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Maple Heights Nursing & Rehabilitative Center

302 E Iowa Street, Hiawatha, KS 66434 · For profit - Limited Liability company · 53 certified beds · (785) 742-7465 Medicare & Medicaid certified

Call the home — (785) 742-7465 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$12,735 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $12,735 in federal fines (most recent 2026-03-19)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
300 Utah St · (785) 742-2161 · Call to confirm hours
Pharmacy
101 S 6th St · (785) 742-2125 · Call to confirm hours
Grocery
808 E Miami St · (785) 742-7639 · Call to confirm hours
Park
201 E Iowa St · (785) 742-7176 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.3%17.9%15.4%better
Long-stay residents who lose too much weight5.4%4.9%5.4%typical
Long-stay residents with a catheter left in their bladder1.9%1.6%0.9%worse
Long-stay residents with a urinary tract infection4.8%2.9%2.0%worse
Long-stay residents with depressive symptoms19.1%6.5%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.2%4.3%3.3%worse
Long-stay residents whose ability to walk worsened12.5%16.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication5.2%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine95.1%95.5%95.3%typical
Long-stay residents with pressure ulcers5.4%4.4%4.7%worse
Long-stay residents with worsening bladder/bowel control29.0%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table22.9%18.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication8.2%1.9%1.4%worse
Short-stay residents given the seasonal flu vaccine86.7%73.8%79.4%typical
Short-stay residents rehospitalized after admission17.9%22.4%22.6%better
Short-stay residents with an outpatient ER visit7.8%11.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.391.801.67better
Long-stay outpatient ER visits per 1,000 resident days2.232.131.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

