Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy At College Hill during CMS and state inspections, most recent first.
The facility did not maintain an effective pest control program, as evidenced by staff and resident reports of rodents and rodent droppings in rooms and common areas. A resident with intact cognition showed surveyors two dead mice caught in traps she placed under her bed, and housekeeping staff found rodent droppings and a dead rodent during cleaning. The pest control service had been discontinued due to unpaid invoices, and the facility's policy requiring ongoing pest control was not followed.
A resident with intact cognition and a housekeeper reported that a section of flooring at the dining room entrance had been missing and covered with water-saturated blankets for several weeks, creating ongoing safety concerns. Administrative staff confirmed the issue was due to a broken pipe and noted a lack of documentation and unresolved payment issues for repairs, resulting in failure to provide a safe and homelike environment.
A resident with dementia, depression, and traumatic brain injury, who was assessed as at risk for elopement, was able to exit the facility unsupervised due to staff failing to keep the Elopement Risk Book current and accurate. The book, used to alert staff to residents at risk for elopement, contained outdated information, lacked required photos and face sheets, and staff were unclear about which residents were at risk or responsible for updates. This lapse in documentation and supervision led to an increased risk of elopement for affected residents.
The facility failed to implement a water management program for Legionella and did not follow proper infection control practices for storing oxygen equipment. Two residents had unbagged oxygen tubing and nasal cannulas left in their wheelchairs, exposing them to potential contamination. The facility lacked documentation of completed water management processes and did not provide a policy for sanitary storage of medical equipment.
The facility failed to maintain a safe and sanitary environment in the main dining room and 400 hall, with issues such as missing flooring, grayish-black substances on vents and air conditioners, and missing mopboard. These deficiencies were verified by staff, who acknowledged the lack of maintenance personnel, placing residents at risk for health issues and falls.
The facility's kitchen failed to meet professional food safety standards, with uncovered food items improperly stored in the refrigerator, maintenance issues like missing tiles and substances on pipes, and expired sanitizer test strips. These deficiencies placed 65 residents at risk for foodborne illness.
The facility failed to offer or obtain informed declination for the pneumococcal PCV20 vaccination for several residents, as per CDC guidance. A review of medical records showed a lack of consent or informed declination for the vaccine, placing residents at risk. Interviews with staff confirmed the absence of a systematic approach to determine vaccination eligibility, relying instead on external medical directors without a definitive tracking system.
A resident was transferred to the hospital without being provided with written information regarding the facility's bed hold policy. The resident, who had multiple serious medical conditions, was transferred due to a decline in health. The facility failed to obtain a signed acknowledgment from the resident's representative, placing the resident at risk of not being able to return to the facility.
A facility failed to implement a person-centered care plan for a resident with PTSD, major depressive disorder, and traumatic brain injury. The care plan lacked specific interventions for PTSD, despite the resident's diagnosis since 2022. Administrative nurses were unaware of this omission, which violated the facility's policy for comprehensive care plans. This deficiency risked the resident's psychosocial well-being and treatment effectiveness.
A resident with cognitive and physical impairments, requiring supervision while smoking, sustained a cigarette burn due to unsupervised smoking. Despite facility policies and care plans indicating the need for supervision, the resident continued to smoke without oversight, obtaining cigarettes from family or other residents. This failure to enforce smoking policies placed the resident and others at risk for smoke or fire-related hazards.
A resident with end-stage renal disease required dialysis three times a week, but the facility failed to document essential details in the care plan, such as the dialysis schedule and site care. This deficiency was confirmed by an administrative nurse and observed during an interview with the resident, who expressed concerns about meal timing related to dialysis sessions.
A facility failed to provide trauma-informed care for a resident with PTSD, major depressive disorder, and traumatic brain injury. The resident's care plan lacked specific interventions to address PTSD triggers, and staff were unaware of this omission. Interviews revealed an expectation for staff to manage PTSD triggers, but no structured guidance was provided. This deficiency placed the resident at risk for decreased psychosocial well-being and ineffective treatment.
A facility failed to ensure the Consultant Pharmacist identified and reported missed insulin administrations and blood sugar readings for a resident with diabetes. The resident's medical records showed numerous undocumented instances of insulin administration and blood sugar readings over several months. Despite the facility's policy, the CP did not report these omissions, placing the resident at risk for unnecessary medication administration and complications.
