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 Via Christi Village Ridge during CMS and state inspections, most recent first.
A resident with intact cognition, total ADL dependence, bladder incontinence, and a colostomy developed persistent MASD and irritant contact dermatitis with large areas of skin breakdown on the buttocks, thighs, and groin. The wound clinic and urology recommended urine diversion with a Pure Wick or Foley catheter, but facility staff did not follow through and stated the resident did not qualify or the facility could not use the device. The resident remained in pain during incontinent care, cried during cleansing, and was reported to have waited about two hours for PRN pain medication despite ongoing wound-related discomfort.
Infection control failures involved a resident with a colostomy and another resident with respiratory equipment. Two CNAs provided direct care without a gown during EBP, used the same gloves while touching the resident’s drawer and applying perineal products, changed gloves without hand hygiene, and moved a mechanical lift without sanitizing it. A resident’s nebulizer mouthpiece, CPAP mask, and oxygen tubing were observed uncovered or improperly stored, and staff confirmed the expected cleaning and storage practices were not followed.
Failure to provide written bed hold information at transfer for two residents. One resident with documented memory problems was sent to the hospital after an emergency response, but the record lacked evidence that a written bed hold with the daily room rate and duration was provided. Another resident with intact cognition reported not being aware of a bed hold policy or receiving written notice, while staff gave inconsistent accounts of who was responsible for providing the information and the EMR lacked documentation of it.
Inaccurate EMR Documentation for Schizophrenia Diagnosis: A resident’s EMR listed schizophrenia and dementia, and the care plan and physician orders reflected use of Zyprexa for schizophrenia, but several historical psychological and medical records did not document schizophrenia as a diagnosis. Staff interviews showed confusion about the diagnosis and how it was entered into the EMR, and the facility did not provide a policy for professional standards of care in diagnosing schizophrenia for use with antipsychotics.
Failure to provide required ADL assistance with personal hygiene and dressing. A resident with intact cognition and total assist needs had long facial hair left unremoved despite stating staff would not help, another resident with hemiplegia and max assist needs had long fingernails cutting into the palm of the hand with red marks, and a third resident with dementia and moderate dressing needs was observed half naked and wearing the same shirt across observations. Staff said facial hair removal, fingernail care, and dressing assistance were provided as needed, but no ADL policy for dependent residents was provided.
Failure to Assist a Resident With Hearing Aid Use: A resident with dementia, acoustic neuroma, and hearing loss was repeatedly observed without his R hearing aid in place, with the device left in a dish on the table and out of reach. The resident stated he did not know where the hearing aid was and needed staff to put it in his ear. Staff interviews confirmed he could not apply it himself and that CNAs were expected to assist with hearing aid use per the care plan.
A resident with HTN and intact cognition had metoprolol 25 mg BID ordered for BP control, but nursing staff held the medication on multiple occasions for low BP readings without a physician order or documented notification to the MD. The chart lacked hold parameters, and staff interviews confirmed they were expected to contact the physician whenever the medication was held.
Laundry Area Sanitation and Maintenance Deficiencies: Surveyors observed uncovered bins of soiled linen, a large section of peeling and unsealed sheetrock, and two clean linen bins with frayed, unsanitary fabric in the laundry area. Laundry staff and maintenance staff confirmed the findings and stated they were unaware of the covering requirement for soiled linen and the inability to sanitize the damaged clean linen bins.
A CNA took and shared a video of a resident with severe dementia, depicting the resident in a state of incontinence, without consent. The video was shown to another CNA during shift change, who reported the incident. The facility's policy prohibits such actions, but staff had not received recent documented education on privacy expectations.
A resident with a history of falls and multiple medical conditions experienced two staff-assisted falls in one day, resulting in a severe ankle fracture. The facility failed to implement immediate interventions after the first fall, where the resident's leg buckled and she was lowered to the floor by therapy staff. Despite the incident, the resident's transfer status was not reassessed, leading to another fall later that day. The facility's fall policy was not effectively followed, contributing to the resident's injury.
The facility failed to secure medications by leaving two medication carts unlocked and unattended during administration. On two separate occasions, medication carts containing narcotics, insulins, and other medications were found unlocked and unattended, potentially affecting 40 residents across two neighborhoods. Staff confirmed that the carts should have been locked when unattended, in accordance with facility policy.
