Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Sanitary food storage and kitchen sanitation deficiencies: Surveyors observed sticky, dirty kitchen floors with heavy dirt buildup around work area legs, an undated and unlabeled cup of pudding in a refrigerator, and seven bags of chicken that were also undated and unlabeled. The dishwasher temperature log was missing multiple days of entries, and Dietary Staff BB stated the floors needed deep cleaning and that the chicken brought in by a family member should have been dated before refrigeration.
Missing informed declination for flu and pneumococcal vaccines: The facility’s EMR lacked evidence that four residents or their representatives received vaccine education, including risks versus benefits, or signed informed declinations after refusing influenza and pneumococcal immunizations. The Immunizations tab only showed the vaccines were offered and refused, while the IP stated the facility kept a log of refusals but did not obtain signed declinations.
Missing Informed Declinations for COVID-19 Vaccine Refusals: The facility failed to obtain signed informed declinations for COVID-19 vaccine refusals for four residents. Their EMRs showed the vaccine was offered and refused, but no signed refusal was present. The IP stated the facility kept a log of refusals instead of obtaining resident or representative signatures, while an admin nurse stated a signed consent or declination should be documented when the vaccine is declined.
Incorrect Medicare ABN Form Provided: The facility gave two residents the wrong Medicare notice form for skilled therapy services. Staff used CMS-R-131 instead of the SNF ABN CMS 10055, and the form did not include an estimated cost for continued services. Social Service staff said they had been told to use that form and did not realize it was incorrect.
A resident with dementia, depression, anxiety, and severely impaired cognition received Risperdal for behaviors, but the record lacked physician documentation of the risk-versus-benefit rationale for this non-approved use. The care record showed psychotropic use, agitation, rejection of care, and constant ambulation, while staff stated nurses, department heads, and the NP were responsible for ensuring the indication and risk-benefit discussion were documented.
Failure to Provide Required Transfer and Bed Hold Notifications: The facility did not provide a resident or representative with the bed hold policy, written transfer notice, or ombudsman notification when a resident was sent to the hospital. For another resident, the Notice of Transfer to Hospital form documented the transfer and phone notification to the RP, but it was not given to the representative and did not include appeal rights or ombudsman contact information. Social Services stated transfer notices were sent with residents and ombudsman notifications were sent monthly, and that one resident’s transfer had no bed hold form, transfer notice, or ombudsman notification because the family verbally agreed.
Failure to Implement Fall Prevention Interventions: Two residents had documented fall risks and care plan interventions, but staff did not consistently carry them out. One resident with hemiparesis and limited mobility had repeated falls during assisted transfers when staff were not fully ready or did not maintain safe transfer setup, and staff later reported uncertainty about the resident’s fall interventions. Another resident with CVA-related weakness and cognitive communication deficit was observed without ordered wheelchair safety devices in place, and staff stated they were unaware of the Dycem and brake extender interventions.
Failure to coordinate hospice services in the care plan for a resident with severe cognitive impairment, hemiparesis, pain, and adult failure to thrive. The resident was on hospice and fully dependent for ADLs, but the care plan only listed general comfort measures and did not document the frequency or type of hospice visits, hospice-provided supplies or equipment, or medications covered by hospice. An admin nurse confirmed the missing hospice details in the care plan.
Infection control practices were not followed during wound care and respiratory equipment storage. An RN consultant performed wound care on a resident with multiple wounds but did not always perform hand hygiene or change gloves between wound sites, including moving from a leg wound to a coccyx wound. In addition, a resident's nasal cannula, nebulizer mask, and another resident's CPAP mask were observed lying uncovered on beds or bedside tables instead of being stored in clean bags when not in use.
Incomplete and inaccurate PBJ staffing submission. CMS PBJ reports for multiple quarters showed excessively low weekend staffing even though the facility schedule reflected adequate weekend coverage. An admin staff member said timesheets and payroll forms were compared and sent to corporate for submission, but another admin staff member stated that administrative staff had been mistakenly reported as hands-on staff during the week and then not counted on weekends.
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.
