Inspection Reports for The Gardens at Aldersgate LLC
3220 SW ALBRIGHT DRIVE, TOPEKA, KS, 66614-4707
Back to Facility ProfileInspection Report Summary
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.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
18.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
215% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
114 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 1
Date: Jul 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an episode of staff-to-resident physical abuse involving a cognitively impaired resident.
Complaint Details
The complaint investigation found substantiated physical abuse by Licensed Nurse G against Resident 1, who is cognitively impaired. The nurse was immediately suspended and terminated. The facility notified the resident's medical provider, resident representative, law enforcement, and the state agency.
Findings
The facility failed to prevent staff-to-resident physical abuse of a cognitively impaired resident, resulting in the termination of the involved licensed nurse. The facility implemented corrective actions including staff education and resident screening.
Deficiencies (1)
Failed to protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Report Facts
Census: 114
Sample size: 4
BIMS score: 8
Incident Report Number: 6463
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in physical abuse incident and terminated from the facility |
| CNA M | Certified Nurse's Aide | Witnessed the physical altercation between Resident 1 and LN G |
| Dietary Staff BB | Witnessed the physical altercation between Resident 1 and LN G | |
| LN I | Licensed Nurse | Provided statements regarding staff training and behavioral management |
| Administrative Nurse D | Administrative Nurse | Reported termination of LN G and described facility abuse prevention policies |
Inspection Report
Annual Inspection
Census: 160
Deficiencies: 1
Date: Dec 30, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding the treatment and services provided to residents diagnosed with dementia, focusing on individualized dementia care plans.
Findings
The facility failed to develop an individualized dementia treatment plan for Resident 1 (R1) to address dementia-related behaviors, which placed R1 at risk for impaired psychosocial well-being and quality of life. Multiple skilled and behavior notes documented R1's disruptive behaviors, wandering, anxiety, agitation, and hallucinations, but the care plan lacked detailed interventions and descriptions of staff responses.
Deficiencies (1)
Failure to develop an individualized dementia treatment plan to address R1's dementia-related behaviors to promote his highest practicable quality of life and well-being.
Report Facts
Census: 160
Residents reviewed for dementia care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Stated staff knew about R1 wandering and had not informed management about an incident |
| Certified Nurse Aide M | Certified Nurse Aide | Reported observations of R1's wandering and behaviors, and interactions with other residents |
| Administrative Nurse D | Administrative Nurse | Expected staff to address resident behaviors and update care plans |
Inspection Report
Complaint Investigation
Census: 152
Deficiencies: 1
Date: Oct 2, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to ensure Resident 1 remained free from avoidable accidents, specifically related to staff not providing care safely according to the resident's plan of care.
Complaint Details
The investigation was complaint-related, triggered by concerns expressed by Resident 1's representative about inconsistent use of mechanical lifts and inadequate staff assistance. The complaint was substantiated as the resident sustained injuries due to staff failing to follow the care plan.
Findings
The facility failed to prevent Resident 1 from sustaining a dislocated right shoulder and fractured right humerus due to inadequate supervision and failure to follow the care plan requiring two staff members for assistance. The resident experienced multiple falls and injuries, and staff did not consistently use mechanical lifts or provide the required assistance.
Deficiencies (1)
Failure to ensure Resident 1 remained free from avoidable accidents due to inadequate staffing and supervision per the resident's care plan, resulting in a dislocated right shoulder and fractured right humerus.
Report Facts
Census: 152
BIMS score: 14
BIMS score: 3
Falls with injury: 2
Falls without injury: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Assisted Resident 1 during fall and was involved in the incident where Resident 1 fell from recliner |
| CNA N | Certified Nurse Aide | Reported that CNA M was not fully aware of Resident 1's transfer and care needs |
| LN G | Licensed Nurse | Responded to Resident 1's fall and provided report on the incident |
| Administrative Nurse D | Administrative Nurse | Stated expectation for staff to follow Resident 1's care plan requiring two staff members for care |
| Administrative Staff A | Administrative Staff | Stated expectation for staff to follow residents' care plans when providing care |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
Date: May 9, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to an accident involving Resident 1 (R1) who sustained an avoidable injury during transfer.
Complaint Details
The investigation was complaint-driven, focusing on an incident where staff pushed on Resident 1's legs during transfer, causing bleeding and a laceration requiring 15 sutures. Resident 1 reported pain and emotional distress. Staff involved received transfer training which was incomplete at the time.
Findings
The facility failed to ensure a safe environment free from accident hazards, resulting in R1 sustaining a laceration requiring sutures due to improper transfer techniques by staff. The investigation revealed staff pushed on R1's legs during transfer, causing injury and pain.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in an injury to Resident 1.
Report Facts
Resident census: 145
Skin tear length left leg: 10.8
Skin tear width left leg: 4.3
Skin tear depth left leg: 0.1
Skin tear length right leg: 3.9
Skin tear width right leg: 5.2
Skin tear depth right leg: 0.2
Laceration length: 13
Sutures required: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Involved in transfer of Resident 1 and noted in witness statements regarding the incident |
| CNA N | Certified Nurse Aide | Involved in transfer of Resident 1 and noted in witness statements regarding pushing on Resident 1's legs causing injury |
| LN G | Licensed Nurse | Assessed Resident 1's injuries and performed dressing changes |
| CNA O | Certified Nurse Aide | Provided statement on proper use of Hoyer lift and transfer procedures |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding staff training and incident details |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident 1 slipped from a sling during a staff-assisted transfer using a Hoyer lift, resulting in serious injury.
Complaint Details
The investigation was triggered by a complaint related to Resident 1's fall during transfer with a Hoyer lift. The fall resulted in serious injuries including a head laceration, thoracic fracture, and intracranial hemorrhage. The complaint was substantiated with findings of staff using the wrong sling type.
Findings
The facility failed to ensure a safe environment free from preventable accidents when staff used the wrong sling during a mechanical lift transfer, causing Resident 1 to fall and sustain a head laceration, spinal fracture, and brain hemorrhage. The facility retrained staff and updated care plans to address the issue.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, specifically using the wrong sling during a mechanical lift transfer.
Report Facts
Resident census: 148
Resident weight: 249
Resident height: 72
Dates: Mar 4, 2024
Dates: Mar 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Involved in the transfer during which Resident 1 fell; acknowledged using the wrong sling |
| CNA N | Certified Nurse Aide | Assisted in the transfer and witnessed Resident 1 slipping out of the sling |
| LN G | Licensed Nurse | Responded immediately to the fall, applied pressure to Resident 1's head, and conducted neurological checks |
| Administrative Nurse E | Administrative Nurse | Reviewed sling and lift use with staff and worked on in-service education |
| Administrative Nurse D | Administrative Nurse | Acknowledged staff used the wrong sling and was involved in staff education |
Inspection Report
Routine
Census: 148
Deficiencies: 20
Date: Feb 22, 2024
Visit Reason
The inspection was a routine regulatory survey of The Gardens at Aldersgate nursing home to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity, medication management, care planning, fall prevention, infection control, and staff training. Specific failures included lack of privacy during blood glucose testing, failure to notify physicians of medication refusals, incomplete investigations of falls, inadequate care plans for hospice and dementia care, failure to provide scheduled bathing, insufficient skin and wound care, ineffective fall prevention interventions, inadequate toileting assistance, failure to monitor fluid restrictions, lack of communication with dialysis center, incomplete nurse aide training, failure to address self-harm statements, improper medication use and storage, unsanitary kitchen conditions, and failure to follow COVID-19 isolation protocols.