A facility failed to maintain a medication administration error rate below 5%, resulting in an 81.48% error rate. An LN administered medications to residents without confirming them against the physician's order or eMAR, leading to 22 out of 27 observed errors. The LN acknowledged the failure to follow the nursing standard of care, and the facility could not provide a relevant policy when requested.
The facility failed to maintain effective infection control practices, as staff mishandled meal trays, improperly cleaned respiratory equipment, and neglected hand hygiene during wound care. Observations showed staff placing fingers on eating surfaces of plates, storing nebulizer and CPAP masks improperly, and not performing hand hygiene between glove changes during wound care. These deficiencies could lead to foodborne illnesses, respiratory infections, and wound infections.
The facility failed to document COVID-19 vaccination education and consent for five residents. Two residents' refusals lacked declination information, while three others received the vaccine without documented education on risks and benefits or written consent. The facility relied on verbal consents, contrary to its policy requiring documented education and signed consent or refusal forms.
A resident with COPD and Parkinson's disease faced potential trip hazards due to multiple electrical cords and oxygen tubing strewn across the floor in their room. Despite the facility's policy to provide a safe environment and the resident's care plan to keep pathways clear, observations showed these hazards were not addressed, posing a risk to the resident's safety.
The facility failed to maintain proper respiratory care for three residents, leading to deficiencies in equipment maintenance. One resident's oxygen tubing and nebulizer were not dated or cleaned, while another's nebulizer and CPAP equipment were improperly stored and not cleaned. A third resident's nebulizer was stored in a coffee cup, and no safety assessment was conducted for self-administration of medication. These practices violated the facility's infection prevention policy, potentially leading to respiratory illnesses.
Failure to provide ordered incontinence management and pain relief
Penalty
Summary
The facility failed to ensure a resident remained free from neglect when staff did not provide the necessary care and services identified in the resident’s care plan, wound clinic notes, and physician orders. The resident had diagnoses including anxiety, contact dermatitis, and overactive bladder, was cognitively intact, required total assistance with toileting hygiene, transfers, and bed mobility, and was always incontinent of bladder with a colostomy. The care plan directed staff to provide perineal cleansing, apply a protective barrier after each incontinent episode, reposition every two to three hours, and provide ordered treatments and pain medications. The resident also had repeated wound clinic findings of irritant contact dermatitis and moisture-associated skin damage involving the buttocks, thighs, and groin, with documentation that moisture and shearing were contributing to the skin breakdown. The record showed repeated failure to carry out the urine-diversion recommendations and orders that were intended to keep the resident’s skin dry. Wound clinic and urology notes documented that the resident was incontinent of urine, continuously dribbling, and had chronic urine leakage that complicated wound healing. The wound clinic recommended a Pure Wick system, and later urology also recommended a Pure Wick for several months or, if declined, consideration of an indwelling Foley catheter. The resident’s EMR lacked evidence that the facility followed up on these recommendations and orders. Facility staff stated the resident did not qualify for a Pure Wick or Foley catheter, that the facility did not use Pure Wick devices, and that there was no way to have continuous suction. Staff also reported the resident refused incontinent care or offloading, while the resident and family reported that the facility would not follow the recommendations from the wound clinic and urologist. The resident’s skin condition and pain persisted over months, with wound measurements showing large areas of redness, irritation, drainage, and enlargement of the affected areas. During observation, the resident was seen sitting in a wheelchair, reported significant pain from the sores on her leg and bottom, and became tearful when discussing the lack of catheter use. When staff assisted with incontinent care, the resident winced and cried from pain and asked for pain medication. The CNA reported the resident complained of pain every time she received incontinent care, and the nurse acknowledged the resident had waited about two hours for pain medication. The physician provider stated it was unacceptable that the resident had to wait that long for pain medication and also indicated the resident would benefit from a Foley catheter, while other facility staff continued to state the resident did not qualify for catheter use and that the facility would not complete the Pure Wick order.