A resident with diabetes and other medical conditions did not receive physician-ordered insulin and blood sugar checks as required. Over several months, staff failed to sign off on multiple doses of insulin and blood sugar readings, with no documentation explaining the omissions. This placed the resident at risk for unnecessary medication administration and complications.
The facility failed to ensure CMS-approved indications for antipsychotic medications for three residents, leading to the risk of unnecessary medication administration. One resident was prescribed Vraylar without a documented physician response to a pharmacist's request for an appropriate indication. Another resident was prescribed risperidone for an unapproved indication of anxiety, and a third resident's clinical record lacked documentation for the continued use of Seroquel. These deficiencies placed the residents at risk for unnecessary medication use.
The facility failed to label and discard insulin medications properly, risking ineffective doses for residents. Observations showed unlabeled insulin flex pens and vials, with some having incorrect expiration dates. Licensed nurses confirmed the need for proper labeling and discarding per policy, which was not followed, placing residents at risk.
A facility failed to ensure proper collaboration with a hospice provider for a resident, leading to inadequate end-of-life care. The resident's care plan lacked essential information such as contact details for the hospice provider, a list of medical supplies, and a schedule of hospice staff visits. This deficiency was identified through observations, record reviews, and staff interviews, highlighting a lack of communication and coordination between the facility and the hospice provider.
A resident with Alzheimer's and Down's Syndrome, dependent on staff for care, developed a stage four pressure ulcer due to the facility's failure to reposition him every two hours, monitor his skin weekly, and provide timely wound treatments. Despite hospice staff's education efforts, the facility continued to neglect repositioning and peri-care duties, leading to further skin breakdown and additional pressure ulcers.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident with Alzheimer's and muscle weakness had a pressure ulcer worsen to stage four and a urinary catheter inserted, but the care plan was not updated. Another resident with diabetes and hemiplegia developed a foot wound, which was not included in the care plan. A third resident with a urinary catheter had a care plan that did not reflect his ability to manage the catheter independently. These oversights violated the facility's policy requiring care plan updates with changes in residents' conditions.
A resident with a history of diabetes and hemiplegia developed an ulcer on her right foot, but the facility failed to provide the ordered treatments, including pressure-relieving boots and regular dressing changes. Observations showed the resident's boot was often on the floor, and staff did not consistently monitor or document the wound's status. Interviews revealed confusion among staff about the care plan, and the facility's policy lacked clear guidelines for wound assessment frequency.
Two residents in a LTC facility were not provided timely incontinence care, resulting in saturated briefs and urine-soaked linens. One resident with Alzheimer's and Down's Syndrome was frequently found wet despite a care plan for two-hour checks. Another resident with hemiplegia and dementia was not changed for several hours, contrary to the care plan. The facility's policy required scheduled toileting, but it was not followed, leading to inadequate care.
A resident with pain and restless leg syndrome missed multiple doses of Norco and a Fentanyl patch due to the facility's failure to reorder medications timely. Despite experiencing significant pain, the facility did not document attempts to notify the physician or pharmacy. Staff interviews revealed a lack of awareness and communication regarding the medication shortage, and the facility's policy lacked clear instructions for reordering medications.
The facility failed to maintain effective infection control practices, including improper glove removal and hand hygiene during resident care, and incorrect positioning of a urinary catheter drainage bag. Staff did not change gloves between tasks, and a resident's catheter bag was positioned above the bladder, contrary to facility policy.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and staff interviews confirming the presence of rodents and rodent droppings in resident rooms and common areas. Pest control vendor reports documented a captured rodent and staff sightings of mice, with recommendations to keep doors closed. Despite these findings, the last documented visit from the pest control vendor was in March, and the service was discontinued due to unpaid invoices. Housekeeping staff reported finding rodent droppings, dried urine, and a dead rodent during deep cleaning of resident rooms, and these findings were reported to supervisors. A resident with intact cognition showed surveyors two dead mice in spring-loaded traps she had placed under her bed, stating this was not the first occurrence and that she needed more traps. Other staff, including a CNA and the maintenance supervisor, confirmed recent sightings of rodent droppings and evidence of rodents in the facility. The maintenance supervisor was unaware that residents were using their own traps and expressed surprise at the findings. The facility's policy requires an ongoing pest control program to ensure the building is free of rodents, but this was not maintained due to the cancellation of the pest control service.