Deficiencies (20)
Failed to treat residents with respect, dignity, and privacy during blood glucose testing in the dining room.
Failed to notify physician of Resident 68's behaviors and refusal to take psychotropic medications.
Failed to complete a full investigation to rule out abuse or neglect after an unwitnessed fall for Resident 105.
Failed to develop a comprehensive care plan for Resident 137's hospice care and fluid restriction.
Failed to revise care plans for Residents 37, 105, and 128 to include person-centered interventions.
Failed to provide scheduled bathing for Resident 61.
Failed to implement protective measures to prevent skin tears and bruising for Resident 140.
Failed to provide off-loading interventions and weekly wound assessments for Residents 13 and 82 with pressure ulcers.
Failed to provide supervision and person-centered fall prevention interventions for Residents 37 and 105.
Failed to follow care plan for toileting assistance for Resident 206 with urinary tract infection.
Failed to inform staff and follow physician-ordered fluid restriction for Resident 137.
Failed to collaborate with dialysis center and obtain contract for Resident 128 receiving dialysis.
Failed to ensure nurse aides completed required 12 hours of annual in-service training.
Failed to provide behavioral health services and timely physician involvement for Resident 37 with self-harm statements.
Failed to ensure Consultant Pharmacist identified inappropriate antipsychotic use and lack of stop dates for PRN antianxiety medications for Residents 123, 128, and 100.
Failed to monitor and provide bowel management interventions for Residents 45 and 100.
Failed to label and date insulin flex pens and discard expired insulin; failed to monitor medication refrigerator temperature daily.
Failed to store, prepare, and serve food in a sanitary manner in the main kitchen.
Failed to ensure COVID-19 isolation protocols were followed, including proper PPE use and disposal.
Failed to offer or obtain informed declination for PCV20 pneumococcal vaccination for residents.
Report Facts
census: 148
sample size: 32
days without bowel movement: 5
days without bowel movement: 5
days without bowel movement: 4
insulin pen expiration days: 28
required nurse aide in-service hours: 12
Inspection Report
Routine
Census: 148
Deficiencies: 22
Date: Feb 22, 2024
Visit Reason
The inspection was a routine regulatory survey of The Gardens at Aldersgate nursing home to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity during care, failure to notify physicians of medication refusals, incomplete investigations of falls, inadequate care planning, failure to provide necessary personal care, inadequate pressure ulcer prevention and care, ineffective fall prevention interventions, failure to follow toileting care plans, failure to monitor fluid restrictions, lack of collaboration with dialysis providers, incomplete nurse aide training, failure to provide behavioral health services, inappropriate medication use, unsanitary food service conditions, failure to follow infection control protocols, and failure to offer pneumococcal vaccinations.
Deficiencies (22)
Failed to treat residents with respect, dignity, and privacy during blood glucose testing in a public dining area.
Failed to notify the physician of Resident 68's behaviors and refusal to take psychotropic medications.
Failed to complete a full investigation to rule out abuse or neglect after an unwitnessed fall for Resident 105.
Failed to develop a comprehensive care plan for Resident 137's hospice care and physician-ordered fluid restriction.
Failed to revise care plans for Residents 37, 105, and 128 to include person-centered interventions.
Failed to provide necessary bathing services for Resident 61.
Failed to implement protective measures for prevention of skin tears and bruising for Resident 140.
Failed to provide off-loading interventions and weekly wound assessments for Residents 13 and 82 with pressure ulcers.
Failed to provide supervision and person-centered fall prevention interventions for Residents 37 and 105.
Failed to follow the care plan for toileting for Resident 206, who had a urinary tract infection.
Failed to inform staff and follow physician-ordered fluid restriction for Resident 137.
Failed to collaborate with dialysis center for Resident 128 and lacked dialysis care plan details.
Failed to ensure nurse aides completed required annual in-service training.
Failed to provide behavioral health services and timely physician notification for Resident 37 who made self-harm statements.
Failed to monitor and provide bowel management interventions for Residents 45 and 100.
Failed to monitor Resident 137's physician-ordered fluid restriction.
Failed to ensure ongoing assessments and communication with dialysis center for Resident 128.
Failed to label and date insulin flex pens and discard expired insulin; failed to monitor medication refrigerator temperature daily.
Failed to store, prepare, and serve food in a sanitary manner in the facility's main kitchen.
Failed to ensure COVID-19 isolation protocols were followed, including proper PPE use and disposal.
Failed to offer or obtain informed declination for PCV20 pneumococcal vaccination for residents.
Failed to ensure Consultant Pharmacist identified and reported inappropriate antipsychotic use and lack of stop dates for PRN antianxiety medications for Residents 123, 128, and 100.
Report Facts
census: 148
sample size: 32
medication refusal days: 32
bowel movement absence days: 5
bowel movement absence days: 5
bowel movement absence days: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant GG | Nurse Consultant | Provided statements on multiple deficiencies including dignity, medication refusals, fluid restriction, dialysis care, and behavioral health |
| Administrative Nurse D | Administrative Nurse | Provided statements on resident care, medication refusals, fall interventions, and behavioral health |
| Certified Nurse Aide N | Certified Nurse Aide | Provided statements on resident behaviors and care |
| Social Service Y | Social Service | Provided statements on resident behaviors and care |
| Certified Medication Aide R | Certified Medication Aide | Provided statements on resident behaviors and care |
| Licensed Nurse J | Licensed Nurse | Provided statements on resident behaviors and care |
| Dietary Staff CC | Dietary Staff | Provided statements on fluid restriction and meal ticket information |
| Certified Nurse Aide M | Certified Nurse Aide | Provided statements on fluid restriction and care |
| Licensed Nurse G | Licensed Nurse | Provided statements on fluid restriction and dialysis care |
| Administrative Staff A | Administrative Staff | Provided statements on fluid restriction, dialysis care, and medication orders |
| Consultant Staff GG | Consultant Staff | Provided statements on fluid restriction and dialysis care |
| Licensed Nurse K | Licensed Nurse | Provided statements on resident falls and behaviors |
| Certified Nurse Aide O | Certified Nurse Aide | Provided statements on resident falls and behaviors |
| Certified Nurse Aide MM | Certified Nurse Aide | Observed and provided statements on infection control and toileting care |
| Licensed Nurse LL | Licensed Nurse | Provided statements on toileting care |
| Certified Nurse Aide OO | Certified Nurse Aide | Provided statements on toileting care |
| Licensed Nurse NN | Licensed Nurse | Provided statements on medication refrigerator temperature monitoring |
| Licensed Nurse H | Licensed Nurse | Provided statements on insulin pen labeling and discarding |
| Administrative Nurse E | Administrative Nurse | Provided statements on wound care and infection control |
| Consultant Nurse HH | Wound Care Consultant | Provided wound care and statements on bruising and skin protection |
| Licensed Nurse UU | Licensed Nurse | Provided statements on PPE use in COVID-19 isolation |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
Date: Jul 18, 2023
Visit Reason
The inspection was conducted to investigate the facility's care and services provided to residents diagnosed with dementia, specifically focusing on Resident 1's wandering behaviors and related care interventions.
