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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 110th out of 130 homes in Kansas.| Staff type | Hours / day | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 35m per day | ▼ 19% State avg: 43m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 56m per day | ▲ 40% State avg: 40m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 2h 37m per day | ▼ 3% State avg: 2h 42m per day · National avg: 2h 21m per day |
|
Total Nursing (Weekend)
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 3h 46m per day | ▲ 5% State avg: 3h 35m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 3m per day | ▲ 50% State avg: 2m per day · National avg: 4m per day |
|
RN (Weekend)
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 24m per day | ▼ 17% State avg: 29m per day · National avg: 29m per day |
Most residents typically stay for a few weeks or months before returning home or moving on.
59% of new residents, usually for short-term rehab.
38% of new residents, often for short stays.
3% of new residents, often for long-term daily care.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #17 / 131Payroll — state benchmarkedThis home is ranked 17th out of 131 homes in Kansas.Shows total annual staff payroll benchmarked to the Kansas average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Lower than the Kansas average: 79.5%The Gardens at Aldersgate LLC is administrated by Morgan Morris.
Key information about the people who lead and staff this community.
In Kansas, the Department for Aging and Disability Services, Survey and Certification Commission performs the unannounced inspections required for facility licensing and federal certification.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Kansas state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies are formal regulatory issues recorded during state inspections.
| Metric | This Facility | KS Average | vs. KS Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 264 | 100 | This facility has 164% more total deficiencies than a typical Kansas nursing home (264 vs. KS avg 100).↑ 164% worse |
|
Deficiencies per year
Average deficiencies per year since 2012.
| 18.9 | 7.1 | This facility has 166% more deficiencies per year than a typical Kansas nursing home (18.9 vs. KS avg 7.1).↑ 166% worse |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
The most recent inspection on May 7, 2021, found no deficiencies, confirming the facility was in compliance with all surveyed regulations. Prior inspections showed a pattern of deficiencies primarily related to medication management, including issues with insulin pen dating and storage, as well as infection control practices such as proper PPE use and cleaning protocols. Complaint investigations occasionally substantiated medication errors and care planning concerns, including a notable medication transcription error that led to emergency hospitalization in 2017. Enforcement actions included denial of payment for new Medicare and Medicaid admissions in 2015 and 2016 due to deficiencies involving pressure ulcer care and quality of care issues, but no fines or license suspensions were listed in the available reports. The facility’s record indicates improvement over time, with recent inspections showing correction of earlier deficiencies and compliance with regulatory requirements.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsKansas average 4.5
Last Health inspection on Jul 2025
Kansas average 26.9
Kansas average 6.07
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
10 of 40 citations resulted from standard inspections; 6 of 40 resulted from complaint investigations; and 24 of 40 came from combined inspections (standard and complaint).
11% worse than Kansas averageKansas average: 0.9
3
233% worse than Kansas averageKansas average: 0.9
Issues related to protecting resident's from harm, including abuse, neglect, or mistreatment.
Jul 16, 2025
Corrected
Issues related to how well residents receive appropriate treatment and support for their medical and daily care needs.
Dec 30, 2024
Corrected
Issues related to how well residents receive appropriate treatment and support for their medical and daily care needs.
Oct 02, 2024
Corrected
Issues related to how well residents receive appropriate treatment and support for their medical and daily care needs.
May 09, 2024
Corrected
Data sourced from CMS Health Deficiencies reports. Citation severity codes range from A (least serious) to L (most serious). Immediate Jeopardy (J-L) citations indicate situations where the facility's noncompliance has placed residents at risk of death or serious harm.
The Gardens at Aldersgate LLC is located in TOPEKA, Kansas.
Here are the financial assistance programs available to residents in Kansas.
0.0 miles from city center
Estimated distance in miles from Topeka's city center to The Gardens at Aldersgate LLC's address, calculated via Google Maps.
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This data corresponds to Q2 2025 and is based on CMS Payroll-Based Journal.
29% better than Kansas averageKansas average ratio: 2.27:1
0% compared with Kansas averageKansas average: 7.7 hours
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.2 hoursThis role is partially covered by contractors.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
8.8 hoursThis role is partially covered by contractors.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.9 hoursThis role is partially covered by contractors.
Total hours from contractors
9,396 contractor hours this quarter
| Certified Nursing Assistant | 157 | 83 | 240 | 29,988 | 91 | 100% | 7.9 |
| Licensed Practical Nurse | 38 | 24 | 62 | 10,778 | 91 | 100% | 8.8 |
| Registered Nurse | 33 | 13 | 46 | 5,803 | 91 | 100% | 9.2 |
| Medication Aide/Technician | 28 | 21 | 49 | 5,665 | 91 | 100% | 8.4 |
| Speech Language Pathologist | 0 | 7 | 7 | 1,824 | 70 | 77% | 5.9 |
| Other Dietary Services Staff | 3 | 0 | 3 | 1,278 | 87 | 96% | 7.7 |
| Clinical Nurse Specialist | 2 | 0 | 2 | 1,123 | 65 | 71% | 9 |
| Administrator | 2 | 0 | 2 | 1,040 | 65 | 71% | 8 |
| Mental Health Service Worker | 3 | 0 | 3 | 979 | 69 | 76% | 7.5 |
| Physical Therapy Aide | 0 | 10 | 10 | 974 | 71 | 78% | 5.9 |
| Physical Therapy Assistant | 0 | 5 | 5 | 569 | 66 | 73% | 5.9 |
| Nurse Practitioner | 1 | 0 | 1 | 520 | 65 | 71% | 8 |
| Dietitian | 1 | 0 | 1 | 512 | 64 | 70% | 8 |
| Qualified Social Worker | 0 | 1 | 1 | 411 | 63 | 69% | 6.5 |
| Respiratory Therapy Technician | 0 | 2 | 2 | 384 | 59 | 65% | 6.5 |
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
148Residents meet regularly to discuss policies, care quality, and activities
Family members meet regularly to discuss policies, care quality, and activities
State-approved Nurse Aide Training and Competency Evaluation Program on-site
Organized group of family members that meets regularly to discuss facility policies, resident care, and activities.
