Inspection Reports for The Gardens at Aldersgate LLC

An offsite revisit survey was conducted on 5/7/21 to verify correction of all previous deficiencies cited on 3/15/21.

All deficiencies cited in the prior inspection have been corrected as of the compliance date of 3/19/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Aldersgate Village in response to a prior survey's statement of deficiencies, outlining the facility's plan for substantial compliance with Federal Medicare and Medicaid requirements.

The facility reviewed policies and procedures related to medication storage and management, provided mandatory in-service training to nurses on medication identification, storage, and distribution, replaced insulin pens for two residents, and established ongoing compliance checks by Unit Managers and oversight by the Director of Nursing.

The inspection was conducted as a Health Resurvey and complaint investigations for complaint numbers #159625, #160205, #160634, and #160358.

The facility failed to date insulin pens when opened or expired for two residents (R130 and R122) in two of eight medication carts, placing residents at risk for use of ineffective medications.

The visit was triggered by complaint investigations #159625, #160205, #160634, and #160358.

A Targeted Infection Control Survey/COVID-19 Focused Survey and an abbreviated complaint survey were conducted on 11/17/2020 for complaints #KS00156518.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. No noncompliance was found and the facility is in compliance with all regulations surveyed.

Complaint #KS00156518 was investigated during the abbreviated complaint survey and found to have no noncompliance.

A Targeted Infection Control Survey/COVID-19 Focused Survey and an abbreviated complaint survey were conducted by the Kansas Department on Aging and Disability Services on behalf of CMS on 11/17/2020.

The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation, and no noncompliance was found during the abbreviated complaint survey.

An abbreviated complaint survey was conducted for complaints #KS00156518 and no noncompliance was found.

A revisit survey was conducted on 10/21/20 to verify correction of all previous deficiencies cited on 8/13/20.

All deficiencies cited in the prior inspection have been corrected as of the compliance date of 8/27/20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices to prepare for COVID-19.

The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation.

A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of CMS on 09/09/2020 to assess compliance with recommended COVID-19 practices.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

The document is a Plan of Correction submitted in response to deficiencies related to Infection Control practices at Aldersgate Village.

The facility reviewed and updated policies and procedures related to Infection Control, focusing on PPE use, chemical dwell times, and staff training. An in-facility survey was conducted by KDHE epidemiologists to monitor compliance, and ongoing monitoring by nursing leadership was established.

The inspection was a Targeted Infection Control Survey/COVID-19 Focused Survey conducted by the Kansas Department on Aging and Disability Services on behalf of CMS, along with an abbreviated complaint survey for complaint #KS00155013.

The facility failed to follow standards of practice for personal protective equipment (PPE), including failure to change gowns between resident rooms on the isolation unit, improper PPE use inside the COVID unit, and failure to remove PPE before leaving the COVID unit. Additionally, the facility did not follow the manufacturer's directions for the cleaning solution's required wet time for disinfecting surfaces, placing residents at risk for transmission of COVID-19 and other communicable diseases.

The abbreviated complaint survey was conducted on 08/13/2020 for complaint #KS00155013.

A Targeted Infection Control Survey/COVID-19 Focused Survey and an abbreviated complaint survey were conducted on 07/21/2020 for complaints #KS00152359 and KS00151564.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. No noncompliance was found related to the complaints, and the facility is in compliance with all regulations surveyed.

Complaints #KS00152359 and KS00151564 were investigated during the abbreviated complaint survey; no noncompliance was found.

A Targeted Infection Control Survey/COVID-19 Focused Survey and an abbreviated complaint survey were conducted on 07/21/2020 by the Kansas Department on Aging and Disability Services on behalf of CMS.

The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation, and no noncompliance was found during the abbreviated complaint survey.

An abbreviated complaint survey was conducted for complaints #KS00152359 and KS00151564 with no noncompliance found.

A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Kansas Department for Aging and Disability Services (KDADS).

The facility was found to be in substantial compliance with 42 CFR 483 subpart B.

