7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Hiawatha, KS
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
302 E Iowa Street, Hiawatha, KS
(785) 742-7465
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
53
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.88
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.34
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.92
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
4.44
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
0%
Annual nurse turnover
SNF VBP
Program rank
9,644
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.1
Performance 20.92% · Measure score 1.1 · Achievement 1.1 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.49
Baseline 5.63% · Performance 7.39% · Measure score 1.49 · Achievement 1.49 · 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
4.32
Baseline 4.47 hours · Performance 4.31 hours · Measure score 4.32 · Achievement 4.32 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.22% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 14.67% · Lower 95% interval 8.45% |
| Discharge to community | 47.41% |
50.57%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 42% · Lower 95% interval 35.73% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 29.69% |
95.27%
65.6 pts worse
|
Numerator 19 · Denominator 64 |
| Falls with major injury | 3.13% |
0.77%
2.4 pts worse
|
Numerator 2 · Denominator 64 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 16 · Denominator 48 |
| Discharge mobility score | 47.92% |
50.94%
3 pts worse
|
Numerator 23 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 6.25% |
2.29%
4 pts worse
|
Numerator 4 · Denominator 64 · Adjusted rate 5.72% |
| Healthcare-associated infections requiring hospitalization | 7.39% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 7.14% · Lower 95% interval 3.23% |
| Staff COVID-19 vaccination coverage | 28.81% |
8.2%
20.6 pts better
|
Numerator 17 · Denominator 59 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 47.92% |
56.45%
8.5 pts worse
|
Numerator 23 · Denominator 48 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 26.67% |
25.2%
1.5 pts better
|
Numerator 8 · Denominator 30 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.2
0.3 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
91.8%
3.8 pts better
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 100.0% · Q3 95.3% · Q4 89.7% · 4Q avg 95.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.1% |
95.5%
0.4 pts worse
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
4.4%
About the same
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 7.0% · Q4 7.7% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.0% |
5.6%
15.4 pts worse
|
11.4%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 28.9% · Q3 30.2% · Q4 13.2% · 4Q avg 21.0% |
| Percentage of long-stay residents who lose too much weight | 10.7% |
5.0%
5.7 pts worse
|
5.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 18.5% · Q3 12.9% · Q4 3.0% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
23.2%
13.6 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 6.9% · Q3 9.4% · Q4 3.0% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.8% |
19.8%
6 pts worse
|
16.7%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q3 28.0% · Q4 25.0% · 4Q avg 25.8% · 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 | 23.1% |
18.4%
4.7 pts worse
|
16.3%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q3 26.1% · Q4 10.7% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.7% |
18.8%
7.9 pts worse
|
14.9%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 32.1% · Q3 39.3% · Q4 6.7% · 4Q avg 26.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.5% |
1.8%
3.7 pts worse
|
1.0%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 9.0% · Q3 7.6% · Q4 0.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.4% |
3.1%
5.3 pts worse
|
1.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 10.8% · Q3 19.0% · Q4 0.0% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.8% |
23.2%
7.6 pts worse
|
19.8%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 46.5% · Q3 23.9% · Q4 22.6% · 4Q avg 30.8% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.6%
0.1 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 4.8% · Q4 10.4% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.4% |
75.6%
0.2 pts worse
|
81.7%
6.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 82.8% · Q3 70.0% · Q4 62.5% · 4Q avg 75.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.7% |
11.7%
7 pts better
|
12.0%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 4.8% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 9.5% |
2.2%
7.3 pts worse
|
1.6%
7.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 9.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
73.5%
13.2 pts better
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.8% |
23.0%
9.2 pts better
|
23.9%
10.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 11.9% · Expected 20.6% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-10
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-10
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-10
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-06-10
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-10
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-06-10
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-08-24
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-08-24
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-08-24
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-08-24
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-24
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-08-24
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-24
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-08-24
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-01-03
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-01-03
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-03
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-01-03
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-01-03
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-01-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-03
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-01-03
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-01-03
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-23
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-23
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-23
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 2025-04-23
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 2025-04-23
Health
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.
Corrected 2025-04-23
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-04-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-19
Health
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.
Corrected 2023-07-19
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-19
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-07-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-19
Health
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.
Corrected 2023-07-19
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-07-19
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-19
Health
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.
Corrected 2023-07-19
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 2023-07-19
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 2023-07-19
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-19
Health
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.
Corrected 2023-07-19
Health
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.
Corrected 2021-12-14
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 2021-12-14
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-12-14
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 · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
General Partnership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
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Sabetha, KS
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