Failure to Maintain Safe and Sanitary Environment Due to Prolonged Flooring Issue
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for its residents. During an initial tour, it was noted that flooring was missing at the entrance of the dining room on the 300 hallway, with an area approximately four feet long by one foot wide covered by water-saturated blankets and surrounded by wet floor caution signs. This condition had persisted for at least two to three weeks, as confirmed by both a resident and a housekeeper. The resident, who was cognitively intact, expressed concerns about safety due to the persistent wet floor. Administrative staff confirmed that the flooring issue was due to a broken pipe under the floor, which had been assessed by a local plumber. However, there was no documentation or estimate available to verify the plumber's visit. The administrator also reported concerns about the facility's ability to pay for repairs, as invoices had not been paid by the corporate office since March 2025. The facility's policy required providing a safe, clean, and homelike environment, which was not met in this instance.
Failure to Maintain Accurate Elopement Risk Documentation and Supervision
Penalty
Summary
The facility failed to implement and maintain up-to-date interventions to mitigate the risk of elopement for a resident with significant cognitive impairment. The resident in question had diagnoses of dementia, depression, and traumatic brain injury, and was assessed as being at risk for elopement based on a recent increase in their elopement risk assessment score. The resident's care plan included the use of a WanderGuard bracelet, 15-minute visual checks, and specific monitoring instructions. Despite these interventions, the resident was able to exit the facility when a transportation company opened the door, indicating a lapse in supervision and monitoring. Staff relied on an Elopement Risk Book at the nurse's stations to identify residents at risk for elopement, but the book was not kept current. Observations and interviews revealed that the Elopement Risk Book contained outdated information, lacked resident photos and face sheets, and had discrepancies regarding which residents were currently at risk or had active WanderGuard devices. Staff members were unclear about which residents were at risk and who was responsible for updating the book, with some staff unaware of recent elopement incidents and the current status of the elopement risk documentation. The facility's policy required that each resident's risk for elopement be assessed upon admission and that a photo and face sheet be placed in the Elopement Risk Book. However, these requirements were not consistently followed, as evidenced by missing photos and outdated lists in the risk books at both nurse stations. This failure to maintain accurate and current elopement risk documentation contributed to the increased risk of elopement for residents identified as at risk.
Failure to Implement Water Management and Infection Control Practices
Penalty
Summary
The facility failed to implement a water management program for Legionella disease, which is a bacterium spread through mist and can cause pneumonia, particularly in adults over 50 and those with weakened immune systems. The facility was unable to provide documentation of any completed water management processes or testing results, as the last maintenance supervisor had left and the information could not be retrieved. Although the facility had materials for a water management process, there was no evidence that the process was completed, and no policy was provided related to the sanitary storage of oxygen or catheter tubing. Additionally, the facility did not adhere to acceptable infection control practices regarding the storage of oxygen tubing and nasal cannulas for two residents. Observations revealed that the oxygen tubing and nasal cannulas for these residents were left unbagged and placed in the seat of their wheelchairs, exposing them to potential contamination as staff and residents moved through the area. Administrative staff acknowledged that the oxygen equipment should have been stored in a bag when not in use, but this practice was not followed, placing residents at risk for infectious diseases.
Environmental Deficiencies in Dining Room and 400 Hall
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, particularly in the main dining room and the 400 hall. Observations revealed several issues, including a section of missing flooring in front of the shower room on the 400 hall, which was approximately 18 inches wide by five feet long and half an inch deep, exposing the concrete beneath. In the main dining room, there were four floor vents and two window air conditioners covered with a grayish-black fuzzy substance. Additionally, the windows around the dining room had numerous streaks of grayish-black areas. Further issues in the dining room included missing mopboard below the window air conditioner and around the floor air vents, as well as a section of mopboard sticking out from the wall below the shelf where iced tea was kept. These environmental deficiencies were verified by Administrating Staff A, who acknowledged the lack of maintenance staff and stated that he was responsible for addressing these issues. The facility's Quality of Life-Homelike Environment Policy, revised in May 2017, emphasized the importance of maintaining a clean, sanitary, and orderly environment, which the facility failed to uphold, placing residents at risk for impaired health and well-being and falls.