A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Kansas Department for Aging and Disability Services (KDADS) on 06/25/20.

The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the COVID-19 Focused Infection Control survey.

The special infection control survey for COVID-19 was conducted at the facility on 06/22/2020.

The survey resulted in findings of no deficiency citations.

A revisit survey was conducted on 8/30/19 for all previous deficiencies cited on 7/23/19.

All deficiencies have been corrected as of the compliance date of 8/8/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

A revisit survey was conducted on 8/30/19 to verify correction of all previous deficiencies cited on 7/12/19.

All deficiencies cited in the prior inspection have been corrected as of the compliance date of 8/5/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a plan of correction submitted by Aldersgate Village in response to a prior survey's statement of deficiencies, outlining the facility's corrective actions to comply with Federal Medicare and Medicaid requirements.

The facility reviewed and updated policies related to medication administration and monitoring, educated staff involved in the cited deficiency, and implemented training for all staff to ensure compliance. The Director of Nursing is responsible for monitoring substantial compliance.

Health Resurvey and Complaint Investigation #KS00135182 conducted to assess compliance with regulatory requirements and investigate complaints.

The facility had multiple deficiencies including failure to maintain a safe, clean, and comfortable environment in a beauty shop, incomplete resident assessments, failure to revise care plans after incidents, inadequate restorative services, medication administration errors, unsanitary food preparation areas, infection control lapses, and failure to prevent accidents including falls and elopement.

Complaint investigation #KS00135182 included a health resurvey with findings of multiple deficiencies related to safety, care planning, restorative services, medication administration, infection control, and environmental sanitation.

This document is a Plan of Correction submitted by Aldersgate Village in response to deficiencies cited in the deficiency report dated 7/23/2019. It outlines the facility's corrective actions to achieve substantial compliance with Federal Medicare and Medicaid requirements.

The Plan of Correction addresses multiple deficiencies related to safe/clean environment, comprehensive assessments, care plans, restorative programs, activities administration, accident hazards, individualized toileting plans, medical equipment sanitization, medication procurement and administration, and infection control. The facility has reviewed and revised policies and procedures, provided staff in-servicing, and assigned monitoring responsibilities to ensure compliance.

The inspection was conducted as a complaint investigation based on multiple complaint investigation numbers (KS00143262, KS00142684, KS00142293, and KS00139974).

The facility failed to prevent a significant medication error when a narcotic pain relief medication was incorrectly transcribed and administered at an increased dose to one resident, resulting in emergency care and hospitalization. The error involved morphine sulfate, a Black Box Warning medication, and was caused by incorrect transcription into the electronic medication administration record.

The findings represent the results of complaint investigations identified by numbers KS00143262, KS00142684, KS00142293, and KS00139974.

This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.

The report shows that multiple deficiencies identified in prior inspections were corrected, with specific regulation citations and correction completion dates provided.

The inspection was conducted as a survey for re-licensure of the assisted living unit in Topeka, KS on 10/3/18, 10/4/18, and 10/8/18.

The facility was found deficient in multiple areas including failure to ensure negotiated service agreements contained required information, improper medication administration practices, lack of proper labeling on over-the-counter medications, incomplete documentation of incidents, and inadequate disaster and emergency preparedness including failure to conduct quarterly reviews and an annual evacuation drill.

An offsite revisit survey was conducted on 09/05/2018 for all previous deficiencies cited on 07/09/2018 to verify correction of prior deficiencies.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/08/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Aldersgate Village in response to a prior survey report dated 06/14/2018, outlining the facility's corrective actions to address alleged deficiencies.

The Plan of Correction details the facility's review and update of policies and procedures related to survey result postings, notification of the State Ombudsman, neuro checks after falls, physician notifications and treatment documentation, and medication use. Staff education and monitoring responsibilities are described for each deficiency.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found a single isolated 'D' level deficiency that constitutes no actual harm but has potential for more than minimal harm and is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-08-08.

A Recertification Survey was conducted in conjunction with investigation of multiple complaint intake numbers to assess compliance with federal regulations.