Complaint Details
The investigation was complaint-related focusing on Resident 1's dementia care and wandering behaviors. The complaint was substantiated as the facility failed to implement adequate interventions, resulting in multiple incidents of aggression and wandering that affected other residents and staff.
Findings
The facility failed to provide appropriate care and services for Resident 1 with dementia by not identifying and implementing resident-centered interventions to address wandering. This deficiency affected Resident 1's ability to maintain his highest practicable level of physical, mental, and psychosocial well-being. Multiple behavioral incidents were documented, including aggression, wandering into other residents' rooms, and difficulty with redirection.
Deficiencies (1)
Failed to provide appropriate treatment and services to a resident diagnosed with dementia, specifically failing to identify and implement interventions to address wandering.
Report Facts
Census: 145
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Described techniques used to redirect Resident 1 and care for residents with dementia. |
| LN G | Licensed Nurse | Reported on Resident 1's increased aggression and behaviors, and care plan update practices. |
| Administrative Nurse D | Administrative Nurse | Discussed Resident 1's behavioral incidents and safety measures including one-on-one supervision. |
Inspection Report
Routine
Census: 135
Deficiencies: 8
Date: Aug 18, 2022
Visit Reason
The inspection was a routine survey of The Gardens at Aldersgate nursing home to assess compliance with regulatory requirements related to resident rights, nutrition, abuse reporting, fall prevention, medication management, psychotropic drug use, and hospice care coordination.
Findings
The facility had multiple deficiencies including failure to treat residents with dignity during medication administration, failure to notify physicians of significant weight loss, failure to report an unwitnessed fall with fracture, failure to implement fall prevention interventions, inadequate monitoring of resident weights, inaccurate reconciliation of controlled substances, failure to follow up on pharmacist recommendations for psychotropic medications, and failure to coordinate hospice care plans.
Deficiencies (8)
Failed to treat residents with respect, dignity, and privacy during medication administration.
Failed to notify the physician of a significant weight loss for one resident.
Failed to report an unwitnessed fall with fracture to the State Agency as required.
Failed to provide a safe environment by not implementing fall prevention interventions as per care plan.
Failed to adequately monitor resident weight to maintain nutritional status.
Failed to provide accurate reconciliation of controlled drugs at the end of daily work shifts.
Failed to follow up on Consultant Pharmacist recommendations for psychotropic medication use, including lack of stop date and risk versus benefit statement for clonazepam and inappropriate diagnosis for buspirone use.
Failed to coordinate care and services with hospice for a resident receiving hospice services.
Report Facts
Residents in census: 135
Sample size: 28
Medication-controlled substance reconciliation missing counts: 8
Medication-controlled substance reconciliation missing counts: 53
Weight loss: 10
Weight gain: 5.5
Skin tear size: 1.5
Skin tear size: 2.5
Medication dose: 0.5
Medication dose: 7.5
Insulin dose: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including failure to report falls, failure to weigh resident, and lack of physician response to pharmacist recommendations |
| Licensed Nurse L | Licensed Nurse | Observed medication administration that lacked resident dignity |
| Licensed Nurse H | Licensed Nurse | Reported resident 16 had not been weighed since 05/20/22 |
| Licensed Nurse J | Licensed Nurse | Administered insulin to Resident 130 and verified medication issues |
| Certified Nurse Aide M | Certified Nurse Aide | Reported staff transferred Resident 107 into recliner and reviewed fall interventions |
| Certified Medication Aide R | Certified Medication Aide | Administered medications and was unaware of fall interventions for Resident 107 |
| Licensed Nurse K | Licensed Nurse | Implemented new fall interventions after resident fall |
| Administrative Nurse E | Administrative Nurse | Verified lack of signatures on medication-controlled substance reconciliation |
| Administrative Staff A | Administrative Staff | Verified lack of physician responses to pharmacist recommendations |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 7, 2021
Visit Reason
An offsite revisit survey was conducted on 5/7/21 to verify correction of all previous deficiencies cited on 3/15/21.
Findings
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.
Report Facts
Previous deficiencies compliance date: Mar 19, 2021
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 19, 2021
Visit Reason
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.
Findings
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.
Deficiencies (1)
Issues related to the storage and management of medications, including insulin pens for two residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Carol George | Administrator | Submitted the Plan of Correction |
| Felicia Majewski | Modified the Plan of Correction | |
| Lanae Workman | Added the Plan of Correction | |
| Director of Nursing | Director of Nursing | Responsible for compliance of the medication storage deficiency |
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 1
Date: Mar 15, 2021
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigations for complaint numbers #159625, #160205, #160634, and #160358.
Complaint Details
The visit was triggered by complaint investigations #159625, #160205, #160634, and #160358.
Findings
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.
Deficiencies (1)
Facility failed to date insulin pens when opened or expired for Resident 130 and Resident 122 in two medication carts.
Report Facts
Census: 135
Medication carts observed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Verified Resident 130 received insulin daily and insulin pen lacked date |
| Licensed Nurse H | Licensed Nurse | Verified Resident 122 received insulin daily and insulin pen lacked date |
| Administrative Nurse D | Administrative Nurse | Stated nurses were to date insulin pens when opened and note expiration date |
Inspection Report
Census: 135
Deficiencies: 1
Date: Mar 15, 2021
Visit Reason
The inspection was conducted to ensure compliance with medication labeling and storage regulations, specifically verifying that insulin pens were properly dated when opened or expired.
Findings
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.
Deficiencies (1)
Failed to date insulin pens when opened or expired for Resident 130's Tresiba and Novolog flex pens, and Resident 122's Novolog and Levemir flex pens.
Report Facts
Residents Affected: 2
Medication carts observed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse (LN) G | Verified Resident 130 received insulin daily and insulin pens lacked dates | |
| Licensed Nurse (LN) H | Verified Resident 122 received insulin daily and insulin pens lacked dates | |
| Administrative Nurse D | Stated nurses were to date insulin pens when opened and note expiration dates |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 17, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey and an abbreviated complaint survey were conducted on 11/17/2020 for complaints #KS00156518.
Complaint Details
Complaint #KS00156518 was investigated during the abbreviated complaint survey and found to have no noncompliance.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 17, 2020
Visit Reason
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.
Complaint Details
An abbreviated complaint survey was conducted for complaints #KS00156518 and no noncompliance was found.