47.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 50 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.4%U.S. median 51.5%
Got home and stayed home
12.2%U.S. median 10.7%
Went back to hospital
33.3%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 33.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 39 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF47.4%CMS range 35.7–62.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.2%CMS range 8.4–17.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge33.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge30.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge25.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified40.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.4%CMS range 3.2–12.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.721.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.55
RN hours/ resident / day
0.54
LPN hours/ resident / day
2.34
Aide hours/ resident / day
3.44
Total nurse hours/ resident / day
0.35
RN hoursweekends
45.7%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 53 beds and averages 52.1 residents a day — about 98% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.554 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.02 hrs/resident/day on weekends vs 3.61 on weekdays — 16% thinner on weekends. RN hours go from 0.64 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-03-26)
15
at the previous standard inspection (2023-06-15)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2026-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 50 residents. The sample included three residents with three residents reviewed for hot liquid safety. Based on observations, record review, and interviews, the facility failed to ensure an environment free from accident hazards when on 02/15/26 Dietary Staff CC provided cognitively impaired Resident (R) 1 with coffee in a lidded cup, without obtaining the temperature of the coffee prior to giving it to her, and R1 spilled the coffee on herself. After the spill, the staff obtained the temperature of the coffee, which was 151 degrees Fahrenheit. R1 sustained second degree burns from the hot liquid spill. Findings included:- R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented diagnoses of generalized muscle weakness, dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (difficulty swallowing), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2025-03-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 44 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 44 residents in the facility, who receive their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food borne illness. Findings included: - On 03/24/25 at 8:20 AM, during initial kitchen tour, observation revealed the following: Two 24 inch by 24 inch, air vent located above the cooking stove area covered with brownish grease/sticky substance and gray fuzzy substance blowing directly on the food preparation and stove cooking area. Four overhead florescent light fixtures had the covers missing and located over the food preperation area. One 36 inch by 24 inch return air grill covered with brownish gray fuzzy substance that covered the metal grill. Six round light bulbs with wire cages around the bulbs, located in the exhaust hood above the stove top with brownish gray fuzzy substance affixed to the wire cages.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 15 residents. Based on observation, interview, and record review, the facility failed to notify the State Long Term Care Ombudsman (LTCO), Resident (R)9's and R15's facility-initiated discharge to the hospital. This placed the residents at risk for impaired rights. Findings included: -R9's Electronic Health Record (EHR) revealed diagnoses of included healing fracture neck of the left femur (thigh bone,) dementia (a progressive mental disorder characterized by failing memory and confusion) osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk,) and muscle weakness. R9's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R9 required extensive assistance of two staff with bed mobility and transfers. The MDS further documented the resident had no falls since reentry on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 15 residents with one reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to initiate effective interventions to prevent the development of a left heel, facility acquired, unstageable pressure ulcer (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus,) for Resident (R) 9. Findings included: - R9 's diagnoses included healing fracture neck of the left femur (thigh bone,) dementia (a progressive mental disorder characterized by failing memory and confusion) osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk,) and muscle weakness. R9's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented required extensive assistance of two staff with bed mobility and transfers. The MDS…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 15 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identify and report Resident (R) 39's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for use. This placed the residents at risk for inappropriate use of medication. Findings included: - The Electronic Medical Record (EMR) for R39 documented diagnoses of dementia (a progressive mental deterioration characterized by confusion and memory failure) without behavioral disturbance, vitamin D deficiency, and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The admission Minimum Data Set (MDS), dated [DATE], documented severely impaired cognition. R39 required set-up assistance from staff for eating, oral hygiene, and partial assistance with dressing.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 15 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identify and report Resident (R) 39's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for This placed the residents at risk for inappropriate use of medication. Findings included: - The Electronic Medical Record (EMR) for R39 documented diagnoses of dementia (a progressive mental deterioration characterized by confusion and memory failure) without behavioral disturbance, vitamin D deficiency, and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The admission Minimum Data Set (MDS), dated [DATE], documented severely impaired cognition. R39 required set-up assistance from staff for eating, oral hygiene, and partial assistance with dressing. R39…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 31 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 12 and R31s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when started in use and when expired. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On 03/24/25 at 09:10 AM, observation of the facility's 100 and 200 hall treatment cart revealed the following: R12's Lantus (long-acting insulin) two flex pens were not labeled with an open or expired date. R31's Humalog (fast-acting insulin) flex pen was labeled with an open date of 02/26/25 and expired date of 03/19/25. (Date of observation 03/24/25 - 5 days past expiration) On 03/24/25 at 09:15 AM, Administrative Nurse D verified the nurses should label and date the insulin flex pens with the date opened and the expiration date and should discard the expired insulin pens. Medlineplus.gov directs open, unrefrigerated Lantus and Humalog can be used within 28 days; after that time, they must be discarded. The…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-26 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility had a census of 44 residents. Based on observation, record review and interview the facility failed to provide a safe, sanitary environment for Resident (R) 15 when staff failed to clean his carpet and recliner. Findings included: 03/24/25 at 10:00 AM, R15's room had a black stain in the carpet in front of a recliner, approximately 18 inches (in) long by eight in wide. The recliner had a red stain on the left arm , approximately six in. by three in wide. The left arm cover had a yellow stain , approximately two in by two in. The room and the recliner had a urine odor. 03/25/25 at 11:47 AM Housekeeping Supervisor (HS) V verified there was a urine odor in R15 room. HS V stated the urine smell was in the carpet and the recliner. HS v verified the stains in the carpet and on the recliner and stated she had cleaned the carpet several times and could not get the urine odor out, it was probably in the carpet pad also. 03/25/25 11:59 AM Administrative Staff A stated she was aware of the urine smell in the resident's room and recliner. The stain in front of the recliner is from…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-06-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 36 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to storage of food. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings included: - On 06/13/23 at 07:15 AM in the kitchen's small refrigerator an observation revealed a bag of mozzarella cheese open with no date. On 06/13/23 at 07:16 AM in the kitchen's small refrigerator an observation revealed bacon, cut into small pieces, in a resealable bag that had no label or date. On 06/13/23 at 07:17 AM in the kitchen's small refrigerator an observation revealed three, unlabeled bottles of salad dressing that were open with no date. On 06/13/23 at 07:26 AM on a small storage shelf in the main kitchen area, an observation revealed a bag of raisin bran cereal that was opened with no date. On 06/13/23 at 07:34 AM in the kitchen's large refrigerator an observation revealed one resealable bag of various lunch meat. The bag did not have a label…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 36 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the nine cognitively impaired, independently mobile residents. The facility additionally failed to identify and implement resident centered fall intervention for Resident (R)20's repeated falls and failed to ensure implemented interventions identified during some investigations were added to the R20's plan of care. The facility further failed to prevent an avoidable accident when staff failed to ensure the floor was dry prior to a transfer, resulting in a fall for R18. This placed the affected residents at risk for preventable accidents and related injuries. Findings Included: - On 06/13/23 at 07:03AM an inspection of the facility's 100 and 200 hallway shower rooms revealed unsecured disinfectant cleaning products accessible inside both unlocked rooms. An inspection of the 100 hallway revealed an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-15 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility reported a census of 36 residents. Based of observations, record review, and interviews, the facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: - On 06/13/23 at 07:02AM a medication treatment cart outside Resident (R)10's room contained a Novolog Flexpen (injectable short-acting hormone which regulates blood sugar) left unsecured on top of the cart from 07:02AM to 07:10AM. The insulin belonged to R10. At 07:10AM Licensed Nurse (LN) G returned to the cart and secured the pen. On 06/15/23 at 12:34PM Licensed Nurse (LN) G stated medication should be secured when not being immediately administered or supervised. He stated staff should locked up medication in the cart when stepping away from the cart. On 06/15/23 at 01:02PM Administrative Nurse D stated staff were expected to lock up medication when not in use or keep constant supervision on medication being prepared for the residents. A review of the facility's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · E2023-06-15 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 35 residents. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to clean supply storage, respiratory equipment, shared care equipment, hand hygiene during medication administration, and providing cares. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 06/13/23 at 07:10AM an inspection of the 100-hallway shower room revealed three opened packages of incontinence briefs stored on a shelf above the toilet. The content of packages (incontinence briefs) was pulled out of the plastic wrapper and stored directly on the shelf. On 06/13/23 at 08:01 AM Laundry Staff V stated she obtained water temperature daily but only recorded the temperature weekly. The facility was unable to provide evidence staff routinely assessed laundry water temperature. On 06/13/23 at 08:01AM Resident (R)35's nebulizer face mask and tubing were on his bed, unbagged. His tubing was not labeled/dated indicating what…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-15 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed provide written notice of transfer with the required information to Resident (R) 90 and/or to their legal representative in a practicable amount of time. The facility also failed to send notification to the office of the state Long-Term Care Ombudsman of the facility's transfers and discharges. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for these residents. Findings included: - R90's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of history of a traumatic brain injury (usually results from a violent blow or jolt to the head or body) and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure a care plan area was initiated to address Resident (R) 2's limited range of motion (ROM) due to contracture (an abnormal permanent fixation of a joint) of her joints, bilateral upper and lower extremities, and neck to maintain her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort. Findings included: - The electronic medical record for (EMR) for R2 documented diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and rheumatoid arthritis (RA-a chronic inflammatory disease that affected joints and other organ systems). The Annual Minimum Data Set (MDS) dated [DATE] for R2 documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R2 required limited assistance with eating…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure Resident (R) 28 had interventions in place to promote healing of a pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This deficient practice placed R28 at risk for delayed healing and additional skin breakdown. Findings included: - The electronic medical record (EMR) for R28 documented diagnoses of unstageable pressure ulcer of the heel, infection of skin (occur when bacteria infect the skin and sometimes the deep tissue beneath the skin), and fracture (broken bone) of left femur (thigh bone). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R28 had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R28 required extensive assistance to total…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the failed to ensure a restorative program was provided to Resident (R) 2, who had limited range of motion (ROM) due to contracture (an abnormal permanent fixation of a joint) of her joints, to maintain her current level of ROM and promote comfort. This deficient practice placed R2 at risk for decreased ROM and impaired comfort. Findings included: - The electronic medical record for (EMR) for R2 documented diagnoses of osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and rheumatoid arthritis (RA-a chronic inflammatory disease that affected joints and other organ systems). The Annual Minimum Data Set (MDS) dated [DATE] for R2 documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R2 required limited assistance with eating but was total dependent on two staff for all other…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 12 residents with four reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized toileting interventions related to bowel and bladder incontinence for Residents (R)17 and provide sanitary Foley catheter (tube inserted into the bladder to drain urine into a collection bag )care for R10. This deficient practice placed the residents at risk for complications related to infection and incontinence. Findings Included: - The Medical Diagnosis section within R17's Electronic Medical Records (EMR) included diagnoses of amputation of right foot great toe, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (high blood…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 12 residents with two reviewed for respiratory care. Based on observation, record review, and interviews, the facility additionally failed to date and store Resident (R)35's supplemental oxygen equipment (masks and tubing) in a sanitary manner. This deficient practice placed R35 at risk for complications related to respiratory care and infections. Findings Included: - The Medical Diagnosis section within R35's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), chronic obstructive pulmonary disorder (COPD), shortness of breath, ,and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). A review of R35's Significant Change Minimum Data…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 36 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure nurse aid staff possessed the competency and skills necessary to care for residents' catheters (a tube placed into the bladder to drain urine into a collection bag). This deficient practice placed the affected residents at risk for catheter related urinary tract infection (UTI-an infection of the organs of the urinary tract) or other urinary system complications. Findings included: - On 06/14/23 at 09:06 AM Certified Nurse Aide (CNA) N and CNA P transferred R10 with a Hoyer lift (a mechanical lift used to aid in the safe transfer of a resident from one surface to another) from a recliner into the bed. R10's urine collection bag, covered by a dignity bag, was attached to the arm of Hoyer lift next to R10's head. On 06/14/23 at 11:42 AM CNA N and CNA P explained to R10 they were going to perform catheter care. CNA N donned gloves, CNA P had gloves on. CNA N removed the tape from the incontinent brief and pulled the brief…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-15 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 36 residents. The sample included 12 residents with six residents sampled for unnecessary medications. Based on observation, record review and interview the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of staff monitoring Resident (R) 36 for side effects and behaviors associated with the use/administration of the antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication mirtazapine. These deficient practices placed R38 at risk of unnecessary mediation administration and potential adverse side effects. Findings included: - The electronic medical record (EMR) for R36 documented diagnoses of major depressive disorder (major mood disorder), and Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS) for R36 documented she had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R36 required supervision with her…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 36 residents. The sample included 12 residents with six residents sampled for unnecessary medications. Based on observation, record review and interview the facility failed to ensure that staff monitored Resident (R) 36 for side effects and behaviors associated with the use/administration of the antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication mirtazapine. This deficient practice placed these resident at risk of unnecessary mediation administration and adverse side effects. Findings included: - The electronic medical record (EMR) for R36 documented diagnoses of major depressive disorder (major mood disorder), and Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS) for R36 documented she had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R36 required supervision with her activities of daily living (ADLs). R36 required the use of