Inspection Reports for
Wg Hearthstone West Sh LLC
3515 SW 6TH AVE, TOPEKA, KS, 66606-1900
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
57% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 23, 2025
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple identified deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the assisted living facility Celebration Villa of Hearthstone West.
Complaint Details
The complaint investigation 196941 was conducted and found no citations.
Findings
The complaint investigation conducted on 09/22/2025 resulted in no citations or deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 22, 2025
Visit Reason
This document is a plan of correction representing the findings of a complaint investigation conducted at the assisted living facility on 2025-09-22.
Complaint Details
The complaint investigation was conducted and resulted in no citations.
Findings
The complaint investigation conducted on 2025-09-22 resulted in no citations.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 15
Date: Aug 25, 2025
Visit Reason
The inspection was a resurvey with attached complaints conducted on 08/18, 08/20, 08/21, and 08/25/2025 at Celebration Villa of Hearthstone West assisted living facility.
Complaint Details
This inspection included attached complaints numbered 187638, 188778, 188876, 189258, 190169, 192119, 193461, 194007, 196278, 194725, 195684, and 196432.
Findings
The facility was found deficient in multiple areas including failure to notify family of medication changes, neglect leading to resident elopement and falls, incomplete negotiated service agreements, failure to provide services as specified, improper medication administration, inadequate infection control, unsafe food storage and preparation, and failure to conduct required emergency preparedness reviews.
Deficiencies (15)
KAR 26-39-103(h)(1)(C) The administrator failed to ensure designated staff notified Resident 6's legal representative or family of a medication change.
KAR 26-41-101(f)(1)(B) The administrator failed to protect residents from neglect by allowing Residents 2 and 7 to leave the facility unsupervised, resulting in falls and immediate jeopardy.
KAR 26-41-202(a)(1)(3) The administrator failed to ensure negotiated service agreements for Residents 1, 3, and 6 were fully developed to include all functional needs, service preferences, and payment responsibilities.
KAR 26-41-202(d)(4) The administrator failed to revise Resident 6's negotiated service agreement when facility staff assumed medication management.
KAR 26-41-203(a)(3) The administrator failed to provide or coordinate services as specified in negotiated service agreements for Residents 1, 3, 5, 6, and 12, including housekeeping and personal care.
KAR 26-41-204(i) The administrator failed to ensure assessments were completed for Residents 1 and 3 regarding bed assist devices to confirm safe use and absence of restraint or entrapment risk.
KAR 26-41-205(d) The administrator failed to ensure medications were administered to Resident 3 in accordance with provider orders, including inconsistent application of diclofenac gel.
KAR 26-41-205(g)(3) The administrator failed to ensure over-the-counter medications were labeled with the resident's full name by a pharmacist or licensed nurse.
KAR 26-41-205(l)(2) The administrator failed to ensure pharmacy recommendations were followed up and responded to by providers for Residents 1, 2, and 3.
KAR 26-41-104(d)(3) The administrator failed to ensure quarterly reviews of the emergency management plan were conducted with all employees and residents.
KAR 26-41-206(d) The administrator failed to ensure food items were served at proper temperatures and documented accordingly.
KAR 26-41-206(e) The administrator failed to ensure food items were stored under safe and sanitary conditions, including undated and unsealed food items and missing temperature logs.
KAR 26-41-207(a) The administrator failed to ensure a safe, sanitary, and comfortable environment for residents, including stained carpets, unclean toilets, strong odors, and inadequate housekeeping.
KAR 26-41-207(b)(5-6), (c) The administrator failed to ensure infection control policies were followed, including employee health screening and tuberculosis compliance.
KAR 26-41-207(c) The administrator failed to ensure compliance with tuberculosis guidelines, including missing annual TB symptom screen for Resident 2 and delayed TB screening for a new employee.
Report Facts
Facility census: 34
Medication application count: 26
Missing food temperature documentation days: 15
Staff in-service attendance: 10
Staff total: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in findings related to medication notification, negotiated service agreements, medication administration, and pharmacy follow-up. |
| CMA F | Certified Medication Aide | Named in findings related to medication administration and inconsistent application of pain relief gel. |
| Administrative Staff A | Administrative Staff | Named in findings related to emergency preparedness, housekeeping, and elopement procedures. |
| CMA Q | Certified Medication Aide | Named in elopement incident where resident was let out unsupervised. |
| CMA K | Certified Medication Aide | Named in elopement incident and witness statement. |
| CMA O | Certified Medication Aide | Named in elopement incident and witness statement. |
| CMA G | Certified Medication Aide | Named in elopement drill and wandering behavior observations. |
| CNA J | Certified Nurse Aide | Named in elopement incident and wandering behavior observations. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 18, 2025
Visit Reason
This document represents the provider's plan of correction following a resurvey with attached complaints conducted on 08/18, 08/20, 08/21, and 08/25/2025 at the assisted living facility.