The facility was found not to be in substantial compliance with 42 CFR 483, Subpart B. Deficiencies included failure to make survey results readily accessible to residents, failure to send required transfer notices to the State Ombudsman, failure to follow neurological check protocols after a resident's fall, failure to notify a physician and document treatment for a resident's skin issue, and failure to ensure a resident's drug regimen was free from unnecessary medications.

The survey included investigation of complaint intake numbers KS00105217, KS00111665, KS00113376, KS00120697, KS00121312, KS00123014, KS00128574, and KS00129701.

A complaint survey was conducted on 04/30/18 for complaint #KS00128624 and KS00125477.

The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.

Complaint #KS00128624 and KS00125477 were investigated and found to be unsubstantiated.

A complaint survey was conducted on 04/30/18 for complaint #KS00128624 and KS00125477.

The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.

Complaints #KS00128624 and KS00125477 were investigated and found not substantiated.

A complaint survey was conducted on 04/30/18 for complaint #KS00128624 and KS00125477.

The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.

Complaint #KS00128624 and KS00125477 were investigated and found unsubstantiated.

A revisit survey was conducted on October 17, 2017 for all previous deficiencies cited on August 23, 2017.

All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a plan of correction submitted by Aldersgate Village in response to a prior survey and complaint alleging deficient practices related to resident care and compliance with Federal Medicare and Medicaid requirements.

The plan addresses deficiencies related to weight monitoring, meal intake, care plan development, and documentation. The facility outlines corrective actions including education for dietitians and direct care staff, policy updates, and ongoing monitoring for compliance.

The plan references a complaint investigation related to Aldersgate Village dated 08/23/2017.

This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The revisit report confirms that the deficiencies previously reported under regulation numbers 483.10(g)(14) and 483.25(b)(1) were corrected as of 03/24/2017. No uncorrected deficiencies remain.

The inspection was conducted as a result of complaint investigations #111980, #111264, #112188, and #112410.

The facility failed to timely notify the physician of abnormal lab results for one resident, resulting in hospitalization for an infected wound. Additionally, the facility failed to provide appropriate interventions to prevent the development of an avoidable pressure ulcer caused by a neck brace for the same resident.

The visit was complaint-related, involving investigations #111980, #111264, #112188, and #112410. The facility was found to have failed in timely physician notification and pressure ulcer prevention for resident #1.

An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found a most serious deficiency at F314, 'G', indicating actual harm that is not immediate jeopardy. Due to these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions.

This document is a Plan of Correction submitted by Aldersgate Village in response to deficiencies cited in a complaint investigation survey conducted on March 9, 2017.

The plan addresses deficiencies related to physician notification and skin assessments under medical devices. The facility outlines corrective actions including re-education of licensed nurses, review of affected residents, and ongoing monitoring by the Director of Nursing to ensure compliance and prevent recurrence.

This Plan of Correction is in response to deficiencies cited during a complaint investigation survey (Aldersgate complaint 03092017).

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The revisit report indicates that all previously cited deficiencies were corrected as of 09/23/2016, with no uncorrected deficiencies remaining.

This revisit inspection was conducted to verify that previously reported deficiencies at Aldersgate Village were corrected and to document the dates such corrective actions were accomplished.

The report confirms that the deficiencies previously cited under regulations 26-41-101 (g) and 26-41-205 (h) were corrected as of 10/24/2016. No uncorrected deficiencies were noted in this revisit report.

This document is a Plan of Correction submitted by Aldersgate Village in response to a prior survey report, outlining corrective actions to address alleged deficiencies.

The plan addresses deficiencies including the posting of the Policy and Procedures manual location signs and the proper dating of insulin pens for residents, with corrective actions and ongoing monitoring described.

The inspection was an Assisted Living Healthcare Licensure resurvey to assess compliance with state regulations.

The facility failed to post a notice of the availability of policies and procedures in a place readily accessible to residents and failed to properly date opened insulin pens used for medication storage.

