Above 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 Sandpiper Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to meet professional standards for food service safety, as observed in their kitchen and walk-in freezer. Uncovered, unlabeled, and undated food items, including ice cream and shredded carrots, were found, along with dirty flour and sugar containers and light fixtures with bugs and debris. The Dietary Manager confirmed these issues, which violated the facility's Food Storage Policy and placed 73 residents at risk for foodborne illness.
A facility failed to date insulin pens for four residents and did not remove expired stock medications, including Senna Plus and Thiamin/vitamin B. An LPN confirmed the oversight, which violated the facility's Medication Storage policy requiring proper dating and disposal of medications.
The facility failed to maintain a sanitary environment in the main dining room, where numerous reddish-brown dried liquid stains were observed on the wall near the kitchen entrance. This condition was confirmed by an administrative nurse, who noted that both housekeeping and dietary staff were responsible for cleaning the area. The stains were in the location where a serving table had been moved, and despite documented daily cleaning tasks, the wall remained uncleaned, posing a risk to residents' health and well-being.
The facility failed to provide timely written notification of transfers for two residents, R25 and R6, to the hospital, as required by policy. R25, with a complex medical history, and R6, with multiple diagnoses, were transferred without written notice or notification to the LTCO. Staff confirmed the oversight, unaware of the requirement for hospital transfers.
The facility failed to provide two residents with written information about the bed hold policy when they were transferred to the hospital. This oversight placed the residents at risk of not being able to return to their original rooms. Staff confirmed the lack of documentation and awareness of the policy.
A resident at risk for pressure ulcers developed two facility-acquired pressure injuries due to the facility's failure to implement timely preventive measures. Despite being identified as at risk upon admission, the care plan lacked specific interventions until after the first ulcer was discovered. The resident developed additional pressure injuries, highlighting inadequate preventive care.
A resident with multiple health conditions and a history of falls was not transferred using a Hoyer lift as required, leading to a fall incident. The care plan did not initially include the need for a Hoyer lift, and staff were unsure of the correct transfer method, resulting in a deficiency in providing a safe environment.
A resident with multiple health conditions, including neuromuscular dysfunction of the bladder, received inadequate catheter care, placing them at risk for urinary tract infections. Observations showed improper management of the catheter collection bag, which was touching the floor and lacked a securement device. Staff failed to follow infection control protocols, such as wearing gowns and gloves, and there was no EBP signage in the resident's room, as confirmed by administrative nurses.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices, leading to increased infection risk. Staff did not consistently wear the required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities, despite facility policy and posted instructions. Observations and interviews confirmed these deficiencies.
The facility failed to store, prepare, and serve food under sanitary conditions, with issues including improper hair restraints, lack of dish machine temperature documentation, undated and uncovered food items, and staff not following recipes or hygiene protocols.
A resident with dementia and moderate cognitive impairment did not receive the physician-ordered gluten-free diet. The dietary staff initially served non-gluten-free chicken parmesan and later replaced it with roast beef without gluten-free gravy, deviating from the prescribed menu. The facility's policies on standardized recipes and therapeutic diets were not followed.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen and walk-in freezer. During an inspection, it was found that there were fourteen uncovered, unlabeled, and undated styrofoam bowls of chocolate ice cream on a tray, a three-gallon container of chocolate ice cream with the lid partially open, and an uncovered, unlabeled, opened, and unsealed plastic bag of shredded carrots. Additionally, an unlabeled, undated opened, and unsealed plastic bag of breaded fish was also found. These findings were verified by the Dietary Manager (DM), who acknowledged that the ice cream bowls were old and that staff should have labeled, dated, and sealed the items before placing them in the freezer. Further observations in the kitchen revealed that the flour and sugar containers had numerous different-sized blackish-gray areas around the outside, and the lids had a greasy gray substance with white particles. Additionally, fourteen fluorescent light fixtures contained bugs and debris inside the covers. The DM confirmed these findings and was unsure if maintenance had cleaned the ceiling lights. The facility's Food Storage Policy, which was undated, required all food items to be labeled with the name of the food and the date by which it should be consumed or discarded. The policy also stated that leftover contents of cans and prepared food should be stored in covered, labeled, and dated containers in refrigerators and freezers. The facility's failure to comply with these standards placed 73 residents at risk for foodborne illness.
