Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Rolling Hills Health And Rehab during CMS and state inspections, most recent first.
The facility failed to ensure a safe environment for residents, leading to multiple deficiencies. A resident was not provided with the correct slide board for transfers, risking falls. Another resident faced entrapment risks due to unsafe bedrails, while hazardous materials were found in a cognitively impaired resident's room. Additionally, a resident smoked without a required apron, violating their care plan. These issues placed residents at risk for preventable accidents and injuries.
A facility failed to update a resident's care plan after the discontinuation of hydrochlorothiazide (HCTZ), a diuretic medication. Despite hospital discharge instructions to stop HCTZ and lisinopril, the resident continued to receive these medications. The care plan still included directives for administering HCTZ, placing the resident at risk for inappropriate care due to uncommunicated care needs. The interdisciplinary team did not revise the care plan, contrary to facility policy.
A facility failed to maintain ongoing communication with a dialysis provider for a resident with stage four CKD, risking health complications. The resident required dialysis thrice weekly, but the facility's records lacked completed information from the dialysis center for over two months. Despite policy requirements for detailed communication, the facility did not receive necessary updates, relying instead on calls from the dialysis center for any changes.
A facility failed to obtain written informed consent for the use of side rails for a resident with dementia and other health conditions, placing her at risk for injury. The resident's family demanded the use of side rails despite the risks, and the facility documented verbal consent but did not secure a signed Risk versus Benefits form. Observations confirmed the presence of side rails, and the facility's policy required written consent for such restraints, which was not obtained.
A facility failed to ensure CNA staff had adequate competency in using a slide board for a resident with a history of cerebrovascular accident and hemiparesis. The resident, dependent on staff for transfers, was lowered to the ground during a transfer due to weakness. Observations showed CNAs struggled with finding a suitable gait belt and using the slide board correctly. The facility's competency policy required regular training, but the provided competencies lacked training for slide board transfers, placing the resident at risk for injury.
A facility failed to ensure proper oversight by the Consultant Pharmacist, leading to deficiencies in medication management for two residents. One resident received an antipsychotic medication without appropriate documentation or indication, while another resident's irregular blood pressure and pulse readings were not reported to the physician as required. These oversights placed the residents at risk for unnecessary medication and side effects.
A facility failed to notify a physician when a resident's blood pressure and pulse were outside the ordered parameters, despite instructions to do so. The resident, with atherosclerosis and impaired cognition, was on amiodarone, and the care plan required notifying the physician if the heart rate was below 60 BPM or DBP below 90. The clinical record showed these conditions occurred without physician notification, confirmed by an administrative nurse, placing the resident at risk for ineffective medication regimens.
A facility failed to ensure a resident did not receive antipsychotic medication without appropriate indication or required physician documentation. The resident, diagnosed with dementia and major depressive disorder, was given Seroquel for unspecified dementia with behavioral disturbances. The facility's policy required proper documentation and non-pharmacological interventions, which were not met, placing the resident at risk for unintended effects.
A resident with a complex medical history was rehospitalized after receiving medications that should have been discontinued upon their return to the facility. The medications, hydrochlorothiazide and lisinopril, were administered due to their presence on the MAR, despite discharge instructions to discontinue them. This error resulted in the resident experiencing low blood pressure and heart rate, necessitating ICU care.
The facility failed to properly prepare pureed diets for two residents, compromising the meals' nutritive value and palatability. Observations revealed that dietary staff did not use a recipe for pureeing meatloaf and initially omitted pureed bread rolls from the menu, contrary to facility policy. This placed the residents at risk for impaired nutrition.
Multiple Safety Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to multiple deficiencies. One resident, who had a history of falls and required assistance for mobility, was not provided with the correct type of slide board during transfers. Despite a previous staff-assisted fall, the facility did not address the risk adequately, and staff continued to use an inappropriate slide board, which posed a risk for further falls and injuries. Observations revealed that staff struggled to find a suitable gait belt and used a flat, wooden slide board that was not appropriate for the resident's needs. Another resident was at risk for entrapment due to large openings in the side rails of their bed. Despite the facility's awareness of the risk, the family insisted on using the quarter-rails, and the facility did not implement alternative safety measures. The facility's policy on the use of physical restraints, including bedrails, was not adequately followed, as there was no signed consent from the resident or responsible party, and the facility failed to explore less restrictive alternatives. Additionally, a resident with moderate cognitive impairment had hazardous materials, including hydrogen peroxide and medicated shampoos, stored openly in their room, contrary to safety protocols. The facility did not have a policy regarding accidents, and the items were only removed after being observed by staff. Furthermore, another resident who required a smoking apron as per their care plan was observed smoking without one, indicating a failure to adhere to the care plan and smoking policy. These deficiencies placed the residents at risk for preventable accidents and injuries.