Infection Control Failures With EBP, Hand Hygiene, Shared Equipment, and Respiratory Storage
Penalty
Summary
The facility failed to utilize Enhanced Barrier Precautions and failed to follow infection control practices related to hand hygiene, sanitization of shared equipment, and sanitary storage of respiratory equipment. On 02/09/26, two CNAs assisted a resident with a colostomy to bed using a mechanical lift, but they did not apply a gown during the care. One CNA used gloved hands to open the resident’s drawer, retrieved hygiene wipes, wiped the resident’s inner thighs, washed the buttocks, mixed perineal lotion and A&D ointment in the same gloved hands, and applied the mixture to the buttocks and coccyx. The CNA then removed gloves and put on new gloves without performing hand hygiene before continuing perineal care. After the care was completed, the CNAs pushed the mechanical lift into the hallway without sanitizing the lift or their hands after glove removal. The facility also failed to store and handle respiratory equipment appropriately for another resident. A resident was observed with oxygen tubing wrapped around the concentrator and hanging without a cover, a nebulizer mouthpiece lying uncovered on the table with clear liquid in it, and a CPAP mask lying directly on the nightstand. The resident’s oxygen tubing was also wrapped around the oxygen tank on the wheelchair, with the nasal cannula touching the tank. Staff interviews confirmed that nasal cannulas and CPAP masks should be stored in a bag or sanitizer box when not in use, and that nebulizer equipment should be taken apart, rinsed, and air dried after treatment. Administrative staff stated the mechanical lift should be wiped after each use, gloves should be removed with hand hygiene performed before new gloves are applied, and gowns should be used for direct care requiring EBP for residents with an artificial opening such as a colostomy.
Failure to Provide Written Bed Hold Information at Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy at the time of transfer for two residents who were sent to the hospital. For one resident, the EMR documented memory problems on the admission MDS, and nursing progress notes showed the nurse called emergency services based on a physician order and the resident was transferred to the hospital. The transfer form stated the facility would provide the resident and/or representative with a bed hold that included the daily room rate and duration of the bed hold prior to transfer, but the record lacked evidence that a written bed hold was actually provided. For another resident, the admission MDS documented a BIMS score of 13, indicating cognition intact, and the resident was later sent to the hospital short of air/breath. During interview, the resident stated she had been transferred to the hospital multiple times and did not recall being made aware of a bed hold policy or receiving a written bed hold. Staff interviews showed inconsistent understanding of who was responsible for providing the written bed hold information, and the Administrative Nurse verified the EMR lacked documentation of a written bed hold that included the daily room rate and/or duration of the bed hold. The facility's Bed-Holds and Returns Policy stated that written information would be given prior to transfer, explaining the duration of the bed hold and reserve bed payment policy.
Inaccurate EMR Documentation for Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure Resident 7’s EMR contained appropriate documentation supporting the schizophrenia diagnosis used for care planning and psychotropic medication management. Resident 7’s EMR listed schizophrenia and dementia, and the resident’s MDS assessments documented a BIMS score of 12 and included schizophrenia as a diagnosis. The care plan also identified schizophrenia and the potential for drug-related complications associated with antipsychotic use, and physician orders included Zyprexa 5 mg by mouth daily for schizophrenia. However, multiple historical records in the chart did not document schizophrenia as a diagnosis, including psychological evaluations from 1979, 1982, and 2003, a history and physical from 2017, and a CARE assessment from 2017 that stated the resident had not been diagnosed with a serious mental disorder. During interviews, an Administrative Nurse stated the resident had schizophrenia on admission and another Administrative Nurse reported she had updated the diagnosis list in the EMR on 09/03/21 based on her understanding that the diagnosis was schizophrenia. A Consultant Staff member also stated she thought the required documentation was present, while another Administrative Nurse stated she expected the EMR to reflect accurate diagnoses. The facility did not provide a policy for professional standards of care in diagnosing schizophrenia for use with antipsychotics.
Failure to Provide Required ADL Assistance With Personal Hygiene and Dressing
Penalty
Summary
The facility failed to provide ADL assistance with personal hygiene for three residents who required staff support. R55’s EMR documented anxiety, contact dermatitis, and overactive bladder, and her MDS indicated intact cognition, no rejection of care, and total assistance with personal hygiene. Her care plan directed staff to provide ADL assistance, including for neuropathy in her hands, yet during multiple observations she had several long white facial hairs on her face and reported she was unable to remove them and wanted staff to do so. R63’s EMR documented hemiplegia following a stroke affecting the right side, depression, and a need for ADL assistance. His MDS documented moderately impaired cognition, no rejection of care, maximal assistance with personal hygiene, and impairment of one upper extremity. His care plan directed extensive assistance with one-person staff support for hygiene. During observation, he was lying in bed with a right-hand contracture and long fingernails that were cutting into the right palm of his hand and causing red marks; later observations showed the fingernails remained long and the red lines on the palm were still present. R8’s EMR documented dementia, acoustic neuroma with hearing loss, and depression. His MDS documented moderately impaired cognition and moderate assistance with dressing, and his care plan directed limited assist of one staff member for dressing. During observation, he was seated in his wheelchair wearing a blue long sleeve shirt and an incontinence brief and reported he was sitting half naked. A later observation showed he was still wearing the same shirt and was seated on the side of his bed with gripper socks on. Staff interviews stated residents would be assisted with facial hair removal, fingernail care, and dressing, but the facility did not provide a policy for ADLs for dependent residents.
