Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Regent Park Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility failed to obtain complete and properly executed informed consents for psychotropic medications for multiple residents. Several residents were receiving antidepressants, antianxiety agents, and antipsychotics, yet their psychotropic consent forms were either missing signatures or did not list the specific medications, dosages, routes, or administration frequencies. Staff reported that informed consent was required before starting or changing psychotropic drugs and that consents were to be provided to residents or their representatives, and facility policy required signed consents at initiation and with dosage increases, but the documentation for these residents did not include the necessary medication details.
A resident’s Medicare Part A coverage ended, and the resident remained for LTC on a private pay basis, but the facility could not produce evidence that the required SNF Advance Beneficiary Notice of Non-coverage (ABN) Form CMS-10055 was provided. Social service notes stated that the ABN was given and that a private pay quote was discussed, and an email to the resident’s representative referenced appeal rights and possible continued therapy, but the documentation did not specifically reference the SNF ABN or include estimated costs for continued therapy. The social worker later acknowledged she could not show that the ABN form had been provided, and no copy of the completed form was in the record, despite facility policy requiring appropriate Medicare discharge notification and appeal information when coverage ends.
A resident with hemiplegia and a documented left-hand contracture risk had physician orders and a care plan directing staff to place a rolled washcloth or splint in the hand on every day and night shift, with the MAR consistently indicating the device was in place and no refusals. However, surveyors repeatedly observed the resident with the left hand hanging in a loose fist, swollen, and without any device, while the prescribed hand splint was found across the room. Therapy staff confirmed the resident’s flaccid left arm and provision of a resting hand splint or rolled towel, and nursing and administrative staff acknowledged the device was supposed to be in the hand at all times and documented on the MAR, demonstrating a failure to follow ordered interventions to prevent contracture.
A resident with pneumonia and post-stroke hemiparesis, care planned and ordered for continuous 2L oxygen due to ineffective gas exchange, was observed in the dining area with a portable oxygen tank attached to the wheelchair but not receiving oxygen; the nasal cannula was hanging unused and the tank was empty. Staff, including an LPN and a CMA, acknowledged the resident was supposed to be on oxygen at all times, and facility policy required use of portable oxygen when off the main concentrator, but this was not followed.
A deficiency was cited when an area of the facility was not kept free from accident hazards and did not provide adequate supervision to prevent accidents, as required by safety standards.
The facility failed to follow sanitary dietary standards related to food labeling, storage, and preparation, placing all residents at risk for food-borne illness. Observations included unlabeled and undated food items, improper handling of food containers, and unsanitary use of a food thermometer.
The facility failed to secure pressurized oxygen cylinders in a locked location, leaving them accessible to six cognitively impaired residents. Additionally, a resident with severe cognitive impairment was found with her bed in a high position while unsupervised, contrary to the facility's Fall policy. These deficiencies placed residents at risk for preventable accidents and injuries.
The facility failed to properly label and store medications, including leaving a medication cart unlocked and unattended, having opened and undated insulin pens and tuberculin vaccine serum vials, and lacking daily temperature documentation for the medication refrigerator. This placed residents at risk for adverse outcomes or ineffective medication regimens.
The facility failed to provide wheelchair foot pedals for a resident with multiple medical conditions, including hemiplegia and dementia. Staff were observed propelling the resident's wheelchair without foot pedals, requiring the resident to hold her feet up. This practice was confirmed by staff interviews and violated the facility's Accommodation of Needs policy, placing the resident at risk of impaired care and decreased quality of life.
A resident with severe cognitive impairment and multiple medical diagnoses had a low air-loss mattress pump set to incorrect weight settings, despite weighing only 111.4 lbs. The care plan and physician's orders lacked specific instructions for the mattress settings, and staff were unsure about the correct settings, leading to a risk of skin breakdown and pressure ulcers.
A facility failed to store a resident's CPAP mask and oxygen tubing in a sanitary manner, placing the resident at increased risk of respiratory infections. The CPAP mask was found on the bedside table, and the oxygen tubing was on the floor, contrary to facility policy requiring these items to be stored in plastic bags when not in use.
The facility failed to administer an as-needed diuretic for a resident with severe cognitive impairment and multiple health conditions and did not consistently monitor blood pressure before administering a beta-blocker to another resident with a history of stroke and hypertension.