Failure to Update Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to revise the care plan for Resident 40 after the discontinuation of hydrochlorothiazide (HCTZ), a diuretic medication. This oversight was identified during a review of the resident's electronic medical record, which documented multiple diagnoses including bradycardia, cerebrovascular accident, chronic kidney disease, hypertension, depression, hypotension, acute kidney failure, and diabetes mellitus. Despite the hospital discharge summary directing the discontinuation of HCTZ and lisinopril, the medication administration record showed that Resident 40 continued to receive these medications. The care plan, which should have been updated to reflect the discontinuation, still included directives for administering HCTZ and monitoring for adverse effects. The interdisciplinary team, responsible for care plan updates, did not remove the diuretic therapy care plan for HCTZ when the medication was discontinued. This failure to update the care plan placed Resident 40 at risk for inappropriate care due to uncommunicated care needs. The facility's policy on using care plans emphasizes the importance of updating care plans to reflect changes in a resident's condition, which was not adhered to in this case. The administrative nurse confirmed that the care plan should have been revised following the discontinuation of the medication.
Failure in Communication with Dialysis Provider
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis provider regarding a resident's dialysis treatments, which placed the resident at risk for complications and health decline. The resident, identified as having stage four chronic kidney disease, required dialysis three times a week. Despite this critical need, the facility's records revealed a lack of completed information from the dialysis center regarding the resident's treatment, monitoring, or orders over a period of more than two months. The facility's policy required detailed communication between the facility and the dialysis provider, including information on medication administration, new orders, lab results, vital signs, weights, and other critical health indicators. However, the facility did not receive the necessary communication sheets back from the dialysis center, and the administrative nurse confirmed that the facility relied on the dialysis center to call them if there were any changes or important information. This lack of communication and documentation was a direct violation of the facility's dialysis policy and placed the resident at risk for health complications.
Failure to Obtain Written Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to obtain written informed consent for the use of side rails for a resident, identified as R10, which placed her at risk for accident or injury due to uninformed choices regarding side rail use. R10 had a history of dementia, anxiety, hypertension, and chronic obstructive pulmonary disease, and was dependent on staff for toileting, mobility, and transfers. The facility's records indicated that R10 used side rails for mobility, but no alternatives to bed rails were attempted, and the family demanded their use despite the risks. The facility's documentation, including the Electronic Medical Record and the Care Plan, noted that side rail precautions were discussed with R10's family, and consent was obtained verbally. However, the Risk versus Benefits form, which outlined the potential risks associated with side rail use, lacked a signature from the resident or responsible party. The form was signed by two administrative nurses, but it only documented that the facility spoke to the responsible party and the physician via phone. Observations confirmed that R10's bed had quarter-rails on both sides, and the facility's policy required written consent for the use of restraints, including bed rails. The policy also mandated that restraints should only be used after other alternatives had been tried unsuccessfully and upon the written order of a physician. Despite these requirements, the facility did not obtain the necessary written informed consent, leading to the deficiency.
Inadequate CNA Competency in Slide Board Transfer
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) staff possessed adequate competency and skill for the use of a slide board for a resident, who was lowered to the ground during a slide board transfer. The resident, identified as R6, had a medical history that included cerebrovascular accident, hemiparesis/hemiplegia affecting the left side, muscle weakness, diabetes mellitus, hypertension, and obesity. The resident was dependent on staff for various activities, including transfers, and had a high risk for falls as documented in multiple assessments. The care plan for the resident directed staff to use a Beasy transfer board, gait belt, and have the right leg leading for transfers. If the resident was too weak, a Hoyer lift with two staff was to be used. However, during an incident, CNA M reported that while performing a two-person transfer with a gait belt and slide board, the resident became weak, and the CNA lowered the resident to the floor. The investigation noted that the care plan was followed, but the CNA was later educated to use the Hoyer lift if the resident experienced weakness. Observations revealed that CNA M and another CNA struggled to find a suitable gait belt for the resident and had difficulty using the slide board correctly. The slide board used lacked a circular seat, and the transfer was not performed correctly, as noted by an administrative nurse. The facility's competency policy required regular in-service training, but the competencies provided did not include training or observation for a transfer with the slide board. The facility failed to ensure that CNA staff had the necessary skills and competencies for the use of a slide board, placing the resident at risk for injury.
Pharmacist Oversight Deficiencies in Medication Management
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication or required physician documentation for a resident's use of an antipsychotic medication, Seroquel. The resident, who had diagnoses of dementia and major depressive disorder, was receiving Seroquel for an inappropriate diagnosis of anxiety, which was later changed to dementia with behavioral disturbances. However, the CP's monthly medication reviews did not consistently address the need for continued use of Seroquel, despite previous recommendations to evaluate its use due to potential metabolic side effects. Another resident's care was compromised due to the facility's failure to ensure the CP identified and reported irregularities in blood pressure and pulse monitoring. The resident, diagnosed with atherosclerosis, was receiving amiodarone, with specific instructions to notify the physician if the heart rate or blood pressure fell below certain parameters. The clinical records showed that these parameters were not met on several occasions, yet there was no documentation of physician notification, and the CP's regimen reviews did not address these irregularities. The facility's Pharmacist Services Overview policy required collaboration with the facility, Medical Director, and Attending Physician to provide timely and appropriate pharmacy services. However, the CP did not fulfill this role effectively, as evidenced by the failure to report the unapproved indication for the antipsychotic medication and the lack of monitoring for the resident's blood pressure and pulse. These deficiencies placed the residents at risk for unnecessary medication and related side effects.
