preferences. Review of the resident’s shower sheets showed no yes/no documentation indicating whether he had been shaved. During observation, the resident was found in bed with unkempt, shaggy facial hair and stated that he wished staff would offer him a shave and that he could not shave himself. A later observation showed his facial hair remained unchanged, and an electric razor was seen on his windowsill out of his reach. Staff interviews reflected differing expectations about who would provide shaving assistance, with a CNA stating shaving was done on shower day or as needed and that therapy often completed ADLs, while a LN stated morning care should include facial hair removal and staff should ask the resident or family about preferences. The administrative nurse stated staff were expected to provide assistance when needed or requested and to shave residents who were unable to shave themselves.
Failure to Investigate Falls and Document Immediate Interventions
Penalty
Summary
The facility failed to thoroughly investigate falls to identify causative factors and implement appropriate immediate interventions for two residents, R64 and R75. R64 had diagnoses including repeated falls, prior CVA, atrial fibrillation, scalp laceration, generalized weakness, and a need for assistance with personal care. His MDS documented moderate cognitive impairment, use of a walker, substantial to maximal assistance for toilet transfers, incontinence, shortness of breath with exertion, and a history of falls before admission. The Falls CAA and baseline care plan identified him as at risk for falls due to decreased mobility, weakness, prior falls, and his drug regimen. After a fall, R64 was transferred to the hospital with a head laceration to the right rear of his head and a skin tear to his left wrist/forearm, and he reported head pain. The record documented that he was alert to self, but the EHR lacked documentation of a thorough investigation into the causative factors of the fall or documentation of interventions to prevent further falls. The facility was unable to provide the fall investigation, and a nurse confirmed the EHR lacked details of the fall and that investigation documentation was not available. An administrative nurse confirmed the facility did not have documentation of an investigation and stated staff were trying to obtain the information from current staff, and employees were not interviewed at the time of the fall. R75 had diagnoses including traumatic pneumothorax, PVD, history of pulmonary embolus, hypertension, atrial fibrillation, and atherosclerotic heart disease. His baseline care plan identified him as high risk for falls, noted a fall with major injury, and directed staff to use a Call Don't Fall sign, ensure adequate lighting, cue him to transfer and change positions slowly, and provide OT and PT evaluations as indicated. After an unwitnessed fall, he was found lying on his back next to his recliner, stated he had hit his head and was trying to get up when he fell, and was alert and oriented to self on assessment. His EHR also lacked documentation of a thorough investigation into the cause of the fall or documentation of interventions to prevent further falls, and the administrative nurse confirmed the record lacked a root cause analysis to determine contributing factors.
Improper Disposal of Kitchen Garbage and Refuse
Penalty
Summary
The facility failed to maintain and dispose of kitchen garbage and refuse properly. During the initial tour of the kitchen, surveyors observed the outside garbage bins with the Dietary Manager present and found one shred bin and one trash bin, both with lids up. When interviewed at the time of the observation, the Dietary Manager said he was not sure why the bins were open and stated they are usually closed. The facility did not provide a policy regarding waste disposal.
Failure to Provide Adequate Supervision and Elopement Interventions for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a history of weakness, insomnia, diabetes mellitus, and moderate cognitive impairment was admitted to the facility and identified as being at moderate risk for elopement based on multiple wandering risk assessments. The resident's care plan, however, did not include any interventions or instructions related to elopement risk prior to the incident, despite documentation of decreased safety awareness, impaired cognition, and a recent non-injury fall. The resident required staff supervision or assistance for ambulation and used a wheelchair for mobility. On the day of the incident, the resident left the second floor, traveled to the first floor, and exited the facility without staff knowledge. The facility became aware of the elopement only after the resident's representative, who had been contacted by a community member, called to alert staff that the resident was seen outside. Staff then conducted a search and located the resident outside the facility. The resident was found uninjured and returned to the building. At the time of the incident, the facility's care plan for the resident lacked any interventions addressing the known elopement risk, and staff had not provided adequate supervision to prevent the resident from leaving the premises. Interviews with facility staff confirmed that the resident was known to be at risk for elopement, and that observation rooms were used for residents requiring close monitoring. However, the care plan was not updated to reflect the resident's elopement risk until after the incident occurred. The facility's policy required individualized care plans for residents at risk of elopement and immediate response to door alarms, but these measures were not effectively implemented for this resident prior to the event.