The facility failed to maintain ongoing communication with hospice services for a resident with severe cognitive impairment and multiple medical conditions. The care plan lacked essential information, and staff were unaware of the specifics of hospice services, placing the resident at risk for delayed services and uncommunicated care needs.
The facility failed to ensure a functional call light system for each resident, affecting their ability to summon assistance. Two residents reported non-functional call lights, which was confirmed upon inspection. Maintenance staff were unaware of the immediate protocol for fixing call lights, and staff were instructed to increase checks on residents every 15 minutes if a call light was not working. The facility's policy required an operational call system, but two of the four hallways had non-functional call lights.
The facility failed to ensure the posted nursing hours included the required information and were posted in a prominent, readily accessible location. The daily census was missing from the posted staff sheet, and the information was placed under a folder outside the assistant director of nursing's office, making it difficult for residents and visitors to access. Additionally, the facility lacked a policy related to the posted nursing information.
Failure to Obtain Complete Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and/or their representatives were fully informed about specific psychotropic medications, including their names, dosages, routes, and frequencies, as required for informed consent. For one resident with orders for mirtazapine for depression, fluoxetine for depression, and alprazolam for anxiety, the psychotropic medication consent form was dated several months after the medication orders and did not list any of the prescribed psychotropic medications or their details. Another resident with orders for mirtazapine for insomnia and fluoxetine for a mood disorder had a signed psychotropic consent form that also lacked the names of the medications, their dosages, routes, or administration frequencies. A third resident had multiple psychotropic orders, including sertraline for depression, quetiapine in two different strengths for major depressive disorder and behavioral disturbances, mirtazapine for depression, and lorazepam for anxiety. The scanned psychotropic consent for this resident was unsigned and similarly did not specify any of the psychotropic medications, their dosages, routes, or frequencies. Staff interviews confirmed that informed consent was expected before starting or changing psychotropic medications and that consents were to be provided to residents and/or their legal representatives. The facility’s own policy required a signed informed consent on initiation and with any dosage increase of psychoactive medications to ensure potential adverse effects were reviewed, but the documentation reviewed for these residents did not meet those requirements.
Failure to Provide Required SNF ABN and Cost Information When Medicare Coverage Ended
Penalty
Summary
The deficiency involves the facility’s failure to provide the required Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) Form CMS-10055 to a Medicare Part A beneficiary when his covered stay ended and he remained in the facility. The resident census was 61, with 15 residents sampled and three reviewed for beneficiary notifications. For one resident, documentation showed that his Medicare Part A last covered day was 01/28/26, after which he remained in the facility for long-term care on a private pay basis. Facility records, including the medical record and business office documentation, did not contain evidence that the SNF ABN Form CMS-10055 was provided. A social service note dated 01/30/26 stated that the social worker provided the SNF ABN and that the resident would remain private pay for approximately 30–60 days until an apartment was available, and that a private pay quote was given to the resident’s representative. Another social service note, created on 02/09/26 with an effective date of 01/30/26, documented that the resident requested staff review the SNF ABN with his representative, who was not present and whose arrival time was unknown. Email communication from the facility to the resident’s representative on 01/27/26 indicated there was a form the resident would need to sign that reviewed his appeal rights and his right to appeal if he believed Medicare should cover the long-term care stay, and that the appeal could take up to four months while therapy continued, with room, board, and therapy to be billed if the appeal was unfavorable. However, this email chain did not mention the SNF ABN or provide an estimated cost to continue therapy services. During an interview on 02/10/26, the social worker stated the ABN should be provided prior to discharge and reported that she had provided the form, but that the resident did not sign or return it because he wanted to review it with his representative. She confirmed she was unable to show that the resident was provided with the ABN Form CMS-10055 because she did not have a copy. The facility’s policy dated 12/01/17 required appropriate notification of discharge from Medicare services, including appeal rights, when Medicare coverage ends, but the appropriate notification of discharge from Medicare services was not provided in this case.
