Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hiawatha Care Center during CMS and state inspections, most recent first.
A facility failed to develop comprehensive, person-centered care plans with measurable, resident-specific target behaviors for four residents receiving psychotropic medications. The care plans for residents with diagnoses including depression, bipolar disorder, dementia, anxiety, and Alzheimer's disease mainly directed staff to monitor for adverse side effects or administer meds as ordered, but did not document individualized behaviors for depression, anxiety, or psychosis. The DON stated there was no broad documentation of target behaviors and the MDS Coordinator said some care plans would be updated.
Food Allergy Not Followed During Meal Service: A resident with a documented banana allergy was served a banana during breakfast and reported nausea and a reaction afterward. The allergy was listed in the EHR and on the dietary tray card, but staff gave inconsistent accounts of how allergy information was checked during meal service, and an LPN administered ondansetron for nausea. The facility’s policy addressed substitutions for allergies but did not describe how allergies were communicated during meal service.
A resident with dementia, osteoporosis, and a high fall risk required assistance with transfers and ambulation, but staff left the call light clipped above the bed and out of reach. The resident reported she could not find the call light, tried to reach for it, and fell, resulting in left arm pain. Staff later confirmed the call light was not accessible and that the resident used a paddle-type call light that should have been placed next to her hand.
A resident with multiple medical conditions and severe cognitive impairment, who required staff assistance and specific equipment for transfers, sustained a serious leg laceration during a transfer when staff failed to use a walker as directed in the Care Plan. The injury was caused by the resident's leg catching on a sharp wheelchair pedal that could not be fully repositioned due to an obstruction, leading to significant bleeding and the need for emergency medical care.
The facility did not maintain safe food temperatures during a noon meal service. The pork loin and turkey burgers were served below the required 135 degrees Fahrenheit, with temperatures dropping to 125 and 111.3 degrees Fahrenheit, respectively. The Dietary Director acknowledged the deficiency, noting that the meat should be held at a minimum of 135 degrees Fahrenheit.
The facility failed to ensure proper hair restraint use during a meal service, with staff having exposed hair while serving food. The Dietary Director expected staff to check each other for compliance, as per the facility's policy requiring hair to be styled away from the collar and fully covered by hair restraints.
A facility failed to follow infection control protocols during a medication pass for a resident with cognitive impairment and multiple diagnoses. An RN handled Potassium Chloride ER capsules with bare hands, without sanitizing or wearing gloves, contrary to facility policy and expectations. The DON confirmed the need for hand hygiene and glove use during such procedures.
The facility failed to respect the dignity and autonomy of three residents. An LPN publicly reprimanded a resident with Alzheimer's, compromising his dignity. Another resident with intact cognition was not allowed to get up at night as requested, feeling mistreated. A third resident's preferences regarding dentures and bedtime were ignored by a CNA. These actions violated the facility's dignity policy, and the administration was unaware of the full extent of complaints.
The facility failed to maintain proper sanitary practices and food temperatures during meal service. A dietary aide served glasses with bare fingers touching the drinking rim, and several food items were not heated or cooled to the appropriate temperatures. The dietary supervisor confirmed that staff are expected to follow proper guidelines, but these were not adhered to during the observed meal service.
The facility failed to notify the ombudsman when residents were transferred to the hospital. This deficiency was observed in three residents with varying degrees of cognitive impairment and serious medical conditions. The facility's practice was to notify the ombudsman only for discharges, not transfers, and lacked a policy on ombudsman notification.
Failure to Develop Person-Centered Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with measurable, person-centered interventions for four residents reviewed for unnecessary medications. For Resident #6, the MDS documented depression as a diagnosis and use of an antidepressant, but the care plan only directed staff to monitor for adverse side effects and did not reflect targeted behaviors showing signs of depression specific to the resident. For Resident #9, the MDS documented diagnoses of non-Alzheimer's dementia, anxiety, depression, and bipolar disorder, with use of an antipsychotic and an antidepressant. The care plan included focus areas for antidepressant medication related to depression and antipsychotic medication related to bipolar disorder, but both plans only directed staff to monitor for adverse side effects and did not identify resident-specific target behaviors for depression or psychosis. For Resident #10, the MDS documented non-Alzheimer's dementia and anxiety disorder, with use of an antipsychotic and an antidepressant. The care plan included a behavior focus area describing forgetfulness, need for transfer assistance, possible non-compliance, impatience, and occasional refusal of showers, but the medication-related care plan entries again only directed staff to monitor for adverse side effects or administer medications as ordered and did not reflect targeted behaviors for depression or psychosis. For Resident #27, the MDS documented Alzheimer's disease and use of antipsychotic, antianxiety, and antidepressant medications. The care plan included a behavior focus area noting occasional refusal to come to the dining room, need for transfer assistance, non-compliance, falls, and a history of combative behavior with care, but the medication-related care plans only directed staff to administer medications as ordered and monitor for adverse side effects. These entries did not reflect resident-specific target behaviors for psychosis, anxiety, or depression. The DON stated the facility did not have broad documentation of target behaviors and that nurses monitored these things each shift without a specific routine, and the MDS Coordinator stated she would go through and update the needed care plans.