Failure to Assist Resident With Hearing Aid Use
Penalty
Summary
The facility failed to ensure Resident 8 received necessary services, including staff assistance, with his hearing devices. Resident 8 had diagnoses of dementia, acoustic neuroma with hearing loss, and depression. His MDS documented a BIMS score of 12, indicating moderately impaired cognition, and noted minimal difficulty with hearing and use of hearing aids. His Communication CAA documented acoustic neuroma with hearing loss of the right ear, deafness in the left ear, and use of a hearing aid for the right ear. His care plan directed staff to ensure he wore a right ear hearing aid and to place important items within his reach. During multiple observations, Resident 8 was seen without his hearing aid in his right ear, and the hearing aid was repeatedly found in a dish on the table to his left and outside his reach. On one occasion, he reported he had a hearing aid but did not know where it was and said he needed staff to put it in his ear. On another observation, he again did not have the hearing aid in place and said he did not know where it was. Staff interviews confirmed he could not apply the hearing aid by himself, that staff should apply it to his ear, and that it was expected for CNAs to follow the care plan and place the hearing aid when he was first gotten up in the morning. An administrative nurse also stated staff were expected to assist residents with their hearing aids.
Medication Held Without Physician Notification
Penalty
Summary
The facility failed to ensure that Resident 31 remained free from significant medication errors when metoprolol was held without a physician's order and the physician was not contacted. Resident 31 had a diagnosis of hypertension, intact cognition with a BIMS score of 14, and a care plan that directed staff to monitor blood pressure and inform the physician of any concerns. The physician's order dated 11/06/25 prescribed metoprolol 25 mg by mouth twice daily for hypertension, but the record did not include any ordered parameters for holding the medication. Nursing documentation showed metoprolol 25 mg was held on three occasions for blood pressure readings of 107/60 mmHg, 98/63 mmHg, and 94/78 mmHg. In each instance, the notes lacked documentation that the physician was notified to obtain a hold order or to report the blood pressure reading. During interviews, a licensed nurse stated nurses should notify the physician if metoprolol was held and confirmed there was no order or ordered parameters to hold the medication. An administrative nurse stated staff were expected to contact the physician and obtain orders for holding medications or parameters if needed, and a consultant staff member stated staff should contact the physician with any medication that was held.
Laundry Area Sanitation and Maintenance Deficiencies
Penalty
Summary
The facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the laundry area for residents and staff. During a tour of the laundry, surveyors observed three linen bins containing soiled laundry that were not covered, a 10-foot by four-inch section of wall with peeling, unsealed, and unsanitary sheetrock, and two clean linen storage bins used to deliver clothes throughout the facility with frayed, unsanitary fabric around the tops where clothes would have direct contact. Laundry staff and maintenance staff later confirmed the findings, stated they were unaware that soiled linen should be covered and that the clean clothes bins could not be sanitized because of the frayed fabric, and verified that the sheetrock along the wall was unsealed and needed repair. Laundry staff reported the damaged sheetrock was caused by laundry carts being run into the wall, and the facility did not provide a policy to address these concerns.
Resident Privacy Breach Due to Unauthorized Video Recording
Penalty
Summary
A Certified Nurse Aide (CNA) took a video of a resident without the resident's consent, violating the resident's right to privacy and confidentiality. The resident involved had a diagnosis of severe dementia, with a Brief Interview Mental Status (BIMS) score indicating severely impaired cognition, and required extensive assistance with activities of daily living, including toileting and incontinent care. The video, which depicted the resident fully clothed and lying in bed with evidence of a bowel movement on both the resident and the wall, was shown by the CNA to another staff member during shift change. The second CNA immediately instructed the first to delete the video and reported the incident to administrative staff. The facility's investigation confirmed that the video was taken and shared without consent, and that staff had not received recent education regarding privacy expectations following the incident. Although the facility's policy prohibits staff from photographing or videotaping residents without consent, and requires training on privacy and abuse prevention, there was no documented evidence that staff had received updated education or signed off on privacy training after the event. The incident was observed through facility camera footage and corroborated by staff interviews and record review.