Failure to Implement Ordered Hand Splint/Positioning Device to Prevent Contracture
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered care and services to prevent reduction in range of motion and contracture development for a resident with left-sided weakness and a left-hand contracture risk. The resident had a history of hemiplegia and hemiparesis following a stroke affecting the left nondominant side, and the admission MDS documented a contracture of the left hand with intact cognition. The care plan and physician’s orders directed staff to place a clean, dry, rolled washcloth between the resident’s fingers and palm and ensure good hygiene on every day and night shift. The MAR from late September through early February documented that the rolled washcloth was in place every day and night with no refusals, and progress notes did not document any refusals or missed treatments. Despite this documentation, surveyor observations on multiple occasions showed the resident without any device in the left hand to address contracture risk. The resident was observed in a wheelchair with the left hand hanging down in a loose fist and swollen, and later in bed with the left hand dangling, swollen, and without a rolled cloth or device. The resident reported that therapy had given her a hand device described as a pool noodle with a strap to prevent her hand from contracting and stated she should have been wearing it at the time, but it was observed across the room on her dresser. A therapy consultant reported that an evaluation had been completed for a left-hand contracture, that the resident’s left arm was completely flaccid, and that a simple resting hand splint or rolled towel had been provided for use. Nursing staff and an administrative nurse confirmed that a towel or splint was supposed to be in the resident’s hand at all times and that nurses were responsible for placement and documentation on the MAR. The facility’s restorative nursing policy stated that goals for elders receiving restorative services include preventing contractures.
Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered continuous oxygen therapy to a resident with significant medical needs. The resident had diagnoses including pneumonia, anxiety, and hemiplegia/hemiparesis following a stroke, and her admission MDS documented intact cognition with receipt of oxygen. Her Care Area Assessment noted impaired physical functioning related to a past stroke with left-sided weakness and a need for staff assistance with all care. The resident’s care plan documented she was to be on oxygen related to ineffective gas exchange, with an order for two liters of oxygen continuously. Physician’s orders directed staff to monitor oxygen saturation and provide oxygen at two liters every day and night shift. During observation, the resident was seated in the dining room in a wheelchair with a portable oxygen tank attached to the back of the wheelchair and a bag containing nasal cannula tubing. The nasal cannula prongs were hanging freely and were not in use, and the resident was not receiving oxygen despite the continuous oxygen order. When a licensed nurse placed the nasal cannula on the resident and attempted to turn on the oxygen, the portable tank was found to be empty, and the nurse then returned the resident to her room to place her on oxygen via a concentrator. Subsequent interviews with a CMA and another licensed nurse confirmed their understanding that the resident required oxygen all the time, and an administrative nurse stated she expected nurses to follow the oxygen orders. The facility’s oxygen therapy policy stated that residents would use oxygen from a portable source when off the main concentrator, but this was not implemented for the resident at the time of observation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents occurring. There is no mention of specific residents, staff, or detailed events, but the deficiency centers on the lack of appropriate hazard prevention and supervision in the area in question.
Failure to Follow Sanitary Dietary Standards
Penalty
Summary
The facility failed to follow sanitary dietary standards related to food labeling, storage, and preparation, placing all residents at risk for food-borne illness. During an initial tour, surveyors observed mixed fruit and a steam table pan containing fruit in the refrigerator without labels or dates, and a large canister of flour also without a label or date. The freezer contained opened and unsealed bags of fish, sausage, potatoes, and chicken, all without labels or dates. Additionally, a storage container of mashed potatoes in the small freezer had no lid, label, or date. During lunch service, dietary staff were seen carrying multiple residents' fruit cups while touching the tops of the opened containers. Furthermore, a dietary staff member touched the probe of a food thermometer with bare hands without cleaning it before checking food temperatures. The facility did not provide a policy related to food storage and preparation when requested.
Failure to Secure Oxygen Cylinders and Maintain Safe Bed Height
Penalty
Summary
The facility failed to secure pressurized oxygen cylinders in a safe, locked location, leaving them accessible to six cognitively impaired, independently mobile residents. During a walkthrough, it was observed that the door to the Clean Room containing 37 pressurized oxygen cylinders was propped open. Staff acknowledged that the door should have been closed and locked, as per the facility's Oxygen Storage policy, which mandates that oxygen cylinders be stored in a secured room with proper ventilation. This oversight placed the residents at risk for preventable accidents and injuries. Additionally, the facility failed to maintain Resident 11's bed at a safe height while she was unsupervised in her room. Resident 11, who had severe cognitive impairment and was dependent on staff for bed mobility, was found with her bed in a high position. Staff confirmed that beds for residents with severe cognitive impairment should never be left in a high position when unsupervised. The facility's Fall policy requires that residents be assessed for fall risks and that interventions be identified to prevent accidents. The failure to lower Resident 11's bed height placed her at risk for preventable falls and injuries.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to properly label and store medications, which placed residents at risk for adverse outcomes or ineffective medication regimens. Specifically, a licensed nurse left a medication cart unlocked and unattended in the 100-hallway. Additionally, the treatment cart contained three opened and undated insulin pens, and the medication room contained two opened and undated vials of tuberculin vaccine serum. The medication refrigerator temperature log also lacked evidence of daily temperature measurements and documentation for multiple dates in March and April 2024. Interviews with staff confirmed that insulin pens and tuberculin vaccine serum vials should be labeled and dated when opened, and the medication refrigerator temperature should be monitored and documented daily. The facility's Storage of Medications policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, with compartments locked when not in use. The facility's failure to adhere to these policies could potentially cause adverse consequences or ineffective treatment for the residents.