Failure to Maintain Sanitary Conditions in Food Preparation Areas
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions, as observed during an initial tour of the kitchen. Specific issues included food debris on the bottom shelf of the reach-in refrigerator next to the coffee machine, a dark brown stain on a plastic shelf cover underneath the coffee and tea machine, and a build-up of food debris on shelves underneath the tray line and a worktable storing cereal boxes. Additionally, there was a large build-up of crumbs underneath the toaster, and four cutting boards were found to be deeply grooved. Dietary Staff BB confirmed these areas of concern needed attention. The Dietary Aide Daily Cleaning Schedule, which was undated, indicated that dietary aides were responsible for cleaning and sanitizing these areas every shift, but this was not being adequately performed.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff. During an initial tour and a follow-up visit to the kitchen, surveyors observed a large amount of food debris and ground-in dirt around the perimeter of the kitchen floor. Additionally, the floor beneath the steam table, cooks' line, and tray lines contained significant food debris. Three floor drains in the kitchen were also found to contain food debris and trash. Dietary staff confirmed these areas of concern needed attention. The facility's cleaning schedules indicated that floor drains should be cleaned on specific days and that cooks were responsible for sweeping and mopping the floors every shift. However, the facility lacked a policy related to the cleaning of kitchen floors.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman of the transfer or discharge of four residents, as required by regulations. Resident 60, who had acute kidney failure, diabetes, and heart disease, was discharged to acute care without notification to the Ombudsman. Similarly, Resident 62, who had pancytopenia, fibromyalgia, and a malignant neoplasm of the breast, left the facility against medical advice without the required notification. Administrative Staff A confirmed the lack of notification and the absence of a policy for such notifications. Resident 18, who had peripheral vascular disease, osteomyelitis, and diabetes with a foot ulcer, was transferred to the hospital and returned without the Ombudsman being informed. Resident 44, diagnosed with metabolic encephalopathy and sepsis, was also transferred to an acute hospital without notification. Both Administrative Nurse D and Administrative Staff A were unaware of the requirement to inform the Ombudsman of hospital admissions. The facility lacked a policy for Ombudsman notification for resident discharges, leading to these deficiencies.
Failure to Complete Comprehensive Assessments and Care Plans
Penalty
Summary
The facility failed to develop comprehensive assessments by not completing the Care Area Assessments (CAAs) for further investigation and development of the comprehensive care plan for seven residents. These residents had various medical conditions and required specific care plans that were not adequately addressed. For instance, one resident with peripheral vascular disease, osteomyelitis, and diabetes mellitus with a foot ulcer did not have CAAs triggered for further investigation, despite requiring substantial assistance with daily activities and receiving multiple medications, including pain management and antibiotics. Observations confirmed the resident's need for a comprehensive care plan, which was not developed due to incomplete CAAs. Another resident with cellulitis and a skin tear, who was dependent on a wheelchair and required oxygen and CPAP at night, also did not have CAAs completed for further investigation. This resident had frequent pain and required specific wound care, which was documented but not followed up with a comprehensive care plan. The facility's failure to complete the CAAs left the resident without a proper care plan to address their complex medical needs. Additionally, a resident with acute and chronic respiratory failure and COPD, who required continuous oxygen therapy, did not have CAAs completed for further investigation. This resident exhibited shortness of breath and was on multiple medications, including antibiotics and antiplatelets. Despite these needs, the CAAs were not developed, leaving the resident without a comprehensive care plan. The facility's lack of a written policy for the completion of MDS or CAAs and reliance on the Resident Assessment Instrument (RAI) manual contributed to these deficiencies, as acknowledged by the administrative staff.