This document is a Plan of Correction submitted by Aldersgate Village in response to a revised complaint dated 09/06/2016, outlining the facility's plan for substantial compliance with Federal Medicare and Medicaid requirements.

The plan addresses deficiencies related to individualized care plans, prevention and treatment of pressure ulcers, infection control practices including proper glove use, and monitoring of interventions. The facility outlines re-education of staff, ongoing monitoring by designated staff, and reporting to the Quality Assurance and Assessment Committee to prevent recurrence.

The visit was related to a complaint investigation resulting in a deficiency cited at F314 on September 6, 2016.

The deficiency initially cited at a 'G' level was lowered to a 'D' level deficiency following an Independent Informal Dispute Resolution on November 22, 2016.

The deficiency cited at F314 was related to a complaint investigation and was downgraded from a 'G' level to a 'D' level after the IIDR process.

An Abbreviated Survey was conducted on September 6, 2016, by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency to be F314 "G", CFR 483.25(c), indicating actual harm that is not immediate jeopardy related to pressure ulcers. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.

The inspection was conducted as a complaint investigation (#104353) to evaluate allegations related to care planning, pressure ulcer prevention and treatment, infection control, and related resident care.

The facility failed to develop individualized care plans for residents requiring toileting assistance and those with pressure ulcers. It also failed to update care plans after new pressure ulcers developed, provide timely and effective interventions to prevent and treat pressure ulcers, and prevent the spread of infection due to improper glove use during resident care.

The complaint investigation (#104353) focused on care planning deficiencies, pressure ulcer prevention and treatment failures, and infection control breaches related to a resident with multiple pressure ulcers and wound infection.

This document is a Plan of Correction submitted by Aldersgate Village in response to deficiencies cited during a prior inspection, addressing allegations for substantial compliance with Federal Medicare and Medicaid requirements.

The plan addresses multiple deficiencies including unexplained injuries, cleanliness issues, care plan updates for dialysis, fall prevention interventions, chemical storage security, and patio door alarm functionality. Staff education and ongoing monitoring by designated personnel are outlined to ensure compliance and prevent re-occurrence.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

All deficiencies previously cited were corrected as of the revisit date, with corrections completed for multiple regulatory requirements.

This report documents a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.

The revisit report indicates that the previously cited deficiency related to regulation 26-40-303 (2)(a)(i)(ii)(iii) was corrected as of 08/19/2016. No other deficiencies or findings are noted.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.

The inspection was conducted as an annual survey to assess compliance with regulatory requirements, specifically focusing on the door monitoring system for resident safety.

The facility failed to provide a functioning door monitoring system on patio doors for two cognitively impaired and independently mobile residents. The patio door alarm was not routinely checked by staff, and maintenance logs lacked proper documentation for this door's monitoring.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report confirms that the previously cited deficiency with ID Prefix F0333 under regulation 483.25(m)(2) was corrected as of 04/20/2016. No other deficiencies or uncorrected issues are noted.

The inspection was conducted as a complaint investigation (#98558) following a significant medication error involving a cognitively impaired resident who was given another resident's medications without physician orders.

The facility failed to provide adequate supervision and orientation to new licensed staff, resulting in a significant medication error that caused the transfer of a resident to an acute care hospital ICU for treatment. The error involved administering multiple cardiac and other medications intended for another resident with the same first name. The facility lacked a policy to ensure proper supervision of new licensed nursing staff during medication administration and failed to correctly identify residents prior to medication administration.

Complaint investigation #98558. The medication error was substantiated by observations, interviews, and record reviews showing a cognitively impaired resident was given another resident's medications, resulting in emergency transfer and ICU admission.

An Abbreviated Survey was conducted on April 19, 2016, by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to this and a history of noncompliance from a prior survey on February 22, 2016, the facility will not be given an opportunity to correct deficiencies before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions effective May 10, 2016.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

All previously cited deficiencies related to regulations 483.20(d)(3), 483.10(k)(2), 483.25(h), 483.30(a), and 483.75(o)(1) were corrected as of 03/12/2016.

The plan of correction was submitted in response to deficiencies identified during a survey related to medication administration and facility orientation processes.