Failure to Provide Wheelchair Foot Pedals
Penalty
Summary
The facility failed to provide wheelchair foot pedals for Resident 40, who has multiple medical conditions including hemiplegia, cerebral infarction, hypertension, dementia, overactive bladder, and glaucoma. The resident's care plan indicated she required extensive assistance with activities of daily living (ADLs) and used a wheelchair for mobility. Despite this, staff were observed propelling the resident's wheelchair without foot pedals on multiple occasions, requiring the resident to hold her feet up while being moved. This practice was confirmed by staff interviews, where both a Licensed Nurse and a Certified Nurse's Aide stated that wheelchairs should have foot pedals when propelled by staff. The facility's Accommodation of Needs policy mandates that each resident has the right to receive services with reasonable accommodation of individual needs, including the use of equipment and assistive devices necessary for daily living activities. The failure to provide wheelchair foot pedals for Resident 40 was a direct violation of this policy, placing the resident at risk of impaired care and decreased quality of life. The deficiency was documented through observations, interviews, and record reviews, highlighting a significant lapse in adhering to the facility's own standards and policies.
Incorrect Low Air-Loss Mattress Settings
Penalty
Summary
The facility failed to ensure that a resident's pressure-reducing interventions were implemented correctly. The resident, who had severe cognitive impairment and multiple medical diagnoses including COPD, dementia, dysphagia, repeated falls, and a pressure ulcer, was dependent on staff for bed mobility, transfers, toileting, bathing, and dressing. The resident's care plan included the use of a low air-loss mattress to prevent further skin breakdown and pressure ulcers. However, the care plan lacked specific instructions related to the monitoring and settings for the mattress pump, and the physician's orders also did not include these details. Observations revealed that the resident's low air-loss mattress pump was consistently set to an incorrect weight setting, ranging from 180 lbs to 210 lbs, despite the resident weighing only 111.4 lbs. Interviews with staff indicated that they were unsure if the care plan covered instructions for the mattress settings and that they were expected to check the bed and equipment each shift. The facility's policy on low air-loss mattresses stated that the mattress should be adjusted no less than 50 pounds above the patient's weight or to the patient's preference or comfort level, but this was not followed in practice. The failure to set the low air-loss mattress pump to the appropriate weight setting placed the resident at risk for complications related to skin breakdown and pressure ulcers. The facility's lack of specific instructions in the care plan and physician's orders, combined with staff's uncertainty about the correct settings, contributed to this deficiency.
Improper Storage of CPAP Mask and Oxygen Tubing
Penalty
Summary
The facility failed to ensure the proper storage of a resident's CPAP mask and oxygen tubing, which were found in unsanitary conditions. The CPAP mask was observed lying directly on the bedside table, and the oxygen tubing was found undated and unbagged on the floor. This was contrary to the facility's policy, which required these items to be stored in plastic bags when not in use to prevent contamination. Interviews with staff confirmed that the CPAP mask and oxygen tubing should always be stored in a sanitary manner, and the oxygen tubing should be replaced if it touches the floor. The resident involved had a history of obstructive sleep apnea, respiratory failure with hypoxemia, and hypertension, and was documented to have severely impaired cognition. The care plan for the resident lacked specific instructions for cleaning and storing the CPAP mask. The facility's failure to adhere to its own policies placed the resident at increased risk of developing respiratory infections and complications. The deficiency was identified during an observation and was corroborated by staff interviews and a review of the resident's medical records.
