Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Maple Heights Nursing & Rehabilitative Center during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, dysphagia, and upper extremity weakness, who had documented hot liquid safety interventions in place, was served a second cup of coffee in a lidded mug without staff checking the temperature. Shortly after receiving the refill, the resident spilled the coffee in the dining area, and nursing staff found redness and blistering from below the belt line to the groin and inner thighs. Post-incident measurement of the remaining coffee showed a temperature of 151°F, and hospital records documented partial-thickness scald burns to the groin and bilateral thighs after exposure to coffee measured at 157°F. Staff interviews confirmed that dietary staff were expected to check every cup of hot liquid to ensure it was below 135°F, but the dietary worker who refilled the cup could not recall taking the temperature, and another staff member acknowledged the second cup’s temperature had not been checked, leading to the resident’s burn injury.
Surveyors found that the kitchen serving all residents had multiple unsanitary conditions, including greasy and dusty air vents above the stove, missing covers on overhead fluorescent lights, and soiled exhaust hood components. Dietary and maintenance staff confirmed these issues, with some surfaces not cleaned for extended periods and light fixture covers missing for about a year.
A resident with limited mobility, dementia, and a recent hip fracture developed a facility-acquired, unstageable pressure ulcer on the left heel despite being identified as at risk and having a care plan that included pressure redistribution devices and weekly skin assessments. The ulcer developed due to inadequate prevention measures, particularly related to the resident's use of a recliner and wheelchair, where her heel was not consistently protected or off-loaded as required.
A consultant pharmacist did not identify or report that a resident was prescribed risperidone, an antipsychotic, without an approved indication. The resident, diagnosed with dementia and exhibiting behavioral symptoms, received the medication for various reasons, but documentation and monthly reviews lacked justification or risk-benefit analysis. Staff were unaware of a proper diagnosis for the medication, and no irregularity was reported, resulting in the risk of inappropriate psychotropic use.
Surveyors found that two residents' insulin flex pens were either not labeled with open or expiration dates or were not discarded after expiration. Nursing staff confirmed the requirement to label and remove expired medications, but these procedures were not followed, resulting in expired and unlabeled insulin pens remaining in use.
Staff did not adequately clean a resident's carpet and recliner, resulting in persistent stains and a urine odor in the room. The Housekeeping Supervisor and administrative staff confirmed awareness of the issue, and repeated cleaning attempts were unsuccessful in removing the odor, which may have penetrated the carpet pad.
Failure to Monitor Hot Liquid Temperature Resulting in Resident Burns
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision related to hot liquid service, resulting in a cognitively impaired resident sustaining burns from spilled coffee. The resident had diagnoses including generalized muscle weakness, dementia, dysphagia, and a cognitive communication deficit, with MDS assessments documenting progression from moderate to severe cognitive impairment. Care plans and a prior hot liquids safety evaluation identified the need for specific interventions with hot liquids, including use of a cup with a lid, non-spill thermal mug if accepted, clothing protector over the chest and lap, consumption of hot liquids only at the table or with staff supervision, and addition of ice cubes to hot beverages and soups per family request. On the day of the incident, the resident was seated in the dining room for breakfast and requested a second cup of coffee. Dietary staff refilled the resident’s metal coffee cup, added sweetener, placed the lid on the cup, and returned it to the resident without confirming whether the coffee temperature was within the facility’s stated safe range. Shortly thereafter, staff in the serving room heard the resident holler and observed coffee on the floor. A CNA checked on the resident and found coffee on the resident’s lap, began to pat it dry, and requested a nurse to assess the resident. The nurse’s assessment documented erythema from below the belt line to the groin, pain in the groin and bilateral thighs, and blistering on the inner thighs consistent with a burn injury. Following the spill, dietary staff measured the remaining coffee in the resident’s cup and recorded a temperature of 151°F. An Emergency Department note documented that the resident had eaten breakfast, spilled coffee in her lap, and was later found during showering to have significant firmness and peeling skin in the lap area. The burn center admission note documented partial thickness scald burns to the bilateral thighs and perineum after spilling coffee measured at 157°F in her lap. Facility staff interviews indicated that dietary staff were expected to obtain the temperature of every cup of hot liquid and not serve it if it exceeded 135°F, and that a list existed to direct which residents required lids and other hot liquid interventions. However, the dietary staff member who refilled the second cup of coffee for the resident could not recall obtaining the temperature before serving it, and another dietary staff member acknowledged that the temperature of the second cup had not been checked, leading to the resident being served excessively hot coffee that spilled and caused the documented burn injuries. The facility’s own reportable investigation concluded that the incident was accidental and related to the resident’s health condition, noting that the resident had a lid on her coffee cup per her care plan but dropped the cup and the lid came off. The investigation also documented that the resident had no prior history of dropping her coffee. Despite existing care plan interventions and a hot liquid safety evaluation specifying the need for controlled hot liquid service and supervision, the failure to verify the temperature of the second cup of coffee before serving it, combined with the resident’s cognitive impairment and physical limitations, resulted in the resident being exposed to a hot liquid hazard and sustaining second-degree burns to the inner groin and bilateral thighs.
