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 Wathena Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure the director of food and nutrition services had the required qualifications of a Certified Dietary Manager (CDM), placing residents at risk for unmet dietary and nutritional needs. The dietary manager had not passed the CDM certification test, and the facility was considering alternative options to address this deficiency.
The facility failed to maintain proper temperature control in its kitchen, with the big cooler observed at 46°F, above the acceptable range. Inconsistent monitoring of cooler, freezer, and dishwasher temperatures was noted, along with lapses in hand hygiene during meal service. These deficiencies placed residents at risk for food-borne illnesses.
The facility did not conduct a thorough facility-wide assessment to determine necessary resources for competent resident care during routine operations and emergencies. The assessment lacked specific staffing levels for each unit and shift, a contingency plan for non-emergency events, and a strategy for staff recruitment and retention. Additionally, it did not include input from residents and their representatives. This affected all 39 residents in the facility.
The facility failed to ensure staff followed Enhanced Barrier Precautions and proper hand hygiene during medication administration, and did not have a Legionella water management plan. Observations showed staff performing care without appropriate PPE and neglecting hand hygiene protocols. The absence of a Legionella management plan was acknowledged by maintenance staff, citing a lapse due to personnel changes. These deficiencies increased the risk of infectious diseases among residents.
The facility failed to ensure agency direct care staff received required infection control training, placing residents at risk. A review of training records for agency CNAs revealed missing evidence of completed infection control training. Administrative staff assumed training was completed by the agency, but no information was provided. The facility could not provide a policy on required training for nurse aides.
The facility failed to provide a bed hold policy notice to two residents or their representatives during hospital transfers. Despite completing bed hold assessments in the EMR, the notices were not sent, posing a risk to the residents' ability to return to the facility or their previous rooms.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications of a Certified Dietary Manager (CDM). The facility, which had a census of 39 residents, relied on a dietary manager who had not yet passed the CDM certification test. The dietary manager, referred to as Dietary BB, had been in the role for four years and had completed the necessary education but had not passed the certification test due to delays caused by the pandemic. The registered dietitian visited the facility every two weeks, but the lack of a qualified CDM placed residents at risk for unmet dietary and nutritional needs. During interviews, Dietary BB acknowledged the need to pass the CDM test and mentioned a 90-day waiting period before retaking it. Administrative Staff A confirmed that Dietary BB had attempted the state test but did not pass, and the facility was considering alternative options, such as certifying another dietary member or hiring a CDM if necessary. The facility's policy outlined the qualifications required for the Dining Services Manager, which included a CDM credential or equivalent qualifications, none of which were met by the current dietary manager.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to maintain appropriate temperature control in its main kitchen, which posed a risk for food-borne illnesses among its 39 residents. During an initial tour, the big cooler was observed to have a temperature of 46 degrees Fahrenheit, which is above the acceptable range of 33 to 41 degrees Fahrenheit. This cooler contained various perishable food items such as produce, cheese, eggs, and dairy products. Further review of temperature logs revealed multiple instances of missing documentation for both the big cooler and other refrigeration units, indicating inconsistent monitoring by the staff. Additionally, the facility did not ensure proper hand hygiene practices during meal service. An administrative nurse was observed handling multiple items and assisting residents without performing hand hygiene between tasks. This included touching food trays and clothing protectors, as well as adjusting her hair, before eventually performing hand hygiene. Interviews with staff revealed discrepancies in the understanding and implementation of hand hygiene protocols, with varying practices reported by different staff members. The facility also failed to consistently monitor the dishwasher temperatures and chemical sanitation levels. Logs for the dish machine and pots and pans sanitization showed missing entries for several scheduled times, indicating lapses in monitoring. The facility's policies required regular checks and documentation of these parameters to ensure proper sanitation, but these were not consistently followed. These deficiencies collectively placed residents at risk for food-borne illnesses due to inadequate food storage, handling, and sanitation practices.