Failure to Provide Reasonable Accommodations for Resident's Grooming Needs
Penalty
Summary
The facility failed to provide reasonable accommodations to a resident with Parkinson's disease, who could not access the mirror in his bathroom to shave. The resident, who had normal cognitive function and required supervision or touching assistance for personal hygiene, was observed with unshaven facial hair on multiple occasions. Despite the resident's preference to be clean-shaven and his difficulty seeing the mirror due to its location, staff did not adequately assist him with shaving. Interviews with various staff members, including a licensed nurse and certified nurse aides, confirmed that the resident required assistance with shaving and had requested help, but the assistance provided was insufficient to meet his needs. The resident's care plan instructed staff to provide assistance with grooming, bathing, and personal hygiene, but the facility's failure to accommodate his physical environment prevented him from accessing the mirror. The facility's policy on ADL services required staff to provide assistance with ADLs every shift, including shaving, but this was not effectively implemented for the resident. The administrative nurse acknowledged that staff should provide grooming assistance per resident preferences, yet the resident continued to have several days' growth of facial hair, indicating a lapse in care and accommodation for his needs.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to notify one resident, R167, with a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare covered Part A stay. The deficiency was identified during a review of discharged Medicare A residents, where it was found that R167 did not receive the required NOMNC. Administrative Nurse D reported that the Social Service Designee (SSD), who was responsible for completing the NOMNCs, had quit about six weeks prior to the survey. The facility's policy, dated 06/20/23, mandates that the NOMNC must be delivered at least two calendar days before Medicare covered services end, and the beneficiary or their representative must sign and date the notice to acknowledge receipt and understanding of the termination decision. The failure to provide the NOMNC as required was a direct result of the SSD's departure and the facility's lack of a replacement to fulfill this responsibility.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide two residents and/or their representatives with a written notice specifying the duration and cost of the bed hold policy at the time of the residents' transfer to the hospital. Resident 44, who had a diagnosis of metabolic encephalopathy and was dependent on staff for assistance with ADLs, was transferred to an acute hospital with a diagnosis of sepsis. The resident's electronic medical record lacked a signed bed hold for this hospital admission. Interviews with Licensed Nurse I and Administrative Nurse D revealed that bed holds were not completed for residents when they transferred to the hospital. Administrative Staff A was unaware of the need for residents and/or their representatives to sign a bed hold when transferred to the hospital. The facility's policy, revised on 03/15/24, stated that notice of bed holds should be provided upon admission and at the time of transfer to the hospital, but this was not followed in the case of Resident 44. Similarly, Resident 18, who had an amputation on his left leg below the knee, was discharged to the hospital and returned four days later. The resident's electronic medical record also lacked evidence of written notification of the bed hold policy. Administrative Staff B reported that she should fill out a short online report about the bed hold and might talk to the family if available, but she did not get signatures for any bed holds. Administrative Nurse D confirmed that nurses did not complete bed holds for residents. Administrative Staff A was unaware of the bed holds not being completed and assumed that the facility would always have a bed available for returning residents. The facility's policy for bed holds was not adhered to in the case of Resident 18 as well.
Failure to Develop Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans for three residents within 48 hours of their admission, as required by their policy. Resident 20, who had diagnoses including aftercare for knee joint prosthesis extraction, diabetes, chronic kidney disease, and atrial fibrillation, was admitted to the facility but did not have a baseline care plan in place. This was confirmed by an interview with Administrative Nurse D. Similarly, Resident 221, who had Alzheimer's disease and was prescribed antipsychotic medication, did not have the use of this medication included in their care plan. Interviews with staff confirmed that antipsychotic medications should be included in care plans, but this was not done for Resident 221. Additionally, Resident 214, who had end-stage renal disease and required dialysis, did not have dialysis care instructions included in their baseline care plan. The resident's electronic medical record showed a physician's order for dialysis, but the baseline care plan lacked necessary details. A Dialysis Communication Form was also incomplete, missing critical information such as the resident's physician's name, contact person, and medication details. Interviews with staff confirmed that dialysis care should be included in care plans, but this was not done for Resident 214. The facility's failure to develop and implement baseline care plans within 48 hours of admission for these residents led to deficiencies in their care.