Sanitary food storage and kitchen sanitation deficiencies
Penalty
Summary
The facility failed to follow sanitary dietary standards related to food storage, kitchen cleanliness, and dishwasher temperature monitoring. During observation on 06/22/2026 at 07:42 AM, the kitchen floors were observed to be sticky and dirty, with thick dark dirt around all standing work area legs. In the single refrigerator, there was a cup of pudding with whipped topping that was undated and unlabeled. In the two-door refrigerator, there were seven small bags of chicken in a steam table pan that were also unlabeled and undated. The dishwasher temperature log was missing recordings for 06/19/2026, 06/20/2026, 06/21/2026, and 06/22/2026. During interview at 08:00 AM, Dietary Staff BB stated the floors needed deep cleaning and that the kitchen floors were deep cleaned twice a year, while staff mopped the floor every night. He stated the chicken had been brought in by a family member and should have been dated before being placed in the refrigerator. He also stated he would dispose of the undated and unlabeled pudding, and that dishwasher temperatures were to be taken daily by the dishwasher. The facility’s Food Brought by Family or Visitors policy required perishable foods to be stored in re-sealable containers with tightly fitting lids and labeled with the resident’s name, item, and use-by date, and the Food Safety Requirements policy stated foods should be received and stored in a manner that complies with safe food handling practices.
Missing Informed Declination for Flu and Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and provide, or obtain informed declination for, the influenza and pneumococcal vaccinations for Resident 1, Resident 5, Resident 49, and Resident 62, or their representatives. The Electronic Medical Record for these residents lacked evidence of an informed declination for either vaccination, and the Immunizations tab only showed that the vaccines had been offered but refused by the residents. When requested, the facility could not provide documentation showing that vaccination information, including risks versus benefits, had been given to Resident 1, Resident 5, Resident 49, and Resident 62, and it could not provide documentation of informed declination. The Infection Preventionist stated that the facility offered influenza and pneumococcal vaccinations each fall and kept a log of who received or refused them, but did not have residents or representatives sign a consent to decline. An Administrative Nurse stated that a consent should be signed by the resident or representative when vaccinations were declined so there would be a record of the declination. The facility policy stated residents would be offered vaccinations per CDC and CMS guidelines, provided education on benefits and potential side effects before receiving them, and that refusals would be documented in the medical record.
Missing Informed Declinations for COVID-19 Vaccine Refusals
Penalty
Summary
The facility failed to obtain an informed declination for the COVID-19 vaccination for four residents, identified in the record as R1, R5, R49, and R62, or their representatives. Review of each resident’s EMR showed the Immunizations tab documented that the COVID-19 vaccine had been offered in June 2026 and refused by the resident, but there was no evidence of a signed informed declination in the record for any of the four residents. During interview on 06/24/2026, the Infection Preventionist stated that COVID vaccinations were offered to residents and administered if accepted, but the facility did not have residents or their representatives sign any consent or informed declination when the vaccine was declined; instead, a log was kept of who received or refused the vaccine each year. An Administrative Nurse stated that a consent or declination should be signed by the resident or representative when vaccinations were declined so there would be a record of the refusal. The facility’s written policy stated residents would be offered vaccinations, provided education on benefits and side effects, and that refusals would be documented in the medical record.
Incorrect Medicare ABN Form Provided
Penalty
Summary
The facility failed to provide the correct CMS Form 10055, Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), for two residents, R34 and R55. Instead of the SNF ABN, staff provided CMS-R-131 forms for the last covered days of 02/10/2026 for R34 and 06/02/2026 for R55. The form used informed beneficiaries that Medicare may not pay for future skilled therapy, but it did not provide an estimated cost to continue services. On 06/23/2026, Social Service X stated the form provided was what she had been told to use and did not realize it was incorrect. On 06/24/2026, Administrative Nurse D stated they would make sure to get the right form to use moving forward. The facility policy dated July 2025 stated that a Medicare beneficiary had the right to have Medicare determine whether skilled services would be covered and that the SNF ABN CMS 10055 informed residents of potential non-coverage and financial liability if services were not covered by Medicare.