Resident #2 was sent to the hospital for evaluation and returned to the facility. Deficiencies included issues with medication administration by a nurse during orientation and the need to improve the facility's orientation process and medication cart functionality.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies in the facility to be at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

This document is a Plan of Correction submitted by Aldersgate Village in response to a complaint survey (Event ID 6PL811) outlining corrective actions to address alleged deficiencies identified during the complaint investigation.

The plan addresses multiple deficiencies related to care plan revisions, fall prevention and management, staffing schedule accuracy, and Quality Assurance and Assessment processes. The facility describes actions taken including resident care plan reviews, staff education, policy updates, removal and evaluation of equipment, and implementation of monitoring and reporting systems to ensure compliance and prevent recurrence.

This Plan of Correction is in response to a complaint investigation identified by Event ID 6PL811. The facility disputes the legitimacy of the survey findings but outlines corrective actions to address the alleged deficiencies.

The inspection was a partial extended complaint investigation involving multiple complaint investigations.

The facility failed to review and revise care plans for residents with significant changes in condition, failed to provide adequate supervision and assistive devices to prevent accidents for multiple cognitively impaired residents, failed to provide sufficient nursing staff to meet resident needs, and failed to maintain an effective quality assurance committee to address identified deficiencies.

The inspection was a partial extended complaint investigation involving complaint investigations #89653, 89883, 91498, 94470, 94612, 94638, 94639, 95223, 96546, 96642, 96928 and 97190.

An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency to be at a level of actual harm that is not immediate jeopardy, requiring corrections. Based on this and the facility's history of noncompliance from a prior survey on March 13, 2015, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed.

The action is based on deficiencies found on the current survey and a complaint survey conducted on March 13, 2015.

This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were accomplished.

The report confirms that the previously identified deficiency with ID prefix S1364 related to regulation 26-40-305 (3) was corrected as of 03/20/2015.

This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report documents that all previously cited deficiencies have been corrected as of the dates listed, with no uncorrected deficiencies remaining.

The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found deficiencies at a level of actual harm that is not immediate jeopardy, with a history of noncompliance from a prior survey in 2013. Enforcement remedies including denial of payment for new Medicare admissions were imposed effective April 5, 2015.

The inspection was a Health Licensure Resurvey to assess compliance with electrical safety requirements related to hydrotherapy equipment.

The facility failed to have the Physical Therapy hydrocollator plugged into a ground-fault circuit interrupter (GFCI) outlet for one of three days observed during the survey. The facility's policy did not address the requirement for GFCI protection.

This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The revisit confirmed that the deficiencies previously cited under regulations 483.15(a), 483.25(h), and 483.35(i) were corrected as of 01/01/2015.

This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Aldersgate Village.

The plan addresses deficiencies related to meal service timing, securing galley kitchen doors, and proper labeling and dating of food items in kitchens. Corrective actions include staff training, daily audits, and ongoing monitoring reported to the facility's Quality Assurance/Assessment committee.

This Plan of Correction is related to a complaint investigation at Aldersgate Village.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be an 'F' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The inspection was conducted as a complaint investigation covering multiple complaint numbers (#73647, 75580, 75852, 77422, and 78789).

The facility failed to promote dignity and respect during meal service for dependent residents, failed to ensure a safe environment and supervision to prevent accidents, and failed to store, prepare, and serve food in a sanitary manner on the Eastminister unit.

The inspection was triggered by complaint investigations #73647, 75580, 75852, 77422, and 78789.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The revisit report shows that deficiencies identified under regulations 483.10(b)(11) and 483.25(m)(2) were corrected as of 09/08/2014.

This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Aldersgate Village.

The plan addresses deficiencies related to timely family notification following resident accidents and medication administration practices, including changes to medication administration locations and staff monitoring.

This Plan of Correction is related to a complaint investigation at Aldersgate Village.

The inspection was conducted as a complaint investigation (#77241) regarding failure to notify a resident's legal representative after a medication administration error.