Failure to Implement Immediate Fall Interventions
Penalty
Summary
The facility failed to implement immediate interventions to prevent further falls for a resident after an initial incident where the resident's left leg buckled, and she was lowered to the floor by therapy staff. This failure resulted in another staff-assisted fall later the same day, leading to a severe fracture of the resident's left ankle. The resident, who had a history of falls and required extensive assistance for transfers and toileting, was admitted to the facility with diagnoses including congestive heart failure, dementia, diabetes mellitus, and hypertension. On the day of the incident, the resident was being assisted by therapy staff when her left leg gave out, and she was lowered to the floor. Despite this event, the resident's transfer status was not immediately reassessed or changed by therapy or nursing staff, and she continued to be assisted with minimal support. Later that evening, the resident experienced another fall when a CNA assisted her to the floor after she was unable to stand. The facility's failure to reassess and adjust the resident's care plan and transfer status after the initial fall contributed to the subsequent fall and injury. The facility's fall policy required evaluation and documentation of falls, as well as the implementation of interventions to prevent further incidents. However, the policy was not effectively followed in this case, as evidenced by the lack of immediate intervention and reassessment of the resident's needs after the first fall. The resident's severe ankle fracture was identified the following day, after which she was sent to the hospital for further evaluation and treatment.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to secure medications by leaving two medication carts unlocked and unattended during the administration of medications. On 04/03/24 at 11:35 AM, a medication cart on the D2 neighborhood was found unlocked with no nurse in the vicinity. Licensed Nurse (LN) D confirmed that the cart, which contained narcotics, insulins, and other medications, was unlocked and unattended. LN D acknowledged that all medication carts should be locked when unattended. Similarly, on 04/04/24 at 09:12 AM, a medication cart on the B2 neighborhood was observed unlocked and unattended while LN C administered medications to a resident down the hallway. LN C confirmed the cart was left unlocked and unattended and stated that it should have been locked when unattended. Administrative Nurse B reiterated that all medication carts should be locked when unattended. The facility's policy on the storage of medications, dated 01/24, mandates that compartments containing drugs and biologicals must be locked when not in use and that carts used to transport such items should not be left unattended if open or otherwise accessible. The facility's failure to adhere to this policy resulted in the medication carts on two separate neighborhoods being left unlocked and unattended, potentially affecting 20 residents on neighborhood D2 and 20 residents on neighborhood B2.
Medication Administration Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, resulting in an error rate of 81.48%. This deficiency was observed when a Licensed Nurse (LN) administered medications to residents without confirming them against the physician's order or the electronic medication administration record (eMAR). Specifically, 22 out of 27 observed medications were administered incorrectly. The LN removed medications from their packaging and administered them based on the outer wrapper's label without verifying each medication against the physician's order or eMAR. This practice was confirmed by the LN, who acknowledged the failure to follow the nursing standard of care. The report highlights specific instances where the LN administered medications to multiple residents without proper verification. For example, the LN administered two medications to one resident and a total of 13 medications to another, all without confirming the medications against the physician's order or eMAR. The facility's administrative nurse confirmed that the expectation is for staff to verify each medication's identification label with the physician's order or eMAR to ensure accuracy. The facility was unable to provide a policy related to medication administration when requested, further indicating a lack of adherence to proper procedures.