Findings
The plan of correction addresses findings from multiple complaints linked to the resurvey conducted over several days in August 2025.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 9, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-04-16.
Findings
All deficiencies have been corrected as of the compliance date of 2024-05-03, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 7
Date: Apr 16, 2024
Visit Reason
Re-Licensure Survey with Complaint Investigations for an Assisted Living Facility conducted on 04/15/24 and 04/16/24.
Complaint Details
The visit included complaint investigations related to allegations of verbal abuse and neglect by a Certified Medication Aide (CMA G) toward resident R6. The complaints were substantiated based on interviews, notarized statements, and record reviews.
Findings
The facility was found deficient in multiple areas including failure to prevent resident abuse, failure to report allegations of abuse timely, inaccurate functional capacity screenings, failure to revise negotiated service agreements after significant changes, incomplete self-administration medication assessments, inadequate emergency preparedness reviews, and incomplete documentation for authorized electronic monitoring.
Deficiencies (7)
KAR 26-41-101(f)(1)(A) The administrator failed to ensure one resident was not subjected to verbal abuse and neglect when a staff member put the resident's call pendant out of reach and told her to get her own drink.
KAR 26-41-101(f)(3) The facility staff failed to report allegations of abuse and neglect to the administrator as soon as staff were aware, potentially affecting all residents served by the implicated staff.
K.A.R 26-41-201(d) The executive director failed to ensure designated staff accurately completed functional capacity screens for two residents, misrepresenting their mobility and fall risk.
KAR 26-41-202(d)(2) The administrator failed to ensure negotiated service agreements were reviewed and revised when two residents experienced significant changes in condition related to therapy services.
KAR 26-41-205(a)(1) The executive director failed to ensure a licensed nurse completed a self-administration of medication assessment for one resident prior to self-administration of medications.
KAR 26-41-104(d)(3) The executive director failed to ensure quarterly reviews of the emergency management plan were conducted with all residents and employees, missing reviews in the third and fourth quarters of 2023.
Kansas Statute 39-981 The executive director failed to ensure the resident's legal representative completed required paperwork for authorized electronic monitoring in the resident's room.
Report Facts
Census: 38
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide G | Certified Medication Aide | Named in findings related to verbal abuse and neglect of resident R6. |
| Administrative Staff A | Interviewed resident R6 and reported on abuse allegations and lack of policy. | |
| Administrative Licensed Nurse B | Administrative Licensed Nurse | Reported on functional capacity screen coding errors and self-administration medication assessment deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 15, 2024
Visit Reason
The document is a Plan of Correction responding to findings from a Re-Licensure Survey with Complaint Investigations conducted on 04/15/24 and 04/16/24 at an Assisted Living Facility.
Findings
The Plan of Correction addresses citations resulting from the Re-Licensure Survey and multiple complaint investigations at the facility conducted on the specified dates.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 14, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-08-23.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2022-09-07, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Aug 22, 2022
Visit Reason
The inspection was a resurvey with complaint investigation 155889 at the assisted living facility.
Complaint Details
The visit was triggered by complaint investigation 155889.
Findings
The operator failed to ensure designated staff offered residents who self-administered medications an opportunity to have a medication regimen review conducted by a licensed pharmacist as required.
Deficiencies (1)
KAR 26-41-205(l)(4) Medication Regimen Review Self Administration: The facility failed to offer 2 residents who self-administered medications an opportunity for a medication regimen review by a licensed pharmacist.
Report Facts
Census: 36
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 22, 2022
Visit Reason
This document is a plan of correction submitted in response to a resurvey with complaint investigation conducted at the assisted living facility on 08/22/2022 - 08/23/2022.
Complaint Details
The visit was complaint-related as it involved complaint investigation 155889.
Findings
The plan of correction addresses citations found during the resurvey and complaint investigation at the facility conducted on the specified dates.
Deficiencies (1)
The citations represent findings from a resurvey with complaint investigation at the assisted living facility conducted on 08/22/2022 - 08/23/2022.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 7, 2020
Visit Reason
This is a follow-up visit to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously reported deficiencies have been corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 33
Deficiencies: 1
Date: Sep 16, 2020
Visit Reason
The inspection was a resurvey with attached complaints conducted at an assisted living facility to evaluate compliance with food preparation and safety regulations.
Complaint Details
The visit was a resurvey with attached complaints; specific substantiation status is not stated.
Findings
The facility failed to ensure food was served at safe and proper temperatures. Observations showed multiple instances where hot foods were served below the required temperature, and staff did not pre-heat serving boxes or check food temperatures immediately before serving.