Unjustified Antipsychotic Use Without Documented Risk-Benefit Review
Penalty
Summary
The facility failed to ensure an appropriate indication and documented physician rationale for the continued use of Risperdal, an antipsychotic medication, for R62. R62’s EMR documented diagnoses of anxiety, major depressive disorder, dementia, and need for assistance with personal care. The admission MDS showed a BIMS score of 6, indicating severely impaired cognition, and also documented use of an antipsychotic and an antidepressant during the observation period. The Psychotropic Drug Use CAA stated R62 triggered for antipsychotic and antidepressant use related to dementia, behaviors, and depression, and noted the resident had recently been re-admitted from a behavioral hospital. R62’s care plan documented agitation, anxiety, restlessness, rejection of care, and constant ambulation related to cognitive impairment and dementia, and a BBW plan noted the increased mortality warning for antipsychotic use in elderly patients with dementia-related psychosis. The physician order in the EMR showed Risperdal 1.5 mg by mouth twice daily for behaviors. Review of the clinical record lacked physician documentation of risk versus benefit for the antipsychotic’s non-approved use in a resident with dementia. Facility staff stated that nurses or department heads were responsible for discussing the correct indication with the physician, that the nurse practitioner wrote psychotropic orders, and that floor nurses and department heads were responsible for ensuring the risk versus benefit was understood and signed by the physician.
Failure to Provide Required Transfer and Bed Hold Notifications
Penalty
Summary
The facility failed to provide Resident 5 or the resident’s representative with a copy of the bed hold policy, written notification of transfer, and notification to the ombudsman when the resident was transferred to the hospital. Resident 5’s EMR showed an unplanned discharge MDS for transfer to an acute hospital with a return anticipated, followed by an entry MDS documenting reentry to the facility from an acute setting. The record lacked documentation that the bed hold information, transfer notice, or ombudsman notification had been provided for the hospital transfer, and the facility was unable to produce those documents when requested. The facility also failed to ensure the Notice of Transfer to Hospital form for Resident 9 included required appeal rights and ombudsman information. Resident 9’s EMR showed an unplanned discharge to an acute hospital with a return anticipated, and the facility had a bed hold, transfer notice, and ombudsman notification for that hospitalization. The transfer form documented when, where, and why the resident was transferred and that the responsible party was notified by phone, but the form was not provided to the representative and did not include information about the right to appeal or ombudsman contact information. Social Services stated that transfer notices were sent with residents to the hospital and that ombudsman notifications were sent at the end of each month, and also stated that for Resident 7 no bed hold form, transfer notice form, or ombudsman notification was completed because the family requested hospital transfer and verbally agreed to the bed hold.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement effective person-centered fall prevention interventions for two residents. One resident had diagnoses including hemiparesis/hemiplegia, reduced mobility, muscle weakness, and absence of the right upper limb, and was documented as needing substantial staff assistance for hygiene, mobility, transfers, and dressing. Although the resident had a high fall risk assessment earlier in the year and a care plan that included multiple transfer and safety interventions, the resident experienced repeated falls during staff-assisted transfers when he attempted to self-transfer before staff were ready. The fall investigations documented three separate events in which staff were assisting the resident with transfers using a slide board or wheelchair-to-bed transfer. In each event, staff briefly turned away, removed wheelchair parts before another staff member was present, or positioned the resident too close to the bed edge, and the resident attempted to transfer himself and fell or was lowered to the floor. One fall caused an abrasion to the left elbow. During later observation, staff members stated they were using a Hoyer lift for transfers, but one CNA was unsure of the resident’s fall interventions and a new CNA was unaware of them. A nurse stated there should always be two staff members in the room for transfers. A second resident had diagnoses including HTN, hemiparesis/hemiplegia following cerebral infarction, and cognitive communication deficit, and the care area assessment triggered for falls due to prior falls, high-risk medication, cerebral infarction, generalized muscle weakness, and need for assistance with personal care. The resident’s care plan included a brake extender with colored tape, Dycem in the wheelchair, anti-rollbacks, and education not to self-transfer. However, during observation the resident did not have the Dycem placed under or on top of the wheelchair cushion and did not have the brake extender with colored tape on the wheelchair. Staff interviewed during the observation stated they were not aware of those interventions being in place, and one CNA said she would need to get the Dycem and have maintenance help with the brake extender.