Failure to Administer Medications as Ordered and Monitor Vital Signs
Penalty
Summary
The facility failed to administer an as-needed diuretic medication as ordered for a resident with severe cognitive impairment and multiple health conditions, including obstructive sleep apnea, respiratory failure, and hypertension. The resident's care plan required staff to administer medications as ordered and to monitor for weight gain, which would necessitate the administration of the diuretic. However, the facility's records showed that the diuretic was not administered on several occasions when the resident's weight indicated it was necessary. Observations also noted that the resident's CPAP mask and oxygen tubing were not properly stored, indicating a lack of adherence to care protocols. Another resident with a history of stroke, hemiplegia, hypertension, and dementia was prescribed metoprolol, a beta-blocker, with specific instructions to monitor blood pressure and pulse before administration. The facility's records lacked consistent evidence that these vital signs were monitored before giving the medication. Interviews with staff confirmed that the blood pressure should be documented before administering the medication, but this was not consistently done. The facility's policies required that all medications be administered as ordered and that residents be monitored for adverse drug reactions. Despite these policies, the facility failed to follow physician orders for both residents, leading to potential risks of unnecessary medication side effects or ineffective therapeutic regimens.
Failure to Maintain Communication with Hospice Services
Penalty
Summary
The facility failed to maintain ongoing communication with hospice services related to a resident's bi-weekly hospice visits. The resident, who had severe cognitive impairment and multiple medical conditions including COPD, dementia, dysphagia, repeated falls, and a pressure ulcer, was dependent on staff for various activities of daily living. Despite being on hospice care, the resident's care plan lacked essential information such as contact details for the hospice service, the services provided, and the frequency of hospice nursing staff visits. Additionally, the facility's electronic medical records did not contain scanned hospice communications showing the bi-weekly visits and the services provided during those visits. Interviews with facility staff revealed a lack of awareness and documentation regarding the hospice services provided to the resident. Licensed Nurse J and Administrative Nurse D were unsure about the location of hospice documentation and the specifics of the services, medications, and equipment provided by hospice. The facility had stopped using communication books, and the hospice documentation was not readily available in the care plan or the nursing office. This lack of communication and documentation placed the resident at risk for delayed services and uncommunicated care needs, as the facility did not collaborate effectively with hospice services to ensure comprehensive care.
Non-Functional Call Light System
Penalty
Summary
The facility failed to ensure a functional and fully operational call light system for each resident, placing them at risk for delayed care and decreased psychosocial well-being. Resident 212 reported that her call light had not worked since her admission, and she was instructed to yell for help if needed. An inspection confirmed the call light was non-functional. Similarly, Resident 6 reported her call light was not working, which was also confirmed upon inspection. Maintenance staff stated the system is checked weekly, but there was no clear protocol for immediate resolution if the call light could not be fixed right away. Licensed Nurse J and Certified Medication Aide M indicated that staff would notify maintenance and increase the frequency of checks on residents every 15 minutes if a call light was not functioning. Administrative Nurse D acknowledged issues with the new call light system and stated that staff were expected to notify the on-call supervisor and maintenance for any outages. The facility's Call Light policy required an operational electronic call system, and in case of malfunction, nursing staff were to initiate 15-minute resident checks. The facility failed to ensure operational call lights in two of the four hallways, affecting the residents' ability to summon assistance when needed.
Failure to Post Required Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the posted nursing hours included the required information and were posted in a prominent, readily accessible location for residents or visitors. The facility identified a census of 66 residents. Upon review of 18 months of posted nurse staffing information, it was found that the daily census was not included on the posted staff sheet. Additionally, the posted nursing staff information was located on the wall outside the assistant director of nursing's office under a folder, which required visitors and residents to flip the folder up to see the information. Administrative Staff A confirmed this setup and acknowledged that the posted staffing was covered. The facility was also unable to provide a policy related to the posted nursing information.
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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) |
|---|---|---|---|---|
| Center At Waterfront Llc | 0.2 mi | ★★★★★ | 19 | 0 |
| Avita Health And Rehab At Reeds Cove | 1.8 mi | ★★★★★ | 11 | 0 |
| Great Plains Post Acute | 2.4 mi | ★★★★★ | 17 | 0 |
| Larksfield Place | 2.8 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Wichita | 3.1 mi | ★★★★★ | 0 | 0 |
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