Deficient Food Safety Practices in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations in the kitchen. During an inspection, it was noted that the walk-in refrigerator contained a box of uncovered bacon and a box of roasted turkey breast stored above a box of bulk pork sausage, which violates proper food storage protocols. The Dietary Manager confirmed these findings and acknowledged that staff should cover food items before refrigeration and store thawing meat on the bottom shelf. Additionally, the outside of the ice machine had streaks of a whitish substance, and the drainage pipe from the dishwasher was improperly positioned, touching the floor drainage area. Further inspection revealed multiple maintenance issues in the kitchen area, including missing tiles under the sinks and dishwasher, grayish-black substances on pipes, peeling sheetrock in a storage closet, and expired sanitizer test strips. The ceiling vent and lights were also found to have grayish and black substances, respectively, and the window above the steam table had streaks of a grayish substance. These deficiencies in food storage, preparation, and kitchen maintenance placed the 65 residents who received meals from the facility's kitchen at risk for foodborne illness.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer or obtain informed declination or physician-documented contraindication for the pneumococcal PCV20 vaccination for several residents, as per the latest CDC guidance. The review of clinical medical records for five residents revealed a lack of evidence that the facility or the resident representative received or signed a consent or informed declination for the pneumococcal vaccine PCV20. This oversight placed the residents at risk for pneumococcal infection and related complications. Interviews with facility staff, including Administrative Nurses E and D, confirmed the absence of a systematic approach to determine residents' eligibility for the PCV20 vaccination. The facility relied on the medical director or clinic physician's office to determine eligibility but lacked a definitive system to track who was eligible, when they were eligible, and whether they had been offered or declined the vaccinations. The facility's existing policy required assessment of pneumococcal vaccination status within five working days of admission, but this was not effectively implemented, leading to the deficiency.
Failure to Provide Bed Hold Policy Documentation
Penalty
Summary
The facility failed to provide Resident 18 with written information regarding the bed hold policy when she was transferred to the hospital. Resident 18, who had a range of serious medical conditions including Influenza A, acute respiratory failure, hypoxia, cerebrovascular accident, dementia, and diabetes mellitus, was transferred to the hospital due to a significant decline in her health. The nurse's notes indicated that the resident was unresponsive, had a high temperature, and low oxygen saturation levels, prompting the nurse practitioner to order her transfer to the hospital. However, the facility did not provide the resident or her representative with a signed copy of the bed hold policy, which is required to ensure the resident's right to return to the facility. The facility's bed hold policy mandates that residents and their representatives be informed in writing about the facility and state bed hold policies, both in advance of any transfer and at the time of transfer. In this case, the facility's records showed that the bed hold policy document was signed by an administrative nurse rather than the resident's representative, and there was no evidence of a signed acknowledgment by the representative. The administrative nurse confirmed that the representative had not signed the document and that the facility could not provide written evidence of the representative's acknowledgment of the bed hold policy. This deficiency placed Resident 18 at risk of not being permitted to return and resume residence in the nursing facility. The facility's failure to provide the necessary documentation and obtain the representative's acknowledgment of the bed hold policy violated the established procedures and policies, which are designed to protect residents' rights during hospital transfers.
Failure to Implement Person-Centered Care Plan for PTSD
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident diagnosed with PTSD, major depressive disorder, and traumatic brain injury. The resident's care plan, last revised on 10/23/24, did not include a specific care area to address PTSD, its triggers, or interventions to prevent re-traumatization. Despite the resident's documented diagnosis of PTSD since 09/09/22, the care plan lacked individualized interventions to manage the condition effectively. This oversight was identified during a survey, where it was noted that the resident had a severely impaired cognition with a BIMS score of six and had displayed behaviors such as rejecting care. Interviews with administrative nurses revealed a lack of awareness regarding the absence of a PTSD care area in the resident's care plan. The facility's policy, revised in March 2022, mandates that care plans should be comprehensive and person-centered, including measurable objectives and timeframes. However, the facility did not adhere to this policy, as the resident's PTSD was not addressed at admission or upon diagnosis. This deficiency placed the resident at risk for decreased psychosocial well-being and ineffective treatment.