Findings
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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 21, 2020
Visit Reason
A revisit survey was conducted on 10/21/20 to verify correction of all previous deficiencies cited on 8/13/20.
Findings
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.
Report Facts
Previous deficiencies corrected: 0
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 9, 2020
Visit Reason
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.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 9, 2020
Visit Reason
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.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 27, 2020
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies related to Infection Control practices at Aldersgate Village.
Findings
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.
Deficiencies (1)
Deficiency related to Infection Control practices, specifically PPE use, chemical dwell times, and staff training.
Report Facts
Date of Plan of Correction completion: Aug 27, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert Geist | Advanced Epidemiologist | Provided in-facility survey and education on Infection Control practices |
Inspection Report
Abbreviated Survey
Census: 142
Deficiencies: 2
Date: Aug 13, 2020
Visit Reason
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.
Complaint Details
The abbreviated complaint survey was conducted on 08/13/2020 for complaint #KS00155013.
Findings
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.
Deficiencies (2)
Failure to change gowns between resident rooms on the isolation unit and improper PPE use inside the COVID unit.
Failure to follow manufacturer's directions for the cleaning solution's required wet time for disinfecting surfaces.
Report Facts
Census: 142
Wet time for disinfectant: 5
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
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.
Complaint Details
Complaints #KS00152359 and KS00151564 were investigated during the abbreviated complaint survey; no noncompliance was found.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
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.
Complaint Details
An abbreviated complaint survey was conducted for complaints #KS00152359 and KS00151564 with no noncompliance found.
Findings
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.
Inspection Report
Routine
Census: 151
Deficiencies: 0
Date: Jun 25, 2020
Visit Reason
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).
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B.
Report Facts
Sample Size: 5
Supplemental: 0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 25, 2020
Visit Reason
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.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the COVID-19 Focused Infection Control survey.
Deficiencies (1)
COVID-19 Focused Infection Control survey
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 22, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 06/22/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 30, 2019
Visit Reason
A revisit survey was conducted on 8/30/19 for all previous deficiencies cited on 7/23/19.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 30, 2019
Visit Reason
A revisit survey was conducted on 8/30/19 to verify correction of all previous deficiencies cited on 7/12/19.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 5, 2019
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failure to follow policy and procedure on administration and monitoring of medication, specifically related to liquid Morphine MARs.
Report Facts
Deficiency report ID: 2567
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol George | Administrator | Submitted the plan of correction |
Inspection Report
Complaint Investigation
Census: 152
Deficiencies: 15
Date: Jul 23, 2019
Visit Reason
Health Resurvey and Complaint Investigation #KS00135182 conducted to assess compliance with regulatory requirements and investigate complaints.
Complaint Details
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.
Findings
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.
Deficiencies (15)
Failed to maintain the beauty shop heating/cooling unit and exhaust fan in good working order.
Failed to ensure comprehensive and accurate assessment of resident #109's hearing ability.
Failed to review and revise care plans for 7 residents regarding accidents, respiratory care, and incontinence.
Failed to provide restorative services for ambulation and range of motion to resident #95.
Failed to provide necessary assistance for personal hygiene related to shaving needs for resident #98.
Failed to provide consistent activity programs to meet the preferences of dependent cognitively impaired residents.
Failed to ensure resident #109 received necessary assistance to maintain hearing abilities with new hearing aides.
Failed to provide restorative services for range of motion exercises to resident #95.
Failed to provide immediate, appropriate interventions following falls for residents #47, #77, and #80 and failed to provide appropriate interventions following an elopement attempt for resident #59.
Failed to develop individualized toileting plans for residents #68 and #95 and failed to provide appropriate catheter care for resident #75.
Failed to provide proper sanitation of respiratory equipment for resident #113 and failed to provide safe oxygen therapy administration for resident #75.
Failed to administer medications as ordered for resident #59.
Failed to provide sanitary food preparation and storage in 3 kitchenettes and 1 activity kitchenette.
Failed to maintain a safe, sanitary, functional and comfortable environment in the Mulvane kitchenette due to black grime buildup on floors.
Failed to maintain an infection control program including proper hand hygiene during incontinence care, dressing changes, and topical medication administration for residents #103, #75, and #98.
Report Facts
Resident census: 152
Residents sampled: 31
Residents reviewed for ADLs: 4
Residents reviewed for accidents: 15
Residents reviewed for medication administration: 10
Residents reviewed for urinary incontinence/urinary catheter: 3
Episodes of continence: 22
Episodes of incontinence: 8
Episodes of incontinence: 24
Episodes of continence: 5
Episodes of continence: 1
Episodes of incontinence: 9
Episodes of continence: 13
Episodes of incontinence: 18
Episodes of continence: 3
Episodes of incontinence: 17
Episodes of incontinence: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff AA | Administrative Staff | Confirmed vent needed painting and lack of exhaust fan in beauty shop |
| Staff RR | Direct Care Staff | Interviewed about resident #109 hearing aides |
| Staff V | Licensed Nursing Staff | Interviewed about resident #109 hearing aides and care plan |
| Staff DD | Administrative Nursing Staff | Interviewed about resident #109 hearing aides and care plan |
| Staff C | Licensed Staff | Interviewed about fall interventions for resident #47 |
| Staff A | Administrative Staff | Interviewed about fall interventions and care plan revisions |
| Staff BB | Direct Care Staff | Interviewed about resident #68 activities and toileting |
| Staff W | Direct Care Staff | Interviewed about resident #68 continence and toileting |
| Staff X | Activity Staff | Interviewed about activity staffing and TV blue tone |
| Staff OO | Activity Staff | Interviewed about activity staffing shortages |
| Staff J | Direct Care Staff | Observed administering nebulizer treatment |
| Staff Q | Licensed Nursing Staff | Interviewed about catheter care and dressing change hand hygiene |
| Staff KK | Direct Care Staff | Observed providing incontinence care and denture care |
| Staff LL | Direct Care Staff | Observed providing incontinence care and dressing change |
| Staff MM | Licensed Nursing Staff | Infection control responsible staff interviewed about hand hygiene |
| Staff B | Licensed Staff | Interviewed about medication administration and topical medication application |
| Staff I | Direct Care Staff | Interviewed about medication availability |
| Staff F | Dietary Supervisor | Interviewed about kitchen cleanliness |
| Staff LL | Direct Care Staff | Interviewed about catheter care and hand hygiene |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Jul 23, 2019
Visit Reason
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.
Findings
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.