Failure to Date Insulin Pens and Remove Expired Medications
Penalty
Summary
The facility failed to adequately store and label biologicals, specifically insulin pens, and expired stock medications. During an observation of the 300-hall medication cart, it was found that insulin pens for four residents were not dated when opened, nor did they have a discard date. This oversight involved long-acting insulin pens for residents who required them to manage high blood glucose levels. Additionally, four bottles of stock medications, including Senna Plus, Thiamin/vitamin B, Bisacodyl, and Allergy relief, were found to be expired and had not been removed or disposed of as required. A Licensed Nurse verified the expiration dates and the lack of dating on the insulin pens, acknowledging that staff were supposed to date the pens upon opening. The facility's Medication Storage policy indicated that all medications should be stored according to the manufacturer's recommendations and that the consultant pharmacist should routinely inspect medication rooms for discontinued and outdated drugs. The failure to date insulin pens and remove expired medications placed residents at risk of receiving expired or ineffective treatments.
Unsanitary Conditions in Main Dining Room
Penalty
Summary
The facility, with a census of 74 residents and a sample of 18 residents, failed to maintain a sanitary environment in one of its three dining rooms, specifically the main dining room. On November 5, 2024, an observation revealed numerous reddish-brown dried liquid stains on the wall to the right of the kitchen entrance door, spanning approximately eight feet long and three feet high. This unsanitary condition was confirmed by Administrative Nurse D on November 6, 2024, who acknowledged that both housekeeping and dietary staff were responsible for cleaning the area. The stains were located in the area where a serving table had recently been moved to the kitchen. The facility's Environmental Services Checklist documented daily cleaning tasks, yet the wall remained uncleaned, placing residents who dined in the main dining room at risk for impaired health and well-being.
Failure to Notify Residents and LTCO of Transfers
Penalty
Summary
The facility failed to provide timely written notification of facility-initiated transfers for two residents, R25 and R6, as required by their policy. R25, who had a complex medical history including congestive heart failure, MRSA, and osteomyelitis, was transferred to the hospital after calling 911 due to pain. The facility did not provide R25 with a written notice of the transfer, nor did they notify the State Long Term Care Ombudsman (LTCO) as required. This oversight was confirmed by Administrative Staff B, who stated that only residents discharged home were included in the monthly report to the LTCO. Similarly, R6, who had diagnoses including diabetes mellitus, schizoaffective disorder, and legal blindness, was transferred to the hospital for pain management. The facility again failed to provide a written notice of transfer to R6 and did not notify the LTCO. Administrative Staff E and Administrative Nurse D confirmed the lack of written notice and were unaware of the requirement to notify the LTCO for hospital transfers. The facility's Transfer and Discharge policy mandates that residents and their representatives receive a notice of transfer, and the LTCO be notified of such transfers. However, the facility did not adhere to this policy for emergency transfers to the hospital, resulting in a deficiency that placed both residents at risk of uninformed care choices and impaired rights.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide two residents, R25 and R6, with written information regarding the facility's bed hold policy when they were transferred to the hospital. This deficiency was identified during a survey that included a sample of 18 residents out of a census of 74. The lack of documentation and communication regarding the bed hold policy placed these residents at risk of not being permitted to return to the facility and resume residence in their original rooms. Resident R25, who had a history of congestive heart failure, MRSA, osteomyelitis, and other serious conditions, was transferred to the hospital due to worsening discitis and an abscess. Despite the facility's policy requiring a bed hold notice to be provided at the time of transfer, R25's clinical record lacked evidence of such documentation. Administrative staff confirmed that the notice was not provided, which was a violation of the facility's own policy. Similarly, Resident R6, who had diagnoses including diabetes mellitus, schizoaffective disorder, and legal blindness, was admitted to the hospital for pain. The facility again failed to provide a bed hold notice, as confirmed by both the resident and staff members. The absence of documentation and awareness among staff about the bed hold policy further highlighted the facility's failure to adhere to its procedures, thereby placing R6 at risk of not being able to return to the facility and resume residence in the same room.