Failure to Assist Resident with Shaving
Penalty
Summary
The facility failed to provide necessary assistance with facial shaving to Resident 29, who has Parkinson's disease and requires supervision or touching assistance for personal hygiene. Despite the resident's normal cognitive function and expressed preference to be clean-shaven, observations revealed that he had several days' growth of facial hair. The resident stated he had difficulty seeing the mirror to shave due to its location in the bathroom, which he could not access while seated in his wheelchair. Interviews with staff, including a licensed nurse and certified nurse aides, confirmed that Resident 29 required assistance with shaving and had requested help. However, the facility did not ensure that this assistance was consistently provided, as evidenced by the resident's unshaven appearance over multiple days. The facility's policy on ADL services, which mandates assistance with grooming every shift as appropriate, was not followed in this case, leading to the deficiency in care for Resident 29.
Failure to Provide Appropriate and Sanitary Wound Care
Penalty
Summary
The facility failed to ensure that Resident 3 received appropriate treatment for an unidentified skin injury and sanitary dressing change. The resident, who had diagnoses including atrial fibrillation, lymphedema, and muscle weakness, was assessed with normal cognitive function and was dependent on staff for bed mobility. The resident had a skin tear, moisture-associated skin damage (MASD), and was at risk for pressure ulcers. Despite these conditions, the facility did not develop a Pressure Ulcer Care Area Assessment (CAA) and failed to follow the care plan instructions to monitor and assist the resident with turning and repositioning. Observations revealed that the resident's coccyx wound was not properly dressed, and the bed linens were not sanitary, which could contribute to the spread of infection. Additionally, the dressing on the resident's right posterior thigh was undated and contained serosanguineous drainage, indicating a lack of proper wound care documentation and treatment. On multiple occasions, the facility staff did not follow sanitary procedures during dressing changes. For instance, an administrative nurse did not sanitize her hands between glove changes while providing wound care. The resident's right thigh wound with drainage and an open area to the buttock were not properly assessed or treated until observed by surveyors. The facility's policy for pressure ulcers, which mandates treatment and care in accordance with professional standards, was not adhered to. Interviews with staff confirmed that the posterior thigh wound had not been assessed until the day of the survey, and the dressing should have been dated and documented. This failure to provide appropriate and sanitary wound care highlights significant deficiencies in the facility's treatment protocols and infection control practices.
Failure to Clean Pressure Ulcer Before Dressing Application
Penalty
Summary
The facility failed to appropriately clean the pressure ulcer (PU) of Resident 5 before applying a new dressing. Resident 5 had a stage III PU on his coccyx, which was documented to have yellow adherent slough over approximately 90% of the wound bed and a small amount of serosanguineous exudate. On 03/14/24, Administrative Nurse F changed the dressing without cleansing the wound, as the physician's order dated 02/06/24 did not include instructions for wound cleansing. This oversight was confirmed by Administrative Nurse F, who admitted to not seeking clarification of the order. The resident's medical record indicated that he was at high risk for PUs due to obesity, decreased mobility, and bowel and bladder incontinence. He was dependent on staff for all activities of daily living and had a pressure-relieving mattress and cushion. Despite these measures, the wound deteriorated, which Consultant GG attributed to the resident's overall decline in health rather than the lack of wound cleansing. However, the facility policy and other staff members, including Licensed Nurse H and Administrative Nurse D, stated that wounds should be cleansed with normal saline or wound cleanser before applying a new dressing, highlighting a failure to follow professional standards of practice.