Inadequate Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment did not specify the required staffing levels for each unit, including the number of RNs, LPNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment lacked detailed staffing requirements for each shift. Furthermore, the facility did not have a contingency plan for situations that could impact resident care without triggering the emergency plan, nor did it have a strategy for recruiting and retaining direct care staff. The assessment also failed to incorporate input from residents and their representatives in its formulation. During an interview, Administrative Staff A acknowledged that the facility had recently revised the assessment but had not covered all necessary areas. The facility was unable to provide a policy related to the facility assessment when requested. This oversight affected all 39 residents residing in the facility, as the assessment was not thorough or updated to ensure competent care.
Infection Control and Legionella Management Deficiencies
Penalty
Summary
The facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) and proper hand hygiene during medication administration, as well as neglected to assess and manage risks associated with Legionella disease. Observations revealed that isolation supplies were present in residents' rooms without appropriate signage indicating the type of isolation or required personal protective equipment (PPE). Specifically, a licensed nurse and a certified nurse aide performed care on residents without wearing isolation gowns. Additionally, a certified medication aide did not perform hand hygiene after removing gloves during medication preparation, which is against the facility's hand hygiene policy. Furthermore, the facility did not have a Legionella water management plan in place, despite having a policy that directed the establishment of strategies for preventing and controlling Legionella infections. The maintenance staff acknowledged the absence of such a plan, attributing it to the previous maintenance person's passing. The facility's policies on EBP and hand hygiene were not effectively communicated or enforced, as evidenced by staff interviews indicating confusion about procedures and expectations. These deficiencies placed residents at risk for infectious diseases.
Infection Control Training Deficiency for Agency Staff
Penalty
Summary
The facility failed to ensure that agency direct care staff received the required infection control training, which placed residents at risk for impaired care and decreased quality of life. During a review of the training records for agency CNAs M, N, and O, it was found that their credentialing files lacked evidence of completed infection control training. Administrative Nurse D acknowledged that while training on resident rights and abuse, neglect, and exploitation was provided, infection control training was not conducted. Administrative Staff A assumed that the agency staff had completed the necessary training, but the agency did not provide this information. The facility was unable to provide a policy regarding the required training for nurse aide staff when requested.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a bed hold policy notice to two residents, R4 and R20, or their representatives when they were transferred to the hospital. This deficiency was identified during a survey that included a sample of 12 residents, with three reviewed for hospitalization. The facility's policy required that at the time of transfer for hospitalization or therapeutic leave, a written notice specifying the duration of the bed-hold policy and information explaining the return of the resident to the next available bed be provided to the resident and/or their representative. Resident R4, who had intact cognition and required assistance with activities of daily living, was transferred to the hospital on multiple occasions without receiving the required bed hold policy notice. Despite documentation in the Electronic Medical Record (EMR) and notifications to the resident's representative about the transfers, there was no evidence that the bed hold policy notice was provided. Interviews with facility staff, including Social Services and Licensed Nurses, revealed that while a bed hold assessment was completed in the EMR, the notice was not sent to the resident or their representative. Similarly, Resident R20, who also had intact cognition and was dependent on staff for all functional abilities, was transferred to a short-term acute hospital multiple times without receiving the bed hold policy notice. The facility was unable to provide evidence that the notice was given on any of the documented transfer dates. Staff interviews confirmed that while the bed hold assessment was completed in the EMR, the notice was not distributed to the resident or their representative. This failure to provide the bed hold policy notice posed a risk of impaired ability for both residents to return to the facility or their previous rooms.
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What surveyors actually found near you
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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 Wathena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Joseph Chateau | 5.8 mi | ★★★★★ | 2 | 0 |
| Advanced Care Of St Joseph | 6.5 mi | ★★★★★ | 2 | 0 |
| St Joseph Manor Health & Rehabilitation | 8.2 mi | ★★★★★ | 2 | 0 |
| Carriage Square Rehab And Healthcare Center | 8.8 mi | ★★★★★ | 5 | 0 |
| Living Community Of St Joseph | 9.9 mi | ★★★★★ | 0 | 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.