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to initiate timely interventions to prevent the development of pressure ulcers for Resident 128, who developed two facility-acquired pressure injuries. Upon admission, Resident 128 was identified as being at risk for pressure ulcers due to factors such as impaired cognition, functional mobility impairment, and incontinence. Despite these risk factors, the care plan lacked specific interventions to prevent pressure ulcers until after the first ulcer was identified on August 9, 2024. Prior to this, the resident's skin was noted to be intact, and no skin concerns were documented on August 8, 2024. On August 9, 2024, a wound was discovered on Resident 128's left heel, and the wound nurse was notified. The initial wound care note documented a pressure ulcer on the left heel with specific measurements and characteristics, including eschar and serous drainage. Interventions such as offloading the heels and nutritional supplements were ordered. However, the interdisciplinary team noted that the resident was not wearing heel protectors while in bed, which contributed to the development of the wound. The care plan was subsequently updated to include heel protectors and other pressure relief measures. Despite these interventions, Resident 128 developed additional pressure injuries, including a new pressure ulcer on the right heel and a deep tissue injury on the left plantar foot. Observations revealed that the resident's feet were hitting the footboard, which was later removed. The facility's failure to implement timely and adequate preventive measures for pressure ulcer risk factors resulted in the development of multiple pressure injuries for Resident 128, placing him at risk for further complications.
Failure to Use Hoyer Lift for Resident Transfer
Penalty
Summary
The facility failed to provide an environment free from accident hazards when staff did not use the Hoyer lift for a safe transfer of Resident 130, who required it according to her admission note. Resident 130 was admitted with multiple diagnoses, including diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, anemia, osteoarthritis, COVID-19 with acute and chronic respiratory failure, sepsis, and neuromuscular dysfunction of the bladder. Her baseline activities of daily living care plan indicated she needed assistance due to weakness from a recent hospitalization and had safety concerns related to a history of falls or risk for falls. Despite this, the care plan did not initially include the requirement for a Hoyer lift, which was only documented after a fall incident. On a specific date, a progress note documented a witnessed fall when staff attempted to transfer Resident 130 from her wheelchair to her recliner without using the Hoyer lift. The resident's legs buckled, and she had to be lowered to the floor, indicating she was unable to stand or participate fully in transfers. Observations and interviews revealed that staff were unsure of the correct transfer method for Resident 130, and the care plan was still being developed. The facility's Fall Prevention Program required that each resident be assessed for fall risks and receive appropriate care, but this was not adequately implemented for Resident 130, leading to the deficiency.
Inadequate Catheter Care for a Resident
Penalty
Summary
The facility failed to provide adequate catheter care for Resident 130, who was at risk for urinary tract infection and other catheter-related complications. Resident 130 had multiple diagnoses, including diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, anemia, osteoarthritis, COVID-19 with acute and chronic respiratory failure, sepsis, and neuromuscular dysfunction of the bladder. Observations revealed that the urinary catheter collection bag was improperly managed, with the bag touching the floor and lacking a securement device. Staff did not follow proper infection control protocols, such as wearing gowns and gloves when handling the catheter. Certified Medication Aide R and Certified Nurse Aide O were observed not adhering to the facility's catheter care policy. CMA R did not wear a gown while emptying the catheter bag, and CNA O handled the catheter bag and tubing without gloves or a gown. Additionally, there was no evidence-based practice (EBP) signage in the resident's room, which was confirmed by Administrative Nurses F and D. The facility's catheter care policy required catheter care every shift, covered drainage bags, and proper documentation, which were not followed, leading to the deficiency.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control protocols for Enhanced Barrier Precautions (EBP) for two residents, one with a peripherally inserted central catheter (PICC) and another with a urinary catheter. Observations revealed that a licensed nurse entered the room of the resident with the PICC line and donned only gloves, despite signage indicating the need for both gown and gloves. Similarly, a certified medication aide did not wear a gown while handling the urinary catheter of the second resident, and the catheter bag was observed on the floor, which was verified as inappropriate by a certified nurse aide. Interviews with administrative nurses confirmed that EBP should have been initiated for the resident with the catheter upon admission, and that staff should have worn the appropriate PPE when providing care. The facility's policy on EBP, dated August 2024, required the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices. The lack of adherence to these precautions placed the residents at increased risk for infection.