Failure to Supervise Resident Smoking Leads to Injury
Penalty
Summary
The facility failed to maintain a safe environment for a resident, identified as R21, who was assessed to require supervision while smoking due to cognitive and physical impairments. Despite being educated on the need for supervision and the use of a protective smoking apron, R21 continued to smoke unsupervised, which led to a cigarette burn on her left iliac crest. The resident's medical history included conditions such as cerebral infarction, major depressive disorder, acute respiratory failure with hypoxia, and pneumonia, which necessitated staff assistance for activities of daily living and supervision for safety. R21's care plan and smoking policy indicated that she was a supervised smoker due to her impaired dexterity and history of smoking inside the facility. The facility's smoking assessment documented that R21 had no cognitive loss but had visual defects and dexterity problems, which increased her risk of injury from smoking. Despite these assessments, R21 was able to obtain cigarettes from family or other residents and smoked without supervision, leading to the burn injury. The facility's smoking policy required that all residents be informed of smoking limitations and that those requiring supervision be directly monitored by staff, family, or volunteers. However, the facility did not enforce these policies effectively, allowing R21 to smoke unsupervised, which placed her and other residents at risk for smoke or fire-related hazards.
Inadequate Dialysis Care Plan Documentation for Resident
Penalty
Summary
The facility failed to provide ongoing care plan communication and documentation for a resident, identified as R70, who required dialysis treatment. R70 had a diagnosis of end-stage renal disease and was admitted to the facility with a physician's order for dialysis three times a week. However, the care plan for R70 lacked essential documentation regarding the dialysis treatment, including the dialysis center, the schedule for dialysis sessions, and the care required for the dialysis site. This lack of documentation was confirmed by Administrative Nurse D, who acknowledged that the care plans were completed by a corporate nurse off-site and updated in-house as needed. The facility's policy on the care of residents with end-stage renal disease outlined the need for staff training and comprehensive care plans reflecting the resident's needs related to dialysis care. Despite this policy, the facility did not ensure that R70's care plan included necessary information about his dialysis treatment, placing him at risk for inadequate care and potential health decline. The deficiency was observed during an interview with R70, who expressed concerns about the timing of his meals in relation to his dialysis schedule, and was further verified by the administrative nurse.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, major depressive disorder, and traumatic brain injury. The resident's electronic medical record documented these diagnoses, and the resident exhibited behaviors such as rejecting care and had a severely impaired cognition score. Despite these indicators, the resident's care plan lacked specific interventions to address PTSD triggers or prevent re-traumatization. The facility's failure to include a PTSD care area in the resident's care plan was noted, and staff were unaware of this omission. Interviews with administrative nurses revealed that there was an expectation for staff to have directions on managing PTSD triggers and interventions, but this was not implemented for the resident. The facility did not provide a policy regarding PTSD care when requested, indicating a lack of structured guidance for managing such cases. This deficiency placed the resident at risk for decreased psychosocial well-being and ineffective treatment, as the facility did not identify trauma-based triggers or implement individualized interventions to prevent re-traumatization.
Failure to Identify and Report Missed Insulin Administration
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported missed insulin administrations and blood sugar readings for Resident 25. The resident had multiple diagnoses, including diabetes mellitus, and was prescribed both fast-acting and long-acting insulin. However, there were numerous instances where the administration of these medications and the required blood sugar readings were not documented in the resident's medical records over several months. Resident 25's medical records revealed a lack of staff sign-off on insulin administration and blood sugar readings across multiple months. Specifically, there were missing sign-offs for Lantus and Humalog insulin administrations and blood sugar readings in November and December 2024, as well as January and February 2025. Despite the facility's policy requiring the CP to perform monthly medication regimen reviews, these omissions were not identified or reported by the CP. Interviews with facility staff indicated an expectation that the CP would identify and report missed medication administrations. However, the CP did not fulfill this responsibility, and there was no documentation explaining why the insulin was not administered as ordered. This oversight placed Resident 25 at risk for unnecessary medication administration and related complications.