Deficiencies (11)
Safe/Clean/Comfortable/Homelike Environment - exhaust fan repair and AC/Heating unit painting
Comprehensive Assessments and hearing assessment accuracy
Care Plans development and updates for fall prevention, bowel/bladder incontinence, and breathing treatment
Restorative Program reassessment and therapy provision
Activities and Administration of Activities meeting individual resident needs
Increasing and prevention of decreasing Range of Motion (ROM) in residents
Accident Hazards, Supervision Devices, and interventions
Individualized toileting plans and care for residents with indwelling catheters
Handling and sanitizing of medical equipment, specifically respiratory equipment
Procurement, administration, and monitoring of medications
Handwashing and Infection Control policies and procedures
Report Facts
Deficiency ID: 2567
Date of statement of deficiencies review: Aug 21, 2019
Date of Plan of Correction completion: Aug 21, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol George | Administrator | Submitted the Plan of Correction |
| Janice Van Gotten | Added the Plan of Correction | |
| Felicia Majewski | Modified the Plan of Correction | |
| Director of Nursing | Director of Nursing | Responsible for monitoring multiple deficiencies and staff in-servicing |
| Director of Environmental Services | Director of Environmental Services | In charge of education and follow-up for environmental safety and comfort |
| General Manager | General Manager | Responsible for monitoring substantial compliance related to environment |
Inspection Report
Complaint Investigation
Census: 153
Deficiencies: 1
Date: Jul 12, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint investigation numbers (KS00143262, KS00142684, KS00142293, and KS00139974).
Complaint Details
The findings represent the results of complaint investigations identified by numbers KS00143262, KS00142684, KS00142293, and KS00139974.
Findings
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.
Deficiencies (1)
Failed to prevent a significant medication error involving incorrect transcription and administration of morphine sulfate resulting in overdose and emergency hospitalization.
Report Facts
Resident census: 153
Medication dosage error: 10
Medication prescribed dose: 0.5
Medication administration error time: 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Assistant O | Certified Medication Assistant | Reported mistakenly administering 5 ml morphine leading to overdose. |
| Licensed Nurse H | Licensed Nurse | Notified physician and EMS after medication error; recorded nursing progress notes. |
| Administrative Nurse D | Administrative Nurse | Acknowledged transcription error and described corrective actions including staff in-service and post testing. |
Inspection Report
Re-Inspection
Deficiencies: 3
Date: Nov 5, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report shows that multiple deficiencies identified in prior inspections were corrected, with specific regulation citations and correction completion dates provided.
Deficiencies (3)
Deficiency related to regulation 26-41-204 (d)
Deficiency related to regulation 26-41-205 (g) (3)
Deficiency related to regulation 26-41-104 (d)
Inspection Report
Renewal
Census: 53
Deficiencies: 5
Date: Oct 8, 2018
Visit Reason
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.
Findings
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.
Deficiencies (5)
Negotiated service agreements lacked the name of the licensed nurse responsible for implementation and supervision of the health care service plan for residents requiring health care services.
Medication aide administered medication not personally prepared by them, specifically pre-drawn morphine sulfate syringes.
Over-the-counter medications were not labeled with the full name of the resident on the packages or containers.
Documentation of incidents, including date, time, action taken, and results, was incomplete for a resident fall with head injury.
Failure to ensure quarterly review of the facility's emergency management plan with staff and residents and failure to conduct an annual evacuation drill.
Report Facts
Census: 53
Residents receiving health care services: 51
Residents receiving medication management: 50
OTC medication bottles in cart 'Purple': 59
OTC medication bottles in cart 'Blue': 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse #B | Licensed Nurse | Named in findings related to negotiated service agreements, medication administration, OTC medication labeling, and incident documentation |
| Operator #A | Facility Operator | Named in findings related to negotiated service agreements, incident documentation, and disaster preparedness |
| Licensed Nurse #C | Licensed Nurse | Observed labeling OTC medication bottles with Licensed Nurse #B |
| Maintenance Staff #D | Maintenance Staff | Interviewed regarding disaster preparedness |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 5, 2018
Visit Reason
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.
Findings
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jul 18, 2018
Visit Reason
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.
Findings
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.
Deficiencies (5)
Policy and signage related to posting of survey results updated; staff in-service conducted on survey result placement.
Policies and procedures related to notification of the State Ombudsman and providing Notice for Transfer reviewed and staff educated.
Policies and procedures related to completion of neuro checks after a fall reviewed; nurse educated and competency returned.
Policies and procedures related to notification of physicians, treatment documentation, and monitoring of skin issues reviewed; staff educated.
Policies and procedures related to unnecessary medications and physician rationale for continued use reviewed; medication changes made and staff educated.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 9, 2018
Visit Reason
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.
Findings
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.
Deficiencies (1)
A 'D' level deficiency, isolated, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact and signatory related to enforcement and plan of correction acceptance. |
Inspection Report
Annual Inspection
Census: 147
Deficiencies: 5
Date: Jun 14, 2018
Visit Reason
A Recertification Survey was conducted in conjunction with investigation of multiple complaint intake numbers to assess compliance with federal regulations.
Complaint Details
The survey included investigation of complaint intake numbers KS00105217, KS00111665, KS00113376, KS00120697, KS00121312, KS00123014, KS00128574, and KS00129701.
Findings
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.
Deficiencies (5)
Survey results were not readily accessible to all 147 residents without staff assistance.
Facility failed to send 'Notice for Transfer' documents to the State Ombudsman's Office for two residents transferred to the hospital.
Failed to follow facility policy for neurological checks after an unwitnessed fall with suspected head injury for one resident.
Failed to notify physician, document treatment, and monitor skin issues for one resident with non-pressure skin issues.
Resident's drug regimen included unnecessary medications without adequate physician rationale.
Report Facts
Sample Size: 44
Residents transferred without notice to Ombudsman: 2
Neurological checks missed: 3
Resident cognitive score: 15
Resident cognitive score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Manager | Confirmed failure to send transfer notices to State Ombudsman. | |
| Director of Nursing | Director of Nursing | Interviewed regarding neurological checks and skin issue notification. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Unaware of resident's skin issue until surveyor inquiry. |
| Elmhurst Court Unit Manager | Commented on lack of physician documentation for medication rationale. | |
| Administrator | Administrator | Acknowledged ongoing issues with physician documentation and rationale. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 30, 2018
Visit Reason
A complaint survey was conducted on 04/30/18 for complaint #KS00128624 and KS00125477.
Complaint Details
Complaint #KS00128624 and KS00125477 were investigated and found to be unsubstantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 30, 2018
Visit Reason
A complaint survey was conducted on 04/30/18 for complaint #KS00128624 and KS00125477.
Complaint Details
Complaints #KS00128624 and KS00125477 were investigated and found not substantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 30, 2018
Visit Reason
A complaint survey was conducted on 04/30/18 for complaint #KS00128624 and KS00125477.
Complaint Details
Complaint #KS00128624 and KS00125477 were investigated and found unsubstantiated.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 17, 2017
Visit Reason
A revisit survey was conducted on October 17, 2017 for all previous deficiencies cited on August 23, 2017.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 10, 2017
Visit Reason
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.
Complaint Details
The plan references a complaint investigation related to Aldersgate Village dated 08/23/2017.
Findings
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.
Deficiencies (1)
Deficiency related to weight monitoring, meal intake, care plan development, and documentation (F325).