Failure to Maintain Sanitary Conditions in Food Storage, Preparation, and Serving
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions for the residents. Observations revealed multiple issues in the kitchen area, including dietary staff not wearing proper hair restraints, such as beard covers and hats that fully cover hair. Additionally, the dish machine log lacked documentation of wash and rinse temperatures since 04/02/24, and various food items in the walk-in refrigerator were either undated, uncovered, or past their expiration dates. For example, a bag of deli meat lacked a date, and several pitchers of juice were past their seven-day usage timeframe. Uncovered trays of muffins and brownies were also noted, and dietary staff were observed handling food without following proper hygiene protocols, such as changing gloves after touching surfaces and before handling food again. Further observations indicated that dietary staff were not following recipes when preparing meals, leading to inconsistencies in food preparation. For instance, pureed chicken parmesan, buttered peas, and buttered noodles were prepared without using recipes or proper measurements. The food temperature log also lacked documentation of measured food temperatures from the lunch meal, and staff were observed not recording temperatures at the time they were measured. Additionally, food items on the steam table were not consistently maintained at safe temperatures, with mechanical soft chicken being removed to be reheated after being found at 123 degrees Fahrenheit. Interviews with dietary staff revealed a lack of adherence to facility policies regarding food safety and sanitation. Staff admitted to not checking dish machine temperatures as required and not following recipes for meal preparation. The facility's policies on food preparation, handling, and storage were not being followed, leading to multiple instances of unsanitary conditions and potential food safety hazards. The facility's failure to maintain proper food storage, preparation, and serving practices compromised the sanitary conditions necessary for resident safety.
Failure to Follow Gluten-Free Diet for Resident
Penalty
Summary
The facility failed to follow the physician-ordered gluten-free diet for a resident diagnosed with dementia and moderate cognitive impairment. Despite the resident's electronic medical record indicating an allergy to gluten and a physician's order for a gluten-free diet, the dietary staff did not adhere to the prescribed menu. On the observed date, the resident was initially served chicken parmesan prepared with flour, which is not gluten-free. Upon realizing the mistake, the dietary staff replaced the chicken with roast beef but almost added non-gluten-free gravy, which was prevented by the surveyor's intervention. The resident was ultimately served roast beef, buttered peas, and potato chips, deviating from the gluten-free menu items. The resident, who had a history of avoiding gluten due to its impact on his energy levels, was not aware of his gluten allergy at the time of the incident. The facility's policies on standardized recipes and therapeutic diets were not followed, as evidenced by the dietary staff's failure to use the correct gluten-free recipe for chicken parmesan. The incident highlights a lapse in the facility's adherence to dietary orders and protocols, resulting in the resident not receiving the appropriate therapeutic diet as prescribed by the physician.
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What surveyors actually found near you
We read the 364 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.
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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Wichita Presbyterian Manor | 0.9 mi | ★★★★★ | 0 | 0 |
| Lakepoint Wichita, Llc | 1.2 mi | ★★★★★ | 0 | 0 |
| Ascension Living Via Christi Village Mclean | 2.1 mi | ★★★★★ | 14 | 0 |
| Meridian Rehabilitation And Health Care Center | 2.3 mi | ★★★★★ | 27 | 0 |
| Rolling Hills Health And Rehab | 3.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.