Failure to Administer and Document Insulin for Resident
Penalty
Summary
The facility failed to ensure that Resident 25's physician-ordered insulin and finger stick blood sugars were administered and documented as required. The resident, who had a range of medical conditions including diabetes mellitus, hypertension, and major depressive disorder, was prescribed both fast-acting and long-acting insulin. However, there were multiple instances over several months where the Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked staff sign-off for the administration of these medications and the completion of blood sugar readings. Specifically, the MAR and TAR for November 2024 through February 2025 showed numerous missed sign-offs for both Lantus and Humalog insulin, as well as for blood sugar readings. Despite the facility's policy requiring documentation when medications are not administered, there was no documentation in the resident's progress notes explaining why the insulin doses were missed. This lack of documentation and adherence to physician orders placed the resident at risk for unnecessary medication administration and related complications. Interviews with administrative nurses confirmed the expectation that nursing staff should administer insulin as ordered and document any reasons for not doing so. The facility's policy, revised in April 2019, emphasized the importance of administering medications safely and timely, and documenting any deviations. The failure to follow these protocols resulted in a deficiency related to the administration and documentation of medications for Resident 25.
Inadequate Indication for Antipsychotic Use in Residents
Penalty
Summary
The facility failed to ensure that three residents had a CMS-approved indication for the use of antipsychotic medications, leading to the risk of unnecessary medication administration and related complications. Resident 25, who had multiple diagnoses including hallucinations and major depressive disorder, was prescribed Vraylar for hallucinations without a documented physician response to a pharmacist's request for an appropriate indication. Despite a recommendation for a gradual dose reduction, the physician maintained the current dosage, citing a history of hallucinations and potential increased symptoms with a decrease. Resident 38, diagnosed with Alzheimer's disease and dementia, was prescribed risperidone for dementia with psychotic disturbances. However, a pharmacist noted that risperidone was listed for anxiety, which is not an approved indication. Although a gradual dose reduction was attempted, the facility did not ensure a CMS-approved indication for the medication, placing the resident at risk for unnecessary use. Resident 22, with severe cognitive impairment and a diagnosis of dementia, was prescribed Seroquel for major neurocognitive disorder. The clinical record lacked physician documentation of the rationale and risks versus benefits for the continued use of Seroquel. The facility's failure to ensure an appropriate indication for the use of Seroquel placed the resident at risk for unnecessary psychotropic medication administration.
Failure to Properly Label and Discard Insulin Medications
Penalty
Summary
The facility failed to properly label and discard insulin medications, which placed residents at risk for receiving ineffective medications. Observations revealed that several insulin flex pens and vials were not labeled with the date they were opened or their expiration dates. Specifically, a Glargine flex pen and a Levemir vial were found without these labels, and two other flex pens had incorrect expiration dates. Licensed nurses verified that the insulin should have been labeled and discarded according to the facility's policy and professional guidelines. Additionally, another resident's lispro insulin pen was found without an open date, which was confirmed by a licensed nurse. The facility's policy requires that insulin pens be labeled with the resident's name and the date opened. The failure to adhere to these labeling and storage policies resulted in a risk of administering ineffective insulin doses to the residents involved.