The facility failed to notify the legal representative of a resident after a medication error where the resident received another resident's medication, resulting in low blood pressure and hospitalization. The facility also administered medication without a physician's order.

The complaint investigation #77241 found that the facility failed to notify the legal representative of resident #1 after a medication error. The resident received another resident's medication, experienced low blood pressure, and required hospitalization. The facility investigation confirmed these findings.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found 'D' level deficiencies indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective September 8, 2014.

This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The revisit confirmed that the deficiency identified under regulation 483.25 (ID Prefix F0309) was corrected as of 05/05/2014.

This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Aldersgate Village.

The plan addresses the use of protective coverings (geri-sleeves changed to tuba grip) for resident #7 to prevent skin injuries, updates to resident care plans and physician orders, development of a skin tear prevention policy, and monitoring through daily risk reviews and Quality Assurance committee reports.

This Plan of Correction is related to a complaint investigation at Aldersgate Village.

The inspection was conducted as a complaint investigation covering multiple complaint investigations (#72220, 72586, 72952, and 74441).

The facility failed to prevent the development of multiple skin tears for one resident (#7) who required extensive assistance and protective arm sleeves as ordered. Staff failed to consistently apply the protective Geri-sleeves, resulting in repeated skin tears and injuries to the resident's left hand.

The findings represent the results of complaint investigations #72220, 72586, 72952, and 74441. The complaint was substantiated by the facility's failure to implement ordered interventions to prevent skin tears.

This revisit report documents the follow-up inspection to verify correction of previously reported deficiencies at Aldersgate Village.

The report shows that previously cited deficiencies identified by regulation numbers 26-40-303 (b)(i)(ii)(iii)(iv)(c) and 26-40-303 (g)(i)(ii)(iii) were corrected as of 12/13/2013.

This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.

All previously reported deficiencies identified by regulation numbers and prefix codes were corrected by 12/13/2013 as verified during this revisit.

This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection, outlining corrective actions to address care plan updates, staff training, and safety interventions.

The plan details multiple corrective actions including updating resident care plans to address wandering, agitation, pain, falls, pressure ulcers, and incontinence; staff training on behavior management, hydration, medication administration, and infection control; and implementation of environmental safety measures such as door locks and call light systems.

The inspection was a Health Resurvey conducted to assess compliance with nursing facility support system requirements, specifically regarding emergency call systems and wireless call system functionality.

The facility failed to provide audible call signals in soiled and clean utility rooms on one unit and lacked emergency call systems in resident showers on one unit. Additionally, the wireless call system malfunctioned for 27 residents on the Westminster unit, with delays in call signal alerts and failure to escalate unanswered calls to other staff.

The inspection was a licensure resurvey conducted to assess compliance for renewal of the facility's license.

The licensure resurvey at Aldersgate Village resulted in no deficiencies.

This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The revisit confirmed that the deficiency identified under regulation 483.25(h) with ID prefix F0323 was corrected as of 07/22/2013.

The inspection was conducted as a complaint investigation related to allegations identified by complaint investigation numbers #KS00063467 and #KS00066230.

The facility failed to implement effective fall prevention interventions for a high-risk resident who fell and sustained a nose fracture. Observations and interviews revealed staff did not follow care plan instructions to stay within arm's reach of the resident while toileting, contributing to the fall and injury.

The complaint investigation identified failures in supervision and fall prevention for resident #1, who had multiple prior falls and was at high risk. The resident fell on 5/25/13 while unattended on the toilet, resulting in injury. Staff interviews confirmed noncompliance with care plan interventions.

This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report confirms that deficiencies previously cited under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) have been corrected as of the revisit date.

This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Aldersgate Village.

The plan addresses deficiencies related to the use of mechanical lifts and sling sizes for residents, including updates to care plans and 24-hour report sheets, staff training, and ongoing audits to ensure compliance.

This Plan of Correction is related to a complaint investigation identified by event ID SDCG11 and complaint ID 051713.

The inspection was conducted as a complaint investigation (#65351) regarding the facility's failure to revise care plans and ensure appropriate use of mechanical lift slings for residents.