Food Allergy Not Followed During Meal Service
Penalty
Summary
The facility failed to ensure that a resident with a documented banana allergy did not receive bananas during a meal service. Resident #60’s record showed intact cognition, independence in eating, and diagnoses including heart failure, end stage renal disease, COPD, and respiratory failure. The nutritional assessment and care plan documented a banana allergy, and the allergy also appeared in the EHR in red print and on the dietary tray card with a red food allergy sticker. During interviews, the resident reported that she was served a banana at breakfast and believed she was having a reaction after touching and being exposed to it. She described nausea and a tight band sensation around her waist after breakfast and stated she had a banana allergy for 50 years. The EMAR showed ondansetron was administered for nausea that morning. The resident also reported that a banana had been placed on her tray and that she gave part of it to another resident at the table. Staff interviews and observations showed that the dietary card system was intended to communicate allergies, but staff gave inconsistent accounts of how the allergy information was checked during meal service. The dietary aide reported the resident got a banana every day, then said the bananas were rotten and the resident got a fruit bowl; the dietary manager stated it was possible another server may have grabbed a banana. Other staff said they reviewed the dietary card for allergies before serving, while the nurse stated she was not aware of the banana allergy. The facility’s policy stated residents with food allergies would be offered appropriate substitutions, but it lacked direction on how food allergies were communicated during meal service.
Call Light Left Out of Reach for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a resident’s call light was kept within reach for a resident who required assistance with transfers and was at high risk for falls. Resident #17 had a BIMS score of 13/15, diagnoses including Non-Alzheimer’s Dementia and age-related osteoporosis, a documented fall history, and a fall risk evaluation showing a high fall risk score. The care plan directed staff to keep the call light within reach and encourage the resident to call for assistance, but the care plan did not document use of a cordless call pendant. After the resident was found on the floor by the head of the bed gripping her left arm, the resident reported that she could not find her call light and was reaching for it when she fell. The incident report and progress note documented left arm pain rated 9/10, and the resident stated she had been unable to call for help because the call light was not accessible. The report also documented that the resident was ambulatory with assistance and that staff later observed her needing assistance with transfers and ambulation. During interviews, staff reported that the resident’s call light had been clipped above the bed by the wall and was out of reach. Staff also stated the resident used a special paddle-type call light that should have been placed next to her hand whether she was in bed or in the wheelchair. The DON reported that the call light was not in reach and acknowledged that the resident’s fall could have been prevented. The incident documentation also lacked clarity on whether the resident fell from the bed or wheelchair.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to transfer a resident according to her Care Plan, resulting in a significant injury. The resident, who had diagnoses including atrial fibrillation, heart failure, and osteoporosis, and was severely cognitively impaired, was dependent on staff for chair-to-chair transfers. Her Care Plan and therapy recommendations required transfers with the assistance of one staff member, a gait belt, and a walker. However, during a transfer from a recliner to a wheelchair, staff did not use the walker as directed. During the transfer, the resident's left leg became caught on a sharp part of the wheelchair's foot pedal, which was obstructed from folding back fully due to a bag hanging on the side. This resulted in a deep laceration to the resident's left leg, causing significant bleeding. The resident was on anticoagulation therapy (Eliquis), which contributed to acute blood loss anemia and necessitated emergency medical intervention, including sutures to control arterial bleeding and a blood transfusion. Interviews with staff revealed inconsistent practices regarding the removal or repositioning of wheelchair pedals during transfers, and it was confirmed that the walker was not used during the incident. The staff member involved acknowledged not following the Care Plan instructions. Observations also noted that the wheelchair pedal was sharp and that the bag hanging on the side prevented the pedal from moving out of the way, directly contributing to the injury.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain a safe and palatable temperature for foods served during the noon meal service on March 11, 2025. Observations in the [NAME] Dining Room revealed that the pork loin and turkey burgers were not held at the required temperature of at least 135 degrees Fahrenheit. Initially, the pork loin was measured at 201.5 degrees Fahrenheit and the turkey burgers at 155 degrees Fahrenheit by Staff D, the cook. However, by 12:40 PM, the Dietary Director recorded the pork loin at 180 degrees Fahrenheit and the turkey burgers at 115 degrees Fahrenheit. Further temperature checks by the surveyor at 12:48 PM showed the pork loin at 125 degrees Fahrenheit and the turkey burgers at 111.3 degrees Fahrenheit, both of which were below the facility's policy requirement. The Dietary Director confirmed that the meat should be held at a minimum of 135 degrees Fahrenheit after the meal service.
