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.

36
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
9
Tags cited more than once
Across separate surveys
14
Inspection & testing records
Of the citations on file

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

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

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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Which alerts

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

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.

This facility36KS median27National median11
Citations on file over three years, compared
MeasureCitations
This facility36
Median facility in KS27
Median facility nationally11

Survey history

Citations at each Life Safety survey
152021-08152023-0262024-08
Citations at each Life Safety survey
Survey dateCitations
August 18, 202115
February 2, 202315
August 7, 20246

Most-cited tags

Most-cited tags at this facility
K-09183K-03533K-03742E-00262K-09202K-03632K-02112K-02222
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.32024-08-07
K-0353Inspect, test, and maintain automatic sprinkler systems.32024-08-07
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.22023-02-02
E-0026Establish roles under a Waiver declared by secretary.22024-08-07
K-0920Ensure proper usage of power strips and extension cords.22023-02-02
K-0363Install corridor and hallway doors that block smoke.22024-08-07
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.22024-08-07
K-0222Add 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.22023-02-02

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 11
  • Emergency Preparedness Deficiencies 7
  • Gas, Vacuum, and Electrical Systems Deficiencies 5
  • Egress Deficiencies 5
  • Other 8
Citations by CMS category
CategoryCitations
Smoke Deficiencies11
Emergency Preparedness Deficiencies7
Gas, Vacuum, and Electrical Systems Deficiencies5
Egress Deficiencies5
Miscellaneous Deficiencies5
Services Deficiencies1
Construction Deficiencies1
Electrical Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

August 7, 2024 — 6 citations

Citations issued on August 7, 2024
TagWhat the surveyor checksStatus
E-0026Establish roles under a Waiver declared by secretary.Deficient, Provider has date of correction (October 17, 2024)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (October 17, 2024)
K-0321Ensure 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-0353Inspect, test, and maintain automatic sprinkler systems.Waiver has been granted (September 30, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (October 17, 2024)
K-0918Have 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

Citations issued on February 2, 2023
TagWhat the surveyor checksStatus
E-0009Include a process for Emergency Preparedness collaboration.Deficient, Provider has date of correction (April 28, 2023)
E-0025Create arrangements with other facilities to receive patients.Deficient, Provider has date of correction (April 28, 2023)
E-0026Establish roles under a Waiver declared by secretary.Deficient, Provider has date of correction (April 28, 2023)
E-0031Provide emergency officials' contact information.Deficient, Provider has date of correction (April 28, 2023)
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (April 28, 2023)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (April 28, 2023)
K-0222Add 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-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 28, 2023)
K-0354Follow 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-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (April 28, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (April 28, 2023)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Waiver has been granted (March 22, 2023)
K-0901Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.Deficient, Provider has date of correction (April 28, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (April 28, 2023)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (April 28, 2023)

August 18, 2021 — 15 citations

Citations issued on August 18, 2021
TagWhat the surveyor checksStatus
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (September 27, 2021)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (September 27, 2021)
K-0222Add 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-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (September 27, 2021)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (September 27, 2021)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (September 27, 2021)
K-0361Ensure 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-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (September 27, 2021)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Waiver has been granted (September 27, 2021)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (September 27, 2021)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (September 27, 2021)
K-0753Have restrictions on the use of highly flammable decorations.Deficient, Provider has date of correction (September 27, 2021)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Waiver has been granted (September 27, 2021)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (September 27, 2021)
K-0920Ensure 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.