Failure to Notify Physician of Out-of-Parameter Vital Signs
Penalty
Summary
The facility failed to notify the physician when a resident's blood pressure and pulse were outside the physician-ordered parameters, which is a deficiency in ensuring the resident's drug regimen was free from unnecessary drugs. The resident, who had a diagnosis of atherosclerosis of the coronary arteries and severely impaired cognition, was prescribed amiodarone to manage an irregular heartbeat. The care plan and physician's order instructed staff to hold the medication and notify the physician if the resident's heart rate was less than 60 beats per minute (BPM) or if the diastolic blood pressure (DBP) was less than 90. Despite these instructions, the resident's clinical record showed that the DBP was less than 90 daily from September 12 to November 13, and the pulse was less than 60 BPM on several specific dates, without documentation that the physician was notified. An administrative nurse confirmed the findings and acknowledged an error in entering the order, but emphasized that staff should have followed the physician's order. This oversight placed the resident at risk for ineffective medication regimens and unnecessary medication side effects.
Failure to Document Appropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, did not receive antipsychotic medication without an appropriate indication or the required physician documentation for its use. R37, who had diagnoses of dementia and major depressive disorder, was receiving Seroquel, an antipsychotic medication, for unspecified dementia with behavioral disturbances. However, the resident's electronic medical record lacked a documented physician rationale that included unsuccessful attempts for non-pharmacological symptom management and an assessment of the risk versus benefits for the continued use of Seroquel. Observations and interviews revealed that the facility's administrative nurse verified the resident received Seroquel for dementia with behavioral disturbances, which she believed was an appropriate indication. However, the facility's policy required that psychotropic medications be used only when necessary and with proper documentation, including non-pharmacological interventions attempted and the resident's quality of life being negatively impacted by the non-use of the medications. The facility's failure to adhere to these requirements placed R37 at risk for unintended effects related to psychotropic medications.
Medication Error Leads to Resident Rehospitalization
Penalty
Summary
The facility failed to prevent a significant medication error for a resident, identified as R40, who received medications that should have been discontinued. R40 had a complex medical history, including bradycardia, cerebrovascular accident, chronic kidney disease, hypertension, depression, hypotension, acute kidney failure, and diabetes mellitus. Upon discharge from the hospital, the physician ordered the discontinuation of hydrochlorothiazide (HCTZ) and lisinopril, but these medications were not removed from the resident's Medication Administration Record (MAR). On the morning following R40's return to the facility, a Certified Medication Aide (CMA) administered the HCTZ and lisinopril as they were still active on the MAR. This administration occurred despite the discharge instructions to discontinue these medications. Later that day, R40 exhibited symptoms of low blood pressure and a low heart rate, leading to rehospitalization in the intensive care unit (ICU) to rule out a cerebrovascular accident and address the low heart rate and blood pressure. The facility's policy on managing medication errors was not followed, as the medications were not discontinued from the MAR, and the error was not immediately identified. The administrative staff and nurses involved did not verify the discontinuation of the medications upon the resident's readmission, leading to the administration of the incorrect medications and subsequent adverse effects on R40's health.
Deficiency in Pureed Diet Preparation
Penalty
Summary
The facility failed to correctly prepare a pureed diet for two residents, which compromised the nutritive value and palatability of the meals. During observations, it was noted that the dietary staff prepared pureed vegetables and meatloaf without following a recipe for the meatloaf, which is against the facility's policy. The vegetables were blended with food thickener and leftover vegetable juice to achieve the correct consistency, while the meatloaf was blended with ketchup. However, the dietary staff did not prepare the bread roll in a pureed form initially, which was part of the menu for residents on a pureed diet. The facility's policy, dated October 2024, mandates that meals should conserve value, flavor, and appearance, and be served at a safe and appetizing temperature. However, the policy lacked specific guidelines for preparing pureed diets, leading to the deficiency. The dietary staff's failure to use a recipe for the meatloaf and to initially provide pureed bread rolls resulted in meals that did not meet the required standards, placing the affected residents at risk for impaired nutrition.
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Family Health & Rehabilitation Center | 0.6 mi | ★★★★★ | 7 | 0 |
| Sandpiper Healthcare & Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Wichita Presbyterian Manor | 4.1 mi | ★★★★★ | 0 | 0 |
| Lakepoint Wichita, Llc | 4.3 mi | ★★★★★ | 0 | 0 |
| Ascension Living Via Christi Village Mclean | 4.8 mi | ★★★★★ | 14 | 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.