Improper Hair Restraint Use During Meal Service
Penalty
Summary
The facility failed to ensure proper application of hair restraints during a meal service, as observed in the [NAME] Dining Room. At 12:01 PM, both Staff B, a Dietary Aide, and Staff C, a Dining Assistant, were noted to have hair not fully tucked into their hair nets, with Staff B having approximately 1.5 inches and Staff C having approximately 3 inches of hair exposed. This issue persisted as Staff B left the dining room at 12:29 PM with the same hair exposure, and Staff C remained with 3 inches of hair exposed at 12:33 PM. The Dietary Director, during an interview, stated that staff are expected to check each other to ensure hair is properly tucked into the hair restraint before serving food. The facility's undated Dietary Infection Control policy requires all staff to style their hair so it does not touch their collar and mandates that hair restraints cover all hair.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to adhere to proper infection control techniques during a medication pass for one resident. Resident #57, who is cognitively impaired with a BIMS score of 08 and has diagnoses including heart failure, non-Alzheimer's dementia, and cancer, was observed during a medication administration. The resident requires substantial assistance with daily activities such as showers, dressing, and footwear. During the medication pass, Staff A, an RN, removed Potassium Chloride ER capsules from blister packs and handled them with bare hands, emptying the contents into a medication cup without wearing gloves. Staff A admitted in an interview that she forgot to sanitize her hands and don gloves before handling the medication. The Director of Nursing confirmed that the expectation is for nurses to use hand sanitizer and wear gloves before emptying capsule contents into a medication cup. The facility's Medication Administration policy also requires adherence to infection control procedures, including handwashing and the use of gloves. This incident highlights a lapse in following established infection control protocols during medication administration.
Failure to Respect Resident Dignity and Autonomy
Penalty
Summary
The facility failed to uphold the dignity and rights of three residents, as observed through staff interactions and resident reports. Resident #4, who has Alzheimer's disease and severely impaired cognition, was publicly reprimanded by an LPN in a loud and harsh manner when attempting to stand from his wheelchair. The LPN's comments were made in the presence of other residents and staff, which compromised the resident's dignity and right to a respectful environment. Resident #10, who has intact cognition, reported that night shift staff did not allow her to get up when she requested, forcing her to wait until later in the night. This restriction on her autonomy and choice was corroborated by other staff members, although it was not reported to the administration. The resident expressed feeling mistreated, likening her treatment to that of a dog, which was not addressed by the facility's management. Resident #11, also with intact cognition, reported that a CNA did not respect her preferences regarding sleeping with dentures and her bedtime. The CNA insisted on removing her dentures and dictated her bedtime against her wishes. These actions were contrary to the facility's policy on dignity, which emphasizes respecting residents' individual needs and preferences. Despite these incidents, the facility's administration was not fully aware of the extent of the residents' complaints, indicating a breakdown in communication and reporting within the facility.
Sanitary Practices and Food Temperature Deficiencies
Penalty
Summary
The facility failed to maintain proper sanitary practices and food temperatures during meal service, as observed by surveyors. During the noon meal service, a dietary aide served 12 glasses to residents with bare fingers touching the drinking rim surface of the glasses. Additionally, during meal preparation and service, several food items were not heated to the appropriate temperature of 165°F or cooled to the appropriate temperature of 41°F before serving. Specifically, pureed ham, pureed mixed vegetables, chicken noodle soup, and tartar sauce were all found to be at incorrect temperatures. Furthermore, several food items were not held at the appropriate temperature of 135°F or higher, or 41°F or lower throughout the meal service. These items included ham, ground ham, pureed ham, pureed mixed vegetables, lettuce salad, and tartar sauce. The dietary supervisor confirmed that staff are expected to follow proper sanitary practices and food temperature guidelines, and acknowledged that the facility has policies in place for these procedures. However, the observed deficiencies indicate that these policies were not followed during the meal service.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the ombudsman when residents were transferred out of the facility. This deficiency was observed in three residents. Resident #11, with moderate cognitive impairment and diagnoses including diabetes mellitus type 2 with diabetic neuropathy, cerebrovascular accident, and seizure disorder, was transferred to the hospital without ombudsman notification. Resident #15, who had no cognitive impairment and was diagnosed with cancer, anemia, and respiratory failure, was transferred to the hospital twice without ombudsman notification. Resident #65, with moderate cognitive impairment and diagnoses including traumatic brain dysfunction, heart failure, and paraplegia, was also transferred to the hospital twice without ombudsman notification. During interviews, the Office Manager and Administrator admitted that the facility's practice was to notify the ombudsman only if a resident was discharged to the hospital, not for transfers. The Administrator acknowledged that this was an oversight on his part and that the facility did not have a policy on Long Term Care Ombudsman notification. The facility reported a census of 105 residents at the time of the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 161 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hiawatha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northbrook Healthcare And Rehabilitation Center | 1.8 mi | ★★★★★ | 24 | 0 |
| St Luke's Helen G Nassif Transitional Care Center | 1.9 mi | ★★★★★ | 4 | 0 |
| Hallmar Village | 3 mi | ★★★★★ | 11 | 0 |
| Meth-wick Health Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Terrace Glen Village | 4.1 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hiawatha Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.