Lack of Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration of care between a resident's hospice provider and the facility, which placed the resident at risk of inadequate end-of-life care. The resident, who had been recently admitted to hospice services, had a significant medical history including Alzheimer's disease, dementia, hemiplegia, heart failure, and cerebral infarction. The resident's care plan was lacking in specific directions for staff on how to contact the hospice provider, details of the medical supplies and equipment provided by hospice, and a schedule of hospice staff visits. The resident's electronic medical record and hospice provider book were missing critical information, such as the hospice plan of care, a list of medications, and other services provided by hospice. Interviews with facility staff revealed that there was an expectation for the hospice plan of care to be included in the hospice book, and for the care plan to reflect all necessary hospice information. However, this information was not present, indicating a lack of coordination and communication between the facility and the hospice provider. The facility's Hospice Program policy outlined the responsibilities of both the hospice and the facility in managing the resident's care, emphasizing the need for coordinated care plans. Despite this policy, the facility did not ensure that the hospice plan of care was integrated into the resident's care plan, nor did it provide staff with the necessary information to effectively coordinate care with the hospice provider. This oversight resulted in a deficiency that compromised the resident's end-of-life care.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and adequate care for a resident, R1, who was at high risk for pressure ulcers due to his medical conditions, including Alzheimer's disease, Down's Syndrome, and muscle weakness. R1 was totally dependent on staff for mobility, transfers, and toileting, and was always incontinent of bowel and bladder. Despite these needs, the facility did not implement a turning/repositioning program and failed to monitor R1's skin weekly, conduct weekly wound assessments, and provide wound treatments as ordered. As a result, R1 developed an unstageable pressure ulcer on his upper medial buttocks, which was not identified by the facility until two weeks after its onset, and it progressed to a stage four pressure ulcer. The facility's inaction and lack of communication contributed to the deterioration of R1's condition. Hospice staff repeatedly found R1 in saturated briefs and linens, indicating a failure to change and reposition him every two hours as required. Despite hospice staff educating facility staff on the importance of repositioning and providing peri-care, the facility continued to fail in these duties. The facility also failed to document wound characteristics and did not have treatment orders in place for R1's pressure area until 15 days after its onset. Additionally, the facility did not notify the dietary staff of R1's pressure area, which could have impacted his nutritional interventions for skin healing. The facility's documentation was inconsistent and incomplete, with missing entries for wound care and repositioning checks. The facility failed to perform weekly skin assessments as ordered and did not document current wound characteristics. R1's condition worsened with the development of additional skin issues, including new pressure ulcers on his left outer ankle, left ear, upper right abdomen, and fingers. The facility's lack of timely intervention and inadequate care led to the progression of R1's pressure ulcers and further skin breakdown.
Failure to Update Care Plans for Residents with Pressure Ulcers and Catheter Management
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. Resident 1, diagnosed with Alzheimer's disease, Down's Syndrome, and muscle weakness, had a significant decline in his pressure ulcer from stage two to stage four, and a urinary catheter was inserted to assist with wound healing. Despite these changes, the care plan was not updated to reflect the new stage of the pressure ulcer or the presence of the urinary catheter, which was a requirement according to the facility's policy. Resident 2, who had diabetes mellitus with neuropathy, hemiplegia, and dementia, developed an arterial wound on her right foot. The care plan did not include this wound or provide guidance for its care, despite multiple assessments and treatments being documented. The facility's failure to update the care plan with the presence of the wound and the necessary care instructions was a clear oversight. Resident 5, who required assistance with personal care and had an indwelling urinary catheter, had a care plan that did not reflect his ability to empty his catheter bag independently. Observations showed improper management of the catheter tubing and drainage bag, which was not addressed in the care plan. The facility's policy required care plans to be revised as residents' conditions changed, but this was not done for Resident 5, leading to a deficiency in his care management.
Failure to Provide Ordered Wound Care and Pressure Relief
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as R2, who had an ulcer on her right foot. R2 had a medical history that included diabetes mellitus with neuropathy, hemiplegia affecting the right side, dementia, muscle weakness, and osteoarthritis. Despite being at risk for pressure ulcers, the facility did not ensure that R2 received the necessary treatments as ordered, including the use of pressure-relieving boots while in bed. Observations revealed that R2's pressure-relieving boot was often found on the floor rather than on her foot, and staff failed to change her dressing as scheduled. The facility's records showed inconsistencies and omissions in the documentation of R2's wound care. The Treatment Administration Record for June 2024 lacked any treatment interventions for R2's right foot, and there was a significant delay in implementing treatment orders for the wound. The Weekly Non-Pressure Wound assessments were incomplete, lacking measurements and descriptions of the wound area. Additionally, the facility's staff did not consistently monitor R2's wound status weekly, as required. Interviews with staff members revealed a lack of clarity and adherence to the care plan for R2. Licensed nurses and certified nurse aides were unsure about the specific requirements for R2's wound care and the use of pressure-relieving boots. The facility's policy on pressure ulcers and skin breakdown did not specify the frequency of assessments, contributing to the inadequate monitoring and treatment of R2's condition. These deficiencies highlight the facility's failure to ensure that R2 received the necessary care and treatment for her ulcer, as ordered by her physician.
