2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
18 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Topeka, KS
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
1031 Sw Fleming Court, Topeka, KS
(785) 440-0500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
90
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Midwest Health
Operator or chain grouping
Approved since
1985-12-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.71
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.09
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.66
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.26
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
5.02
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
6,560
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9871
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.66% · Performance 22.95% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.41
Baseline 4.25% · Performance 6.52% · Measure score 4.41 · Achievement 4.41 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
5.34
Baseline 4.84 hours · Performance 4.60 hours · Measure score 5.34 · Achievement 5.34 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.95% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 310 · Observed rate 9.68% · Lower 95% interval 8.71% |
| Discharge to community | 72.32% |
50.57%
21.7 pts better
|
Better than the National Rate · Eligible stays 295 · Observed rate 72.54% · Lower 95% interval 67.72% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.71% |
95.27%
0.6 pts worse
|
Numerator 215 · Denominator 227 |
| Falls with major injury | 0.44% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 227 |
| Discharge self-care score | 46.43% |
53.69%
7.3 pts worse
|
Numerator 78 · Denominator 168 |
| Discharge mobility score | 41.07% |
50.94%
9.9 pts worse
|
Numerator 69 · Denominator 168 |
| Pressure ulcers or injuries, new or worsened | 1.32% |
2.29%
1 pts better
|
Numerator 3 · Denominator 227 · Adjusted rate 1.72% |
| Healthcare-associated infections requiring hospitalization | 6.52% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 199 · Observed rate 4.52% · Lower 95% interval 4.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 146 |
| Staff flu vaccination coverage | 42.34% |
42%
0.3 pts better
|
Numerator 58 · Denominator 137 |
| Discharge function score | 45.24% |
56.45%
11.2 pts worse
|
Numerator 76 · Denominator 168 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 199 · Denominator 199 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 73.17% |
25.2%
48 pts better
|
Numerator 90 · Denominator 123 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.2
1.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
91.8%
1.8 pts better
|
93.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 90.7% · Q3 94.5% · Q4 94.3% · 4Q avg 93.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.0% |
95.5%
5.5 pts worse
|
95.5%
5.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
4.4%
3 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 3.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
5.0%
3.7 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 2.8% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.8% |
23.2%
1.4 pts better
|
19.6%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 24.4% · Q3 23.7% · Q4 19.4% · 4Q avg 21.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
19.8%
9.3 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 11.8% · Q3 15.6% · Q4 12.1% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.3% |
18.4%
3.9 pts worse
|
16.3%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
18.8%
5.6 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 20.0% · Q3 16.2% · Q4 11.1% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.8%
0.1 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.4% · Q3 1.8% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
3.1%
1.7 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.9% · Q4 1.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.9% |
23.2%
5.7 pts worse
|
19.8%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 35.4% · Q3 20.6% · Q4 29.6% · 4Q avg 28.9% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.6%
0.4 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.7% · Q3 3.5% · Q4 5.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
75.6%
15.9 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.6% · Q2 88.3% · Q3 90.8% · Q4 94.8% · 4Q avg 91.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
11.7%
1 pts worse
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 11.3% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.2%
1.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.9% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.3% |
73.5%
2.8 pts better
|
79.7%
3.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.5% |
23.0%
9.5 pts worse
|
23.9%
8.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.5% · Observed 25.3% · Expected 18.5% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (1 deficiency)
18 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Nursing and Physician Services (1 deficiency)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Pharmacy Service (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-09-11
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-09-11
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-11
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-09-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-13
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-11
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-11
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-11
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-09-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-11
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-11
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-09-11
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-11
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-16
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-11
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-13
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-13
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-22
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-22
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-05-22
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-22
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-22
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-05-22
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-22
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-22
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-22
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-05-22
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-22
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2021-12-02
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-02
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2021-12-02
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-12-02
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-02
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-12-02
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-12-02
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-02
Fire Safety
Use approved construction type or materials.
Corrected 2021-12-02
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-02
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-12-02
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-12-02
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-02
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-02
Inspection history
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-08-15
Health
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.
Corrected 2024-08-15
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-04-30
Health
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.
Corrected 2023-04-30
Health
Post nurse staffing information every day.
Corrected 2023-04-30
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-12
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-11-12
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-11-12
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Nearby options
Topeka, KS
2-star overall rating with 2-star inspections with $39,105 in total fines with 15 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
Topeka, KS
3-star overall rating with 2-star inspections with $15,076 in total fines with 5 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
Topeka, KS
1-star overall rating with 1-star inspections with $93,073 in total fines with 21 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
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