Unsanitary Kitchen Conditions Affecting Food Safety
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchen, which serves all 44 residents. Specifically, two air vents located above the cooking stove area were covered with a brownish grease and a gray fuzzy substance, blowing directly onto the food preparation and stove cooking areas. Four overhead fluorescent light fixtures above the food preparation area were missing covers, and a return air grill was found to be covered with a brownish gray fuzzy substance. Additionally, six round light bulbs with wire cages in the exhaust hood above the stove top were coated with a brownish gray fuzzy substance, and two fire suppression spigots in the same area were similarly soiled. Dietary and maintenance staff confirmed the presence of these unsanitary conditions, noting that the light fixture covers had been missing for about a year and that the air grill and registers had last been cleaned about a month prior. The facility's policy required regular cleaning and disinfection of environmental surfaces, but these standards were not met, as evidenced by the visible accumulation of dirt and debris on critical kitchen surfaces and equipment.
Failure to Prevent Facility-Acquired Pressure Ulcer on Resident's Heel
Penalty
Summary
The facility failed to initiate effective interventions to prevent the development of a facility-acquired, unstageable pressure ulcer on the left heel of a resident. The resident had a history of a healing left femur fracture, dementia, osteoporosis, and muscle weakness, and was assessed as being at moderate risk for pressure ulcers due to limited mobility, moist skin, and dependence on staff for transfers and activities of daily living. The care plan and physician orders directed the use of a pressure redistribution mattress and pressure relief cushions, as well as weekly skin assessments and reporting of any skin concerns. Despite these interventions, the resident developed a new unstageable pressure ulcer on the left heel, which was not present on admission. Documentation indicated that the resident required extensive assistance with mobility and was chairfast, with the Braden Scale indicating risk for pressure injury. The pressure ulcer was first identified by staff, who noted the area of concern and subsequently added heel protector boots and off-loading interventions. However, it was determined that the ulcer likely developed due to the resident resting her heel on the footrest of her recliner, which was not adequately addressed in the initial care plan or interventions. Observations confirmed that the resident continued to be at risk, as her heel was seen slipping between the metal footrest pedals of her wheelchair, even after the pressure relieving boot was applied. The facility's policy required comprehensive assessment and identification of risk factors for pressure ulcers, as well as appropriate preventative approaches, but the interventions in place were not sufficient to prevent the development of the pressure ulcer in this case.
Consultant Pharmacist Failed to Identify and Report Unapproved Antipsychotic Use
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the lack of an approved indication for the use of an antipsychotic medication prescribed to a resident with dementia. The resident's electronic medical record documented diagnoses of dementia without behavioral disturbance, vitamin D deficiency, and hypothyroidism. The resident exhibited severely impaired cognition, required assistance with daily activities, and displayed physical and verbal behaviors, wandering, and rejection of care. Despite these behaviors, the resident was prescribed risperidone, an antipsychotic, for various indications including anxiety, agitation, and later for dementia without behavioral disturbance. The medication orders changed multiple times, but documentation in the medical record and monthly pharmacist reviews from December to March did not include an approved indication or a risk versus benefit analysis for the continued use of risperidone. Interviews with staff revealed that the administrative nurse was unaware of a proper diagnosis supporting the use of risperidone and had not received any irregularity reports from the CP regarding the medication. The facility's pharmacy services policy required pharmaceutical services to meet resident needs and comply with regulations, but the CP did not document or report the irregularity of prescribing risperidone without an approved indication. This failure placed the resident at risk for inappropriate use of psychotropic medication.
Failure to Properly Label and Remove Expired Insulin Pens
Penalty
Summary
Surveyors observed that insulin flex pens for two residents were not properly labeled according to professional standards and facility policy. Specifically, two Lantus insulin flex pens for one resident were found without an open or expiration date, and a Humalog insulin flex pen for another resident was labeled with an open date but had not been discarded after its expiration date had passed. These observations were made during a review of the treatment carts in two facility halls. Administrative staff confirmed that nursing staff are responsible for labeling insulin pens with both the date opened and the expiration date, and for discarding expired pens. The facility's policy requires all drugs and biologicals to be labeled with expiration dates and stored properly, with expired medications removed from active stock. The failure to follow these procedures resulted in the presence of expired and unlabeled insulin pens in active use areas.
Failure to Maintain Sanitary Resident Room Environment
Penalty
Summary
Staff failed to maintain a safe and sanitary environment for a resident by not adequately cleaning the carpet and recliner in the resident's room. Observations revealed a black stain on the carpet in front of the recliner, a red stain on the left arm of the recliner, and a yellow stain on the left arm cover. Both the room and the recliner had a noticeable urine odor. The Housekeeping Supervisor confirmed the presence of the urine odor and stated that repeated cleaning attempts had not removed the smell, suggesting the odor may have penetrated the carpet pad. Administrative staff acknowledged awareness of the urine odor and stains, noting that the carpet stain was partially due to a previous paint spill when the resident was able to do crafts. The facility's policy required cleaning and disinfection of environmental surfaces according to CDC and OSHA standards.
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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.
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Nursing homes near Hiawatha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Falls City Nursing And Rehabilitation Center | 15 mi | ★★★★★ | 1 | 0 |
| Sabetha Manor | 15.7 mi | ★★★★★ | 7 | 0 |
| Apostolic Christian Home | 15.8 mi | ★★★★★ | 0 | 0 |
| Falls City Care Center | 15.9 mi | ★★★★★ | 0 | 0 |
| Oregon Care Center | 21.8 mi | ★★★★★ | 9 | 0 |
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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.