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
9.4
10% better than Kansas averageKansas average: 10.5
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
15.6
25% better than Kansas averageKansas average: 20.7
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
10.4%
45% better than Kansas averageKansas average: 19.0%
Percent of long-stay residents whose ability to move independently worsened
20.5%
6% worse than Kansas averageKansas average: 19.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
15.9%
33% better than Kansas averageKansas average: 23.8%
Percent of long-stay residents experiencing one or more falls with major injury
4.9%
11% worse than Kansas averageKansas average: 4.4%
Percent of long-stay high risk residents with pressure ulcers
6.9%
48% worse than Kansas averageKansas average: 4.6%
Percent of long-stay residents with a urinary tract infection
1.6%
49% better than Kansas averageKansas average: 3.1%
Percent of long-stay residents who lose too much weight
4.4%
14% better than Kansas averageKansas average: 5.1%
Percent of long-stay residents who have depressive symptoms
0.0%
100% better than Kansas averageKansas average: 5.2%
Percent of long-stay residents who received an antipsychotic medication
22.5%
33% worse than Kansas averageKansas average: 16.9%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
96.9%
5% better than Kansas averageKansas average: 91.9%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
93.7%
In line with Kansas averageKansas average: 95.5%
Number of hospitalizations per 1,000 long-stay resident days.
1.38
25% better than Kansas averageKansas average: 1.84
Number of outpatient emergency department visits per 1,000 long-stay resident days.
1.45
33% better than Kansas averageKansas average: 2.16
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
94.5%
25% better than Kansas averageKansas average: 75.6%
Percent of short-stay residents who newly received an antipsychotic medication
1.7%
20% better than Kansas averageKansas average: 2.2%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
84.6%
15% better than Kansas averageKansas average: 73.5%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
26.8%
17% worse than Kansas averageKansas average: 23.0%
Percentage of short-stay residents who had an outpatient emergency department visit.
11.4%
In line with Kansas averageKansas average: 11.7%
Percentage of SNF residents who experience falls with major injury during their stay.
0.9%
16% worse than Kansas averageKansas average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
67.8%
26% better than Kansas averageKansas average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
64.1%
27% better than Kansas averageKansas average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database (Data as of Jan 2026)
29% higher than Kansas averageKansas average: $44K
24% more fines than Kansas averageKansas average: 2.4
Serious action where Medicare and/or Medicaid temporarily stops payments for new residents until issues are fixed.
0
100% fewer payment denials than Kansas averageKansas average: 0.3
Penalties are imposed by CMS for violations of federal nursing home regulations.
3 penalties in the past 3 years
Multiple penalties were reported in the last 3 years.
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
Oct 2, 2024
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
May 9, 2024
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
Feb 22, 2024Last updated: Jan 2026
The information below is reported by the Kansas Department for Aging and Disability Services.
| Brighton Place West Health Center LLC |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Topeka (Central Topeka 1) | 50 | 96.0% | +21% | 2.68 | +30% | -42% | 1 | 20 | 5.0 | 2 | 49 | - | 43 | - | $3.2M | $1.0M | 31.7% | 175547 | ||||
| The Gardens at Aldersgate LLC |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Topeka (Downtown) | 175 | 81.6% | +3% | 3.72 | +5% | -20% | 3 | 40 | 4.4 | 4 | 143 | B- | 78 | - | $18.1M | $6.7M | 36.8% | 175340 | ||||
| Tanglewood Nursing and Rehabilitation |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Topeka (Downtown) | 54 | 87.3% | +10% | 3.12 | +3% | -33% | 4 | 46 | 9.2 | 3 | 47 | - | 78 | - | $4.9M | $1.8M | 37.3% | 175463 | ||||
| Plaza West Healthcare and Rehab Center |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Topeka (Southwest Topeka) | 151 | 81.3% | +2% | 3.09 | -35% | -33% | 12 | 75 | 7.5 | 5 | 126 | - | 52 | - | $13.1M | $5.9M | 45.1% | 175255 | ||||
| Topeka Center for Rehabilitation and Nursing | - |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Topeka (Southwest Topeka) | 120 | 86.9% | +9% | - | - | - | - | - | - | 0 | - | - | - | - | - | 62 | - | $8.2M | $1.6M | 19% | 175172 |
Historical financial and operational data for The Gardens at Aldersgate LLC based on CMS SNF Cost Reports.
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The Gardens at Aldersgate LLC is in the Downtown neighborhood of TOPEKA.
The legal owner and operator of The Gardens at Aldersgate LLC is Betten End Snf Realty Llc.
The Gardens at Aldersgate LLC has a walk score of 78. Very walkable. Most errands can be accomplished on foot, and many essentials are within a short walk.
According to KS state health department records, The Gardens at Aldersgate LLC's license number is 175340.
The Gardens at Aldersgate LLC's occupancy is 65%.
Morgan Morris is the administrator of The Gardens at Aldersgate LLC.
The Gardens at Aldersgate LLC has 175 beds.
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