an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 36 residents. The sample included 12 residents with five residents reviewed for reviewed for vaccination status. Based on record reviews, and interviews, the facility failed to obtain influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination consent, declination, or administration information for Resident (R) 35. This deficient placed R35 at increased risk for influenza and related complications. Findings included: - Review of the R35's EMR under the Immunization tab lacked documentation of influenza vaccination. The facility was unable to provide a signed consent or declination On 06/15/23 at 12:34 PM Licensed Nurse (LN) G stated residents were offered immunizations at the time of their admission. LN G stated the resident would sign a consent or declination at that time. LN G stated the local pharmacy came to the facility to administer the vaccine. On 06/15/23 at 11:35 AM Administrative Staff B stated the Infection Preventionist (IP) tracked the immunizations at the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-15 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 36 residents. The sample included 12 residents with five residents sampled for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccinations. Based on record review and interviews, the facility failed to obtain signed consents or declinations for COVID-19 vaccinations for Resident (R) 35. This deficient practice placed the resident at increased risk for COVID-19. Findings included: - R35 admitted to the facility on [DATE]. His medical record lacked evidence a COVID-19 vaccination was previously received or offered upon admission. The record lacked evidence of a signed consent or declination for COVID-19 vaccination for R35. On 06/15/23 at 11:35 AM Administrative Staff B stated the Infection Preventionist (IP) tracked the immunizations at the time a resident was admitted to the facility. Administrative Staff B stated the IP checked online for the immunization status under the Kansas Department…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-11-04 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The facility identified a census of 44 residents. The facility had two medication storage rooms. Based on observation, record review and interview, the facility failed to ensure medications were stored properly in one of the two medication storage rooms. This placed residents at risk for decreased medication effectiveness and unnecessary side effects. Findings Included: - On 11/02/2021 at 07:40 AM observation revealed the medication storage refrigerator which contained controlled substances (drugs which have a high abuse risk) was not locked. The following medications were present: R1's morphine sulfate (controlled narcotic pain medication) 20 milligrams (mg)/milliliter (ml) bottle, lorazepam (medication used to treat agitation, anxiety and air hunger) 2mg/ml bottle R15's morphine sulfate 20mg/ml bottle, lorazepam 2mg/ml bottle R9's morphine sulfate 20mg/ml bottle, lorazepam 2mg/ml bottle R38's morphine sulfate 20mg/ml bottle, lorazepam 2mg/ml bottle On 11/02/2021 at 07:45 AM, the medication refrigerator temperature log lacked 11 of 30 entries for September 2021 and 12 of 31 entries…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-04 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 44 residents. The sample included 15 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified a blood pressure medication order for Resident (R)35 lacked a pulse parameter ordered by the physician or documentation of the pulse , and blood pressure and pulse reading for R13 was not documented. This deficient practice had the potential risk for unnecessary medication and unwarranted side effects for those two sampled residents. Findings included: - The electronic medical record (EMR) for R35 documented diagnoses of atrial fibrillation (a rapid, irregular heartbeat), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS) documented R35 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. He required extensive assistance…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-04 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 44 residents. The sample included 15 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure that a pulse was obtained and documented for Resident (R)35's metoprolol tartrate (a medication used to control heart rhythm, treat chest pain, and reduce blood pressure) prior to administration; and blood pressure and a pulse reading for R13 was not documented prior to administration of carvedilol (a medication used to high blood pressure and heart failure). This deficient practice had the potential risk for unnecessary medications and unwarranted side effects for those two sampled residents. Findings included: - The electronic medical record (EMR) for R35 documented diagnoses of atrial fibrillation (a rapid, irregular heartbeat), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS) documented R35 had a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$12,735 in federal fines across 1 penalty.

  • $12,735 — penalty dated 2026-03-19

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
HIAWATHA JV HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTEREST100%since 07/25/2023
ANEW HEALTHCARE HOLDINGS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/10/2023
ANEW HOLDINGS KANSAS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/10/2023
ANEW KS JV, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/09/2023
SIYO HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 03/14/2022
GRUNBAUM, YONIIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2023
HASTINGS, MARKIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 08/01/2023
TREITEL, NASSANIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 08/01/2023

CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$2.3M
Net patient revenuemost recent cost report
-8.7%
Operating marginrevenue minus expenses
$60K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 55%Medicare 7%Other / private 38%

This home reported $60K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$268per resident / day
operating cost
$8,132per month
≈ monthly operating cost
$246per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KS

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.

Typical monthly cost in Kansas
$8,669/mo
Nursing home (semi-private)
$9,064/mo
Nursing home (private)
$5,975/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175508. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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