Deficiencies (1)
26-41-206(d) Food Preparation: The facility failed to ensure food was served at safe and proper temperatures, with several hot foods served below the required 135 degrees Fahrenheit.
Report Facts
Resident census: 33
Food temperature: 89.4
Food temperature: 90.1
Food temperature: 94.7
Food temperature: 102
Food temperature: 50.5
Food temperature: 104
Food temperature: 104.9
Food temperature: 143
Food temperature: 148.6
Food temperature: 148.7
Food temperature: 150
Food temperature: 155.3
Food temperature: 170.2
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
The facility underwent a special infection control survey for COVID-19 conducted on June 17, 2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 3, 2018
Visit Reason
A survey for re-licensure with attached complaint was conducted at the assisted living facility in Topeka, KS on 7/3/18.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 1
Date: Jan 26, 2017
Visit Reason
The visit was a re-inspection following a Revisit Correction Order, Notice of Assessment, and Ban on Admission at the assisted living facility.
Findings
The Administrator failed to ensure all medications administered to resident #2219 were in accordance with written physician orders and professional standards of practice. Discrepancies were found between the medication administration record and physician orders.
Deficiencies (1)
KAR 26-41-205(d)(1)(2) Facility administration of medications. The Administrator failed to ensure all medications administered to resident #2219 matched the physician's written orders and professional standards of practice.
Report Facts
Resident census: 32
Residents with facility managed medications: 22
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Company Compliance Nurse | Interviewed and confirmed discrepancies in medication administration record |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 26, 2017
Visit Reason
This document is a plan of correction form indicating completion of corrective actions for previously cited deficiencies.
Findings
All listed deficiencies have been marked as corrected and completed as of the report date.
Deficiencies (1)
Regulation 26-41-101 (f) (1) was corrected and completed by 2017-01-26.
Inspection Report
Abbreviated Survey
Census: 30
Deficiencies: 3
Date: Dec 22, 2016
Visit Reason
The visit was a licensure abbreviated survey conducted at an assisted living facility to assess compliance with regulatory requirements.
Findings
The survey found multiple deficiencies including failure to provide independent direct access to residents' electronic records, medication administration errors placing residents at immediate jeopardy, and failure to ensure medications were administered according to professional standards, particularly regarding PRN medications administered by certified staff without nurse instruction.
Deficiencies (3)
KAR-39-103(d)(2) The operator failed to ensure independent direct access to each resident's electronic records for inspection and failed to provide facility monitored direct access to each resident's electronic record by a department representative.
KAR 26-41-101(f)(1)(B) The operator failed to prevent neglect by allowing medication administration by unlicensed staff and failed to ensure accurate medication records and physician confirmation, placing resident #1218 in immediate jeopardy of harm.
KAR 26-41-205(d) The operator failed to ensure all medications and treatments were administered in accordance with professional standards, as certified staff administered PRN medications without nurse instructions for residents #1218 and #1219.
Report Facts
Census: 30
Medication administrations by certified staff: 17
Medication administrations by certified staff: 8
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 4
Date: Oct 31, 2016
Visit Reason
The inspection was a licensure re-survey with an attached complaint conducted at the assisted living facility in Topeka, Kansas on 10/26/16, 10/27/16, and 10/31/16.
Complaint Details
The inspection included an attached complaint investigation as part of the licensure re-survey.
Findings
The facility failed to ensure access to resident records for inspection by department representatives, failed to complete negotiated service agreements in collaboration with residents or their representatives including payment responsibilities, allowed unlicensed outside provider staff to administer medications without proper documentation, and failed to maintain resident records according to professional standards including missing admission physical assessments.
Deficiencies (4)
KAR-39-103 (d) The operator failed to ensure access to each resident's records for inspection and photocopying by any representative of the department.
KAR 26-41-202 (a) The operator failed to ensure negotiated service agreements were completed in collaboration with residents or legal representatives and included identification of parties responsible for payment of outside services.
KAR 26-41-205 (d) The operator failed to ensure medications were administered according to professional standards and only by licensed nurses or medication aides, allowing unlicensed outside provider staff to administer medications without documentation.
KAR 26-41-105 (a) The operator failed to maintain resident records in accordance with accepted professional standards, including missing admission physical assessments and incomplete documentation.
Report Facts
Census: 29
Medications listed: 18
Residents reviewed: 4
Residents with outside medication providers: 5
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jul 24, 2015
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies from the survey completed on 2015-06-23.
Findings
The report documents that the deficiency identified as Reg. # 26-41-104 (d) with ID Prefix S3280 was corrected as of 2015-07-24. No other deficiencies are listed as corrected or uncorrected.
Deficiencies (1)
Regulation 26-41-104 (d) deficiency identified by code S3280 was corrected on 2015-07-24.
Report Facts
Date of Revisit: Jul 24, 2015
Date of Original Survey: Jun 23, 2015
Inspection Report
Renewal
Census: 31
Deficiencies: 4
Date: Jun 23, 2015
Visit Reason
The inspection was a Licensure Resurvey of the Assisted Living Facility, including investigation of Complaint #86148.
Complaint Details
Complaint #86148 was investigated during the resurvey.
Findings
The facility failed to accurately complete functional capacity screens for residents, did not ensure qualified staff provided all health care services including blood sugar monitoring, failed to conduct required assessments for self-administration of medications, and did not perform quarterly reviews of the emergency management plan with employees and residents.
Deficiencies (4)
KAR 26-41-201(d) Functional Capacity Screen was inaccurately completed for residents #187 and #189, with incorrect coding in the cognition section.
KAR 26-41-204(i) Health Care Services Standards of Practice were not met for resident #185, as staff failed to notify physicians of elevated blood sugar results as ordered.
KAR 26-41-205(a)(1) Self Administration of Medication assessment was not performed by a licensed nurse for resident #185 prior to self-administering medications.
KAR 26-41-104(d) Disaster and Emergency Preparedness quarterly reviews of the emergency management plan with employees and residents were not conducted or documented.
Report Facts
Facility census: 31
Employees hired since last resurvey: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Service Director #G | Confirmed inaccurate FCS coding and lack of physician notification for blood sugar results. | |
| Licensed Nurse #H | Interviewed regarding FCS training and completion. | |
| Licensed Nurse #J | Completed FCS for resident #189 before May 2015. | |
| Operator | Interviewed regarding medication self-administration and emergency preparedness. | |
| Maintenance Director | Confirmed lack of documentation for disaster plan reviews. |
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 4
Date: Mar 4, 2014
Visit Reason
The inspection was a resurvey conducted on 2014-02-26, 2014-02-27, and 2014-03-04 to assess compliance with regulatory requirements at an assisted living facility.
Findings
The facility was found deficient in multiple areas including failure to ensure licensed nurse assessments following functional capacity screenings, incomplete negotiated service agreements, inadequate medication disposition records, and failure to conduct quarterly reviews of the emergency management plan with employees and residents.
Deficiencies (4)
KAR 26-41-201(b) The operator failed to ensure a licensed nurse assessed residents whose functional capacity screening indicated the need for health care services.
KAR 26-41-202(a) The operator failed to ensure the negotiated service agreement included a description of services, identification of service providers, and payment responsibilities for outside providers.
KAR 26-41-205(i) The operator failed to maintain records of receipt and disposition of all medications in sufficient detail for accurate reconciliation.
KAR 26-41-104(d) The operator failed to ensure quarterly review of the facility's emergency management plan with employees and residents.
Report Facts
Census: 39
Medications for discharged residents: 127
Medications for current residents: 73
Narcotics for discharged residents: 6
Narcotics for current residents: 3
Over the counter medications to be destroyed: 24
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Mar 4, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of the facility.
Findings
The Plan of Correction indicates that no corrective action was required for the listed deficiencies as of the completion date.
Deficiencies (5)
S0000 No plan of correction required for this deficiency.
S3080-E No plan of correction required for this deficiency.
S3085-D No plan of correction required for this deficiency.
S3216-F No plan of correction required for this deficiency.
S3280-F No plan of correction required for this deficiency.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified by State ID N089030.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC 5G4Z11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Aspen, linked to event ID 5G4Z11.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC 6S7G11
Visit Reason
This document is a plan of correction related to a prior deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a record of the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC ZM4F11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Aspen, linked to a deficiency report dated 9.16.2020.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC ZM4F12
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as ASPEN with State ID N089030.
Findings
No deficiency details or findings are included in this Plan of Correction document. It serves as a corrective action response to a previous inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC EOL911
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as ASPEN with State ID N089030 and Event ID EOL911.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC EOL912
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as EOL912 for the facility with State ID N089030.
Findings
No deficiency details or findings are provided in this Plan of Correction document. It only references the related deficiency report but states no records found.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC HIIH11
Visit Reason
This document is a plan of correction related to a prior deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a placeholder for the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC HIIH12
Visit Reason
This document is a plan of correction related to a previous inspection revisit conducted on January 26, 2017.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or administrative record for the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC I8F711
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency records or details are provided in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC QXJJ11
Visit Reason
This document is a Plan of Correction related to a previously conducted deficiency report for the facility.
Findings
No specific findings are detailed in this document; it serves as a corrective action plan linked to a prior deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N089030 POC V96Q11
Visit Reason
This document is a Plan of Correction related to deficiencies identified in a prior inspection of the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
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