Inadequate Incontinence Care for Residents
Penalty
Summary
The facility failed to provide timely incontinence care to two residents, resulting in saturated briefs and urine-soaked linens. Resident 1, diagnosed with Alzheimer's disease, Down's Syndrome, and muscle weakness, was always incontinent of bowel and bladder and dependent on staff for toileting. Despite a care plan requiring staff to check and change his brief every two hours, multiple hospice visit notes documented that Resident 1 was frequently found saturated with urine, indicating neglect in providing necessary care. Resident 2, diagnosed with hemiplegia, dementia, muscle weakness, and osteoarthritis, was also always incontinent of bowel and bladder and dependent on staff for toileting. Observations revealed that Resident 2 was not checked or changed for several hours, despite the care plan instructing staff to do so every two hours. The resident reported feeling wet and not being changed since early morning, and staff confirmed the delay in providing care. The facility's policy on urinary continence and incontinence management required scheduled toileting and interventions to manage incontinence. However, the facility's failure to adhere to these policies resulted in inadequate care for both residents, as evidenced by the repeated findings of saturated briefs and soiled linens.
Failure to Timely Reorder Pain Medications
Penalty
Summary
The facility failed to ensure timely reordering of medications for a resident, identified as R4, resulting in missed doses of critical pain management medications. R4, who had diagnoses of pain and restless leg syndrome, was assessed with intact cognition and required scheduled pain medication. The resident missed eight doses of Norco and one dose of a Fentanyl patch over a period from July 27 to July 29, 2024. The facility's Medication Administration Record (MAR) indicated that the medications were unavailable, and there was no documentation of attempts to notify the physician or pharmacy to obtain the medications. R4 reported experiencing significant pain, which affected her sleep and daily activities, with pain levels reaching up to eight or nine on a scale of ten. Despite the administration of PRN acetaminophen, which was sometimes ineffective, the facility did not document the use of other available pain management options, such as Voltaren gel. The resident expressed that the facility had run out of her medication in the past and noted that the medication aides did not reorder in a timely manner, leading to a delay in obtaining a new prescription over the weekend. Interviews with facility staff revealed a lack of awareness and communication regarding the medication shortage. Certified Medication Aide R and Administrative Nurse D described the process for reordering medications, which involved using the electronic system or faxing a request to the pharmacy. However, there was a failure to follow these procedures effectively, as evidenced by the lack of documentation and follow-up. The facility's policy on medication administration did not provide clear instructions for reordering medications, contributing to the oversight that led to R4's missed doses.
Infection Control Deficiencies in Glove Use and Catheter Positioning
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations involving improper glove removal and hand hygiene practices. On one occasion, a Certified Nurse Aide (CNA) removed a resident's wet disposable brief with gloved hands and then handled a new brief without changing gloves. Additionally, a Licensed Nurse (LN) performed wound care on a resident's pressure ulcer without performing hand hygiene between glove changes, despite acknowledging the importance of doing so. The LN also used scissors to cut a foam piece and applied it to the resident's wound without proper hand hygiene, and the CNA assisted with the same gloves used to handle the wet brief and trash can. Another incident involved a CNA providing peri-care to a resident after incontinence and then placing clean bedding and a brief on the resident without changing gloves. The CNA later acknowledged the need to change gloves between tasks. Furthermore, a resident's pressure-reducing boot was stored directly on the floor, which is not in line with proper infection control practices. The facility also failed to ensure proper positioning of a resident's urinary catheter drainage bag. The catheter tubing was observed exiting from the bottom of the resident's pant leg and crossing a lap tray before reaching the drainage bag, which was positioned above the bladder. This improper positioning was noted on two separate occasions, and staff acknowledged that the drainage bag should be positioned lower than the bladder to prevent complications. The facility's policies on hand hygiene and catheter care were not adhered to, contributing to these deficiencies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wichita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Great Plains Post Acute | 1.3 mi | — | 11 | 0 |
| Larksfield Place | 1.5 mi | — | 0 | 0 |
| Life Care Center Of Wichita | 2 mi | — | 0 | 0 |
| Catholic Care Center, Inc | 3.2 mi | — | 1 | 1 |
| Center At Waterfront Llc | 3.3 mi | — | 19 | 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 August 2026) and official state health department websites.