Infection Control Deficiencies in Meal Handling, Respiratory Equipment, and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several observations and interviews. Staff were observed mishandling meal trays by placing their thumbs over the edge and into the eating surface of plates while delivering them to residents in the dining area. This practice was contrary to the facility's expectations, as confirmed by dietary staff and administrative nurses, who stated that plates should be carried by the bottom to avoid contamination. The facility's policy on preventing foodborne illness lacked specific instructions on handling resident plates, contributing to this deficiency. In addition, the facility did not adhere to infection control standards in the cleaning of respiratory equipment for residents with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA). Observations revealed that nebulizer and CPAP masks were improperly stored and not cleaned after each use, as required by the facility's respiratory care policy. Administrative staff confirmed that nebulizers should be cleaned and dried after use, and CPAP masks should be cleaned according to manufacturer's guidelines, which were not provided. This oversight had the potential to lead to respiratory illnesses for the affected residents. Furthermore, the facility failed to ensure proper hand hygiene during wound care for a resident with a history of transient ischemic attack, stroke, vascular dementia, and osteoarthritis. A licensed nurse was observed changing gloves multiple times without performing hand hygiene between phases of wound care, contrary to the facility's wound care policy. This lapse in infection control practices could lead to wound infections, negatively impacting the resident's health.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to ensure that five residents or their representatives acknowledged receipt of COVID-19 vaccination information and education. Specifically, the documentation for two residents indicated that they refused the COVID-19 vaccine, but the facility was unable to provide any declination information. For three other residents, the documentation showed that they received the COVID-19 vaccine, but there was no evidence of education provided regarding the risks and benefits, nor was there a written consent to administer the vaccine. The facility's policy required that residents be educated about vaccines and that this education be documented in the resident's record. Additionally, residents or their representatives were to sign a consent or refusal form for vaccines. However, the facility relied on verbal consents and did not have a no acceptance/declination consent form or an education information form, as confirmed by the Administrative Nurse. This lack of documentation and adherence to policy led to the deficiency identified in the report.
Trip Hazards from Electrical Cords and Oxygen Tubing
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for a resident, identified as R28, who had chronic obstructive pulmonary disease and Parkinson's disease. The resident required extensive assistance for most activities except eating and ambulation, which were independent. Observations revealed multiple electrical cords plugged into two power strips next to the resident's recliner, with cords strewn across the floor in the walking path between the recliner and the bed. Additionally, the resident's oxygen tubing was found on the floor in the walking path from the bathroom to the bed and recliner area. These conditions were observed on multiple occasions, indicating a failure to address the potential trip hazards. The facility's Safety and Supervision of Residents policy, dated December 2017, stated the commitment to providing a safe environment but did not specifically address the placement of power cords or oxygen tubing. Interviews with the administrative nurse and maintenance staff confirmed that the cords and tubing on the floor posed a trip hazard. Despite the resident's care plan, which included instructions to keep pathways clear due to a moderate risk for falls, the facility did not take adequate measures to prevent these hazards, potentially compromising the resident's safety and wellbeing.
Deficient Respiratory Care Practices in LTC Facility
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in maintaining respiratory equipment. For one resident, the oxygen tubing and nasal cannula were not dated, and the nebulizer equipment was left uncovered and unlabeled with an unknown liquid remaining in the chamber. This was confirmed by multiple staff members, including a Certified Nurse Aide, a Licensed Nurse, and a Certified Medication Aide, who acknowledged the lack of proper labeling and cleaning of the equipment. The facility's policy required the nebulizer components to be rinsed and dried after each use, which was not adhered to, potentially leading to respiratory infections. Another resident with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) had a nebulizer mask stored with an unknown liquid inside the chamber and a CPAP mask hung from the bedrail. Observations over several days showed that the equipment was not cleaned or stored properly, as required by the facility's infection prevention policy. Administrative nurses confirmed that the equipment should be cleaned after each use, but this was not done, posing a risk of infection. A third resident, also diagnosed with COPD, had nebulizer equipment stored improperly, with one setup left intact inside a coffee cup. The resident reported that staff pre-loaded the nebulizer with medication for self-administration, but no safety assessment was performed to ensure the resident could safely self-administer the medication. The facility's policy required cleaning and drying of nebulizer components after each use, which was not followed, increasing the risk of respiratory illnesses.
What surveyors are citing around you — mapped
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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 341 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
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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) |
|---|---|---|---|---|
| Azria Health Wichita | 0.6 mi | ★★★★★ | 11 | 0 |
| Wichita Presbyterian Manor | 3.2 mi | ★★★★★ | 0 | 0 |
| Lakepoint Wichita, Llc | 3.5 mi | ★★★★★ | 0 | 0 |
| Sandpiper Healthcare & Rehabilitation Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Meridian Rehabilitation And Health Care Center | 4 mi | ★★★★★ | 27 | 0 |
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