Failure to Ensure Proper Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure an appropriate system for ongoing communication with the dialysis facility regarding dialysis care and services for Resident 214, who had a diagnosis of end-stage renal disease (ESRD). The baseline care plan for the resident, dated 03/06/24, lacked staff instructions regarding dialysis. Additionally, a physician's order indicated that the resident would receive dialysis at a local dialysis center on Tuesdays and Saturdays, but the Dialysis Communication Form dated 03/12/24 was incomplete. The form lacked critical information such as the name of the resident's physician, the contact person at the facility, the facility phone number, face sheet, medication list, vital signs, medications received before dialysis, and medications sent with the resident to the dialysis center. No other Dialysis Communication Form was made available for review. Licensed Nurse I confirmed that a dialysis communication form needed to be sent with the resident each time he went to dialysis, with the appropriate sections filled out. Administrative Nurse D stated that it was the expectation for the staff to complete the pre-dialysis information on the form and send it with the resident to the dialysis center. The facility policy for Dialysis Protocol, dated 04/28/20, also required that the dialysis communication sheet be given to the dialysis center with the facility and resident information. The facility failed to adhere to these protocols, resulting in a lack of proper communication with the dialysis facility regarding the resident's care and services.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
The facility failed to ensure staff followed physician-ordered parameters for administering medications to two residents, R29 and R18. For R29, who has Parkinson's disease and is at risk for fluid imbalance, the physician ordered Midodrine Hydrochloride to be administered three times a day for hypotension, with instructions to hold the medication if the standing systolic blood pressure exceeded 120 mmHg. However, staff administered the medication outside of these parameters on seven occasions, with blood pressure readings ranging from 122/87 to 166/88. This failure was confirmed by Administrative Nurse D during an interview on 03/18/24, who acknowledged that the staff did not adhere to the physician's instructions for holding the medication based on blood pressure readings. For R18, who has diagnoses including peripheral vascular disease, osteomyelitis, and insulin-dependent diabetes mellitus, the physician ordered a sliding scale insulin regimen to manage blood glucose levels. Despite this, staff failed to administer the ordered sliding scale insulin on multiple occasions when the resident's blood glucose levels were elevated, with readings ranging from 257 to 340. This was verified by Licensed Nurse K and Administrative Nurse D, who confirmed that the insulin was not administered as ordered and that there were no entries on the Treatment Administration Record (TAR) or nurse progress notes to indicate that the insulin had been given. The facility's failure to follow physician-ordered parameters for medication administration for both residents resulted in deficiencies in care. The facility's policy on physician orders, revised on 08/20/22, instructed staff to administer medications as per the written orders of licensed and authorized prescribers. However, the staff's non-compliance with these orders led to the identified deficiencies, as confirmed by the interviews and record reviews conducted during the survey.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to monitor Resident 35 for the use of antipsychotic medications. The resident, diagnosed with dementia with psychotic disturbance, had a BIMS score indicating moderately impaired cognition and was receiving Seroquel for forgetfulness and possible dementia. Despite the facility's policy requiring an AIMS assessment for residents on antipsychotic medications, no such assessment was completed for Resident 35 when the medication was ordered. This oversight was confirmed by both a Licensed Nurse and an Administrative Nurse during interviews. The facility's policy, revised recently, mandates that residents on antipsychotic medications be evaluated for tardive dyskinesia at least every three months and upon starting the medication in-house. However, the resident's electronic medical record lacked any documentation of an AIMS assessment. This failure to adhere to the policy resulted in inadequate monitoring of the resident's condition and the potential side effects of the antipsychotic medication.
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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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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 | 0.2 mi | ★★★★★ | 21 | 0 |
| Avita Health And Rehab At Reeds Cove | 1.9 mi | ★★★★★ | 11 | 0 |
| Great Plains Post Acute | 2.1 mi | ★★★★★ | 17 | 0 |
| Larksfield Place | 2.5 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Wichita | 3 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.