Failure to Coordinate Hospice Services in Care Plan
Penalty
Summary
The facility failed to collaborate the care and services it provided with the hospice services provided for a resident with senile degeneration of the brain, hemiparesis/hemiplegia, pain, and adult failure to thrive. The resident's quarterly MDS documented severely impaired cognition, total dependence on staff for all ADLs, and receipt of hospice services. The resident's care plan included interventions such as giving comfort medications before activities, anticipating weight changes due to terminal diagnosis, assisting with ADL support, following practitioner and hospice orders for symptom control, and keeping the resident comfortable to the extent possible. The care plan did not include information about the hospice services being provided, including the frequency and type of hospice visits, the supplies and medical equipment provided by hospice, or the medications covered by hospice. The resident had been admitted to hospice care for senile degeneration of the brain, and on observation the resident was lying in bed with eyes closed. An administrative nurse confirmed that the visits, supplies, and medications provided by hospice were not documented in the resident's care plan and stated she had recently audited hospice residents' care plans but missed this one.
Infection Control Lapses During Wound Care and Respiratory Supply Storage
Penalty
Summary
The facility failed to implement adequate infection control practices during wound care for R4. On 06/23/2026 at 08:55 AM, Consultant GG and her assistant entered R4's room and began wound care while LN G was present. LN G had prepared the top of a table with a barrier and wound care supplies. During the procedure, hand hygiene was performed at some points, but Consultant GG applied clean gloves without performing hand hygiene before continuing care, and later used the same gloves while moving from cleaning one wound site to another. After cleaning R4's right leg wound and applying a new dressing, Consultant GG did not change gloves or sanitize her hands before beginning care to the coccyx wound. The wound care involved multiple sites on R4, including the right leg, left posterior leg, and coccyx. Consultant GG wiped the right leg wound with gauze moistened with wound cleanser, discarded the gauze, removed gloves, and then reapplied clean gloves to place calcium alginate and a new dressing. Later, without changing gloves, she placed calcium alginate in the left posterior leg wound bed and applied a new dressing. She then used another gauze pad sprayed with wound cleanser to wipe the coccyx wound. Consultant GG later stated that she should have changed her gloves and sanitized her hands after cleaning the leg wound and again before beginning the coccyx wound. The facility also failed to store respiratory equipment in a sanitary manner. During a 06/22/2026 walk-through, R20's nasal cannula was lying on the bed and the nebulizer mask was uncovered on the bedside table. R68's CPAP mask was lying on the bottom of the bed with the resident's feet on it. LN G and Administrative Nurse D stated that oxygen tubing, CPAP masks, and nebulizer masks should be stored in clean storage bags when not in use. The facility's nebulizer policy stated that cleaned equipment should be stored in a plastic bag with the resident's name and date, while the CPAP/BiPAP policy lacked guidance on mask storage.
Incomplete and inaccurate PBJ staffing submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through the Payroll Based Journal (PBJ) as required. CMS PBJ reports for FY 2025 Quarter 3 and 4 and FY 2026 Quarter 1 and 2 showed excessively low weekend staffing, even though review of the facility staffing schedule showed adequate weekend staffing for those quarters. During interview, Administrative Staff B stated she compared timesheets and payroll forms and sent them to the corporate office, where the payroll specialist reviewed them before submission to CMS, and she did not understand why weekend staffing appeared low because the same number of staff worked on weekends as during the week. Administrative Staff A later stated that administrative staff had been accidentally reported as hands-on staff during the week and then were not counted on weekends. The facility’s PBJ policy stated that staffing data, including community, agency, and contract staff, would be submitted electronically to CMS based on payroll and other verifiable and auditable data.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 293 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wichita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| 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 | ★★★★★ | 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 October 2026) and official state health department websites.