Report Facts
Date of resident discharge: Apr 29, 2017
Plan of correction review date: Sep 6, 2017
Plan of correction completion date: Sep 10, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for plan of correction assistance | |
| Lemapulemanua | Administrator | Submitted the plan of correction |
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 8, 2017
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 483.10(g)(14)
Deficiency related to regulation 483.25(b)(1)
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 2
Date: Mar 9, 2017
Visit Reason
The inspection was conducted as a result of complaint investigations #111980, #111264, #112188, and #112410.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to notify the physician of abnormal lab results indicating infection for resident #1.
Failed to provide appropriate interventions to prevent development of an avoidable pressure ulcer related to use of a neck brace for resident #1.
Report Facts
Resident census: 169
White blood cell count: 23600
Pressure ulcer wound size: 3.7
Pressure ulcer wound size: 4.1
Open wound size: 2
Open wound size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician L | Physician | Discovered critical lab results late and confirmed lack of timely notification. |
| Staff J | Licensed Nursing Staff | Provided information about resident's fall and wound development. |
| Staff D | Administrative Nursing Staff | Expected timely notification of abnormal lab results by staff. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 9, 2017
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency F314 related to Pressure Ulcers at a level of actual harm that is not immediate jeopardy.
Report Facts
Denial of payment effective date: Mar 29, 2017
Noncompliance period: 6
Termination recommendation date: Sep 9, 2017
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to complaint coordination and contact for questions regarding the matter. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 9, 2017
Visit Reason
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.
Complaint Details
This Plan of Correction is in response to deficiencies cited during a complaint investigation survey (Aldersgate complaint 03092017).
Findings
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.
Deficiencies (2)
Failure to notify physician timely regarding lab results for Resident #1
Failure to complete skin assessments under medical devices for Resident #1
Report Facts
Plan of Correction completion date: Mar 24, 2017
Quality Assurance Committee review date: Mar 15, 2017
Inspection Report
Follow-Up
Deficiencies: 4
Date: Oct 25, 2016
Visit Reason
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.
Findings
The revisit report indicates that all previously cited deficiencies were corrected as of 09/23/2016, with no uncorrected deficiencies remaining.
Deficiencies (4)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.65
Report Facts
Date corrections completed: Sep 23, 2016
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Oct 24, 2016
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficiency under regulation 26-41-101 (g)
Deficiency under regulation 26-41-205 (h)
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Oct 20, 2016
Visit Reason
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.
Findings
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.
Deficiencies (2)
Notice of availability sign for the location of the Policy and Procedures manual was not properly posted.
Insulin pen for resident #4 was not dated when opened.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Lemapulemanua | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 52
Deficiencies: 2
Date: Oct 18, 2016
Visit Reason
The inspection was an Assisted Living Healthcare Licensure resurvey to assess compliance with state regulations.
Findings
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.
Deficiencies (2)
Failed to ensure a notice of the availability of the policies and procedures in a place readily accessible to residents.
Failed to ensure injectable insulin was dated upon opening in one of four opened insulin pens.
Report Facts
Census: 52
Opened insulin pens inspected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 23, 2016
Visit Reason
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.
Findings
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.
Deficiencies (4)
Resident #2 care plan was not individualized for toileting.
Resident #1 care plan lacked appropriate interventions for prevention and treatment of pressure ulcers.
Resident #1 head to toe assessment and care plan updates were incomplete.
Resident #1 antibiotic treatment and assessment timing issues.
Report Facts
Deficiency tags: 4
Dates of care plan updates: July 21, 2016 and August 2, 2016 for Resident #1
Antibiotic treatment duration: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 6, 2016
Visit Reason
The visit was related to a complaint investigation resulting in a deficiency cited at F314 on September 6, 2016.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Deficiency cited at F314
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the Complaint Coordinator who signed the letter regarding the deficiency level change. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 6, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers, actual harm level "G"
Report Facts
Denial of payment effective date: Sep 27, 2016
Compliance deadline: Mar 6, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named in relation to complaint coordination and enforcement communication |
Inspection Report
Complaint Investigation
Census: 180
Deficiencies: 4
Date: Sep 6, 2016
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failed to develop an individualized care plan for toileting for an incontinent and dependent resident.
Failed to update the care plan after development of pressure ulcers for a cognitively impaired dependent resident.
Failed to provide timely and effective interventions to prevent development of 5 facility-acquired pressure ulcers and to promote healing of existing pressure ulcers for a resident.
Failed to establish and maintain an infection control program to prevent spread of infection, specifically improper glove use during care of a resident with pressure ulcers and wound infection.
Report Facts
Census: 180
Residents sampled: 4
Pressure ulcers: 5
Weight loss: 34
BIMS score: 4
BIMS score: 12
Wound measurements: 5
Wound measurements: 6.3
Wound measurements: 2.5
Wound measurements: 1.4
Braden Scale score: 9
Braden Scale score: 8
Protein level: 5.3
Albumin level: 2.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrative Nursing Staff | Expected staff to develop toileting care plans, update care plans, and turn residents every hour. |
| Staff I | Licensed Nursing Staff | Reported resident toileting needs, pressure ulcer care, and proper glove use. |
| Staff P | Direct Care Staff | Provided peri-care and was observed not changing gloves properly. |
| Staff Q | Direct Care Staff | Reported resident pressure ulcers and turning schedule. |
| Staff J | Licensed Nursing Staff | Provided peri-care and was observed not changing gloves properly. |
| Staff K | Licensed Nursing Staff | Changed dressings on resident's wounds. |
| Staff H | Licensed Nursing Staff | Assisted resident with nutritional drink and repositioning. |
| Staff R | Direct Care Staff | Turned and repositioned resident. |
| Staff O | Direct Care Staff | Turned and repositioned resident and changed protective pads. |
| Staff S | Direct Care Staff | Placed pillow under resident's legs. |
| Staff DD | Licensed Dietary Staff | Reported resident's poor appetite and hospice status. |
| Physician KK | Physician | Expected staff to turn residents every 2 hours and provide appropriate skin care. |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Aug 19, 2016
Visit Reason
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.
Findings
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.
Deficiencies (5)
Resident #215’s fall on July 17, 2016, was self-reported to the state agency; staff education on investigating unexplained injuries is planned.
Insects found in overhead fluorescent light and carpet cleanliness issues in multiple areas; cleaning schedules and staff education planned.
Care plan for resident #149 updated with dialysis interventions; staff education on care plan workflow provided.
Fall prevention interventions for residents #194 and #215 reviewed and implemented; chemicals secured in locked location.
Battery replaced in alarm of east patio door; policy developed for daily checks and battery replacement schedule.
Report Facts
Residents at potential risk: 28
Inspection Report
Follow-Up
Deficiencies: 4
Date: Aug 19, 2016
Visit Reason
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.
Findings
All deficiencies previously cited were corrected as of the revisit date, with corrections completed for multiple regulatory requirements.
Deficiencies (4)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(k)(3)(i)
Deficiency related to regulation 483.25(h)
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 19, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency related to regulation 26-40-303 (2)(a)(i)(ii)(iii)
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 1, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiencies found were 'E' level deficiencies, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Annual Inspection
Census: 174
Deficiencies: 1
Date: Aug 1, 2016
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements, specifically focusing on the door monitoring system for resident safety.
