Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
HERITAGE GROVE ESTATES
TOPEKA, KS · 80 certified beds · Last Life Safety survey August 7, 2024
CMS Certification Number 175171 · first certified June 1988
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within KS
36 citations — more than 78% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 15. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (March 2026 to June 2026), and past the point by which nine in ten KS facilities have been surveyed. This facility’s last Life Safety survey was August 2024. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
7 of the 36 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 36 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 36 |
| Median facility in KS | 27 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 18, 2021 | 15 |
| February 2, 2023 | 15 |
| August 7, 2024 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2024-08-07 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-08-07 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2023-02-02 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 2 | 2024-08-07 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2023-02-02 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-08-07 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2024-08-07 |
| K-0222 | 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. | 2 | 2023-02-02 |
What the citations cover
- Smoke Deficiencies 11
- Emergency Preparedness Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 5
- Other 8
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Emergency Preparedness Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 5 |
| Miscellaneous Deficiencies | 5 |
| Services Deficiencies | 1 |
| Construction Deficiencies | 1 |
| Electrical Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 7, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (October 17, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 17, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 17, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (September 30, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 17, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 17, 2024) |
February 2, 2023 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (April 28, 2023) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (April 28, 2023) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (April 28, 2023) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (April 28, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (April 28, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted (March 22, 2023) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 28, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 28, 2023) |
August 18, 2021 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (September 27, 2021) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 27, 2021) |
| K-0222 | 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. | Deficient, Provider has date of correction (September 27, 2021) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (September 27, 2021) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 27, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 27, 2021) |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Waiver has been granted (September 27, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 27, 2021) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Waiver has been granted (September 27, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 27, 2021) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (September 27, 2021) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (September 27, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted (September 27, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 27, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 27, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.