The facility failed to revise care plans for 2 of 3 sampled residents to reflect changes in transfer methods and sling sizes. The facility also failed to thoroughly assess the appropriateness of mechanical lift slings, resulting in a resident falling through the bottom of a sling and sustaining a head injury. Staff training and communication regarding sling use were inadequate, and the facility lacked a formal system to assess sling appropriateness prior to the incident.

Complaint investigation #65351 focused on care plan revisions and safety related to mechanical lift sling use. The complaint was substantiated with findings of care plan deficiencies and safety hazards leading to a resident injury.

This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.

The report shows that deficiencies previously cited under regulations 483.10(b)(11) and 483.65 were corrected as of 02/09/2013.

This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Aldersgate Village.

The plan addresses deficiencies related to physician notification for changes in resident conditions and proper cleaning procedures for isolation rooms, including training for nursing and housekeeping staff and ongoing compliance monitoring.

This Plan of Correction is related to a complaint investigation identified by Event ID P30811 and Complaint ID 011113.

The inspection was conducted as a complaint investigation based on complaint investigation numbers #62923, #62939, and #62387.

The facility failed to promptly notify physicians and family members regarding significant changes and transfers of residents, specifically for two residents with serious health issues. Additionally, the facility lacked an effective infection control program, failing to perform ongoing surveillance for diarrhea and Clostridium difficile infections and did not properly clean the room of a resident in isolation.

The investigation was triggered by complaints #62923, #62939, and #62387. The facility failed to notify physicians timely about a resident's diarrhea and bleeding and failed to notify family members about hospital transfers. The facility also failed to maintain an effective infection control program to prevent spread of infections including Clostridium difficile.

This post-certification revisit was conducted to verify that previously identified deficiencies from the prior survey were corrected as of the revisit date.

The report shows that all previously cited deficiencies were corrected by the specified dates, with no uncorrected deficiencies noted at the time of this revisit.

This document is a Plan of Correction submitted by Aldersgate Village in response to deficiencies cited in a prior inspection report.

The plan addresses multiple deficiencies including updating care plans for residents, ensuring individualized hygiene and toileting programs, fall prevention measures, behavior monitoring for psychoactive medications, dining service sanitation, oral hygiene assessments, and medication vial management.

Health Resurvey and Complaint Investigation conducted under the Quality Indicator Survey process to assess compliance with care plan development, resident rights, ADL care, urinary incontinence care, restorative services, fall prevention, medication monitoring, food sanitation, dental services, and medication storage.

The facility failed to develop comprehensive care plans for restorative services and resident preferences, provide adequate grooming and oral care, offer toileting and perineal care after incontinence, provide restorative services to lower extremities, utilize fall interventions resulting in a hip fracture, maintain sanitary food preparation and storage, obtain ordered dental consultation, monitor behavioral medications, and label opened insulin vials with dates.

The inspection was conducted as a Health Resurvey and Complaint Investigation under the Quality Indicator Survey process. Specific complaints included failure to develop care plans, inadequate grooming and oral care, failure to provide toileting and perineal care, failure to provide restorative services, fall prevention failures resulting in injury, medication monitoring failures, food sanitation issues, failure to obtain dental consultation, and medication storage issues.

This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Aldersgate Village.

The plan addresses a deficiency related to fall prevention for resident #1, including staff education and ongoing compliance audits to prevent falls among residents at risk.

This Plan of Correction is linked to a complaint investigation at Aldersgate Village.

This document is a Plan of Correction submitted by Aldersgate Village in response to deficiencies identified in a prior inspection, addressing issues such as abuse allegations, wound care, medication administration, food safety, behavior monitoring, blood glucose monitoring, and equipment safety.

The plan outlines corrective actions for multiple deficiencies including abuse investigation, accurate MDS documentation for surgical wounds, pressure ulcer management, proper enteral medication administration, food labeling and cross-contamination prevention, behavior monitoring, individual blood glucose monitoring, and hydrotherapy equipment safety.