Findings
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.
Deficiencies (1)
Failed to provide a functioning door monitoring system on patio doors for two cognitively impaired residents.
Report Facts
Resident census: 174
Sample size: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Staff AA | Removed the cover to the door alarm and stated maintenance staff did not check the patio door routinely | |
| Maintenance Staff Y | Stated uncertainty about when the door was last checked and that patio doors were not checked daily | |
| Maintenance Staff Z | Stated staff checked the patio doors three times daily | |
| Licensed Nursing Staff H | Stated nursing staff did not check the patio door alarm | |
| Maintenance Staff BB | Stated it was nursing staff's responsibility to check the patio door alarm but denied documentation of completion | |
| Administrative Nursing Staff A | Stated the patio door alarm was not checked routinely |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 2, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency with ID Prefix F0333 under regulation 483.25(m)(2) corrected
Report Facts
Deficiency correction date: Apr 20, 2016
Inspection Report
Complaint Investigation
Census: 179
Deficiencies: 1
Date: Apr 19, 2016
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to provide adequate supervision and orientation to new licensed staff to prevent significant medication error involving wrong administration of another resident's medications.
Report Facts
Resident census: 179
Sample size: 4
Medication doses administered in error: 8
Dates: 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff I | Licensed nursing staff | Administered the wrong medications to resident #2 during orientation on 3/21/16. |
| Licensed nursing staff K | Licensed nursing staff | Provided orientation to licensed nursing staff I and observed the medication error on 3/21/16. |
| Licensed nursing staff J | Licensed nursing staff | Reported being hired in March and described medication administration procedures. |
| Licensed nursing staff G | Licensed nursing staff | Reported receiving supervision and training for medication administration. |
| Direct care staff N | Direct care staff | Reported use of resident photos on EMAR for medication identification. |
| Direct care staff O | Direct care staff | Reported orientation and training for medication administration and use of photos on EMAR. |
| Licensed nursing staff H | Licensed nursing staff | Observed resident symptoms during medication error event and described facility practices. |
| Administrative nursing staff E | Administrative nursing staff | Described orientation process and efforts to separate residents with same names. |
| Administrative nursing staff D | Administrative nursing staff | Reported expectation that preceptor/mentor stay with new staff during medication administration. |
| Physician consultant FF | Physician consultant | Provided medical opinion on resident's condition and treatment following medication error. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 19, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency at a level of actual harm that is not immediate jeopardy requiring corrections
Report Facts
Denial of payment effective date: May 10, 2016
Prior survey date: Feb 22, 2016
Compliance deadline: Oct 19, 2016
Civil Money Penalty minimum: 5000
IDR submission deadline: 10
Hearing request deadline: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to instructions for Informal Dispute Resolution and contact for questions |
| Lisa Hauptman | CMS Contact | Contact person for questions regarding the matter |
| Darla McCloskey | Branch Manager, Division of Survey & Certification | Authorized the letter |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Apr 5, 2016
Visit Reason
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.
Findings
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.
Deficiencies (4)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.30(a)
Deficiency related to regulation 483.75(o)(1)
Report Facts
Date corrections completed: Mar 12, 2016
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 24, 2016
Visit Reason
The plan of correction was submitted in response to deficiencies identified during a survey related to medication administration and facility orientation processes.
Findings
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.
Deficiencies (1)
Medication administration errors by a nurse during orientation and issues with medication cart wheels impacting efficiency and accuracy.
Report Facts
Date resident sent to hospital: Mar 24, 2016
Date wheels placed back on medication carts: Mar 31, 2016
Date nurse removed from medication cart: Mar 21, 2016
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 18, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy.
Report Facts
Effective date for denial of payments: Jun 18, 2016
Provider agreement termination date: Sep 18, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Mar 12, 2016
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failure to revise and implement appropriate care plans for residents.
Inadequate fall prevention and management practices including improper use of assistive devices and bedside commode policies.
Inaccurate staffing schedules not reflecting appropriate licensed staff on duty.
Failure to ensure residents' needs are met and follow-up on unmet needs through social services and Quality Assessment and Assurance processes.
Report Facts
Deficiency tags: 4
Plan of Correction monitoring period: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Lemapulemanua | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 176
Deficiencies: 4
Date: Feb 22, 2016
Visit Reason
The inspection was a partial extended complaint investigation involving multiple complaint investigations.
Complaint Details
The inspection was a partial extended complaint investigation involving complaint investigations #89653, 89883, 91498, 94470, 94612, 94638, 94639, 95223, 96546, 96642, 96928 and 97190.
Findings
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.
Deficiencies (4)
Failed to review and revise care plans for resident #3 placed in isolation for infection and resident #6 who experienced a significant change of condition with activities of daily living.
Failed to provide supervision and assistive devices to prevent accidents for 6 of 8 residents reviewed, including falls resulting in multiple fractures and injuries.
Failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Failed to maintain an effective quality assurance committee that developed and implemented appropriate plans of action to correct identified quality of care and quality of life concerns.
Report Facts
Resident census: 176
Residents requiring two staff assistance: 55
Fall risk assessment scores: 10
Fall risk assessment scores: 12
Fall risk assessment scores: 21
Fall risk assessment scores: 13
Fall risk assessment scores: 25
Fall risk assessment scores: 27
Number of falls: 9
Fall duration: 280
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 12, 2016
Visit Reason
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.
Complaint Details
The action is based on deficiencies found on the current survey and a complaint survey conducted on March 13, 2015.
Findings
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.
Deficiencies (1)
Noncompliance with F 323, CFR 483.25(h) resulting in Substandard Quality of Care
Report Facts
Denial of payment effective date: Mar 14, 2016
Termination recommendation date: Aug 12, 2016
Civil Money Penalty minimum amount: 5000
Timeframe for hearing request: 60
Timeframe for IDR request: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named in relation to instructions for Informal Dispute Resolution and contact for questions |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 7, 2015
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were accomplished.
Findings
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.
Deficiencies (1)
Deficiency with ID prefix S1364 related to regulation 26-40-305 (3)
Report Facts
Deficiency correction date: Mar 20, 2015
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 7, 2015
Visit Reason
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.
Findings
The report documents that all previously cited deficiencies have been corrected as of the dates listed, with no uncorrected deficiencies remaining.
Report Facts
Deficiency correction dates: 7
Inspection Report
Enforcement
Deficiencies: 1
Date: Mar 13, 2015
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency related to pressure ulcers (F314) indicating noncompliance with prevention and care requirements.
Report Facts
Enforcement effective date: Apr 5, 2015
Noncompliance correction deadline: Sep 13, 2015
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as Enforcement Coordinator for the survey |
| Gregg Brandush | Branch Manager, Division of Survey & Certification | Authorized the enforcement letter |
Inspection Report
Census: 184
Deficiencies: 1
Date: Mar 9, 2015
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with electrical safety requirements related to hydrotherapy equipment.
Findings
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.
Deficiencies (1)
Failure to have the hydrocollator plugged into a ground-fault circuit interrupter (GFCI) outlet.
Report Facts
Census: 184
Sample size: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| maintenance staff | Interviewed and confirmed the hydrocollator was plugged into a standard electrical outlet |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jan 1, 2015
Visit Reason
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.
Findings
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.
Deficiencies (3)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.35(i)
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Dec 10, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Aldersgate Village.
Complaint Details
This Plan of Correction is related to a complaint investigation at Aldersgate Village.
Findings
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.
Deficiencies (3)
Failure to serve residents immediately upon arrival to their dining room table.
Galley kitchen door was not closed and locked, posing risk to cognitively impaired/mobile residents.
Outdated or unlabeled food items found in kitchens.
Report Facts
Dates for completion of corrective actions: Jan 1, 2015
Date statement of deficiencies taken to committee: Dec 10, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcia Stecklein | VP of Clinical Services | Submitted the Plan of Correction to KDADS. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 3, 2014
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiency was an 'F' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person for the survey and certification. |
Inspection Report
Complaint Investigation
Census: 180
Deficiencies: 4
Date: Dec 2, 2014
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint numbers (#73647, 75580, 75852, 77422, and 78789).
Complaint Details
The inspection was triggered by complaint investigations #73647, 75580, 75852, 77422, and 78789.
Findings
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.
Deficiencies (4)
Failed to promote dignity of six dependent residents during dining service on the Eastminister unit.
Failed to ensure the resident environment was free of accident hazards and provide adequate supervision for two cognitively impaired independently mobile residents on the Eastminister neighborhood.
Failed to ensure supervision and safety to prevent burns from hot water for two cognitively impaired independently mobile residents on the Eastminister unit.
Failed to store, prepare, and serve food in a sanitary manner, including serving expired juices and unlabeled pureed meals in the kitchenette for the Eastminister unit.
Report Facts
Census: 180
Residents on Eastminister unit: 38
Expired juice containers: 4
Unlabeled pureed meals: 4
Water temperatures: Array
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff DD | Served residents in dining room and delivered food service. | |
| Direct care staff M | Delivered room trays and assisted residents with meals. | |
| Direct care staff N | Delivered room trays and prepared glasses of juice. | |
| Direct care staff Q | Assisted residents during meal service and reported nursing staff delivered trays before assisting residents. | |
| Dietary staff CC | Reported on expired juices and unlabeled meals, exited kitchenette leaving door open. | |
| Consultant dietary staff GG | Reported kitchen did not make enough altered texture diets. | |
| Dietary staff FF | Referred to dry-erase board for pureed diet counts. | |
| Consultant dietary staff EE | Reviewed dietary lists and confirmed expired juices and unlabeled meals. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 17, 2014
Visit Reason
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.
Findings
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.
Deficiencies (1)
Most serious deficiency found was an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Dec 17, 2014
Provider agreement termination date: Mar 17, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carl Noyes | Administrator | Named as facility administrator in relation to the survey |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Joe Ewert | Commissioner | Mentioned in correspondence copy |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 8, 2014
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.25(m)(2)
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 27, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Aldersgate Village.
Complaint Details
This Plan of Correction is related to a complaint investigation at Aldersgate Village.
Findings
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.
Deficiencies (2)
Failure to timely notify family/DPOA of resident accidents involving injury or significant change.
Medication administration errors related to administering medications only in resident rooms and failure to follow the 6 rights.
Report Facts
Complete Date for F0000: Sep 10, 2014
Complete Date for F157-D: Sep 8, 2014
Complete Date for F333-D: Sep 8, 2014
Mandatory Skills Fair Dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcia Stecklein | VP of Clinical Services | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 186
Deficiencies: 2
Date: Aug 18, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#77241) regarding failure to notify a resident's legal representative after a medication administration error.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to notify the resident's legal representative following a medication administration error.
Failure to administer medication as physician ordered, resulting in significant medication error.
Report Facts
Census: 186
Residents on Eastminister unit: 38
Residents reviewed for medication administration: 3
Medication dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff J | Licensed Nursing Staff | Reported notification procedures after medication error |
| Licensed nursing staff K | Licensed Nursing Staff | Reported notification procedures after medication error |
| Administrative nursing staff D | Administrative Nursing Staff | Reported failure to notify resident's responsible party after medication error |
| Licensed nursing staff I | Licensed Nursing Staff | Reported notification procedures after medication error |
| Licensed nursing staff H | Licensed Nursing Staff | Reported not notifying resident's responsible party about medication error |
| Consultant pharmacist HH | Consultant Pharmacist | Reported pharmacy observations and training related to medication errors |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 18, 2014
Visit Reason
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.
Findings
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.
Deficiencies (1)
'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 5, 2014
Visit Reason
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.
Findings
The revisit confirmed that the deficiency identified under regulation 483.25 (ID Prefix F0309) was corrected as of 05/05/2014.
Deficiencies (1)
Deficiency under regulation 483.25 previously cited was corrected.
Report Facts
Deficiency correction date: May 5, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 23, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Aldersgate Village.
Complaint Details
This Plan of Correction is related to a complaint investigation at Aldersgate Village.
Findings
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.
Deficiencies (1)
Use of geri-sleeves (changed to tuba grip) for resident #7 to prevent skin injuries, with updated care plans and physician orders.
Report Facts
Complete Date for F0000: Apr 23, 2014
Complete Date for F309-D: May 5, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcia Stecklein | VP of Clinical Services | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 188
Deficiencies: 1
Date: Apr 11, 2014
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint investigations (#72220, 72586, 72952, and 74441).
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to prevent multiple skin tears for a resident requiring extensive assistance and protective arm sleeves.
Report Facts
Resident census: 188
Residents sampled: 7
Residents reviewed for accidents: 4
Size of skin tear: 3
Size of wound area: 2.5
Size of second wound area: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff D | Reported failure to place Geri-sleeves on resident as ordered and care planned. | |
| Direct care staff P | Reported staff placed Geri-sleeves on resident's arms in the morning. | |
| Direct care staff O | Reported staff placed Geri-sleeves on resident's arms in the morning and removed at night. | |
| Licensed nursing staff H | Reported resident experienced another skin tear on the left hand. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jan 22, 2014
Visit Reason
This revisit report documents the follow-up inspection to verify correction of previously reported deficiencies at Aldersgate Village.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 26-40-303 (b)(i)(ii)(iii)(iv)(c)
Deficiency related to regulation 26-40-303 (g)(i)(ii)(iii)
Inspection Report
Follow-Up
Deficiencies: 10
Date: Jan 22, 2014
Visit Reason
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.
Findings
All previously reported deficiencies identified by regulation numbers and prefix codes were corrected by 12/13/2013 as verified during this revisit.
Deficiencies (10)
Deficiency identified under regulation 483.15(f)(1)
Deficiency identified under regulations 483.20(d), 483.20(k)(1)
Deficiency identified under regulations 483.20(d)(3), 483.10(k)(2)
Deficiency identified under regulation 483.25
Deficiency identified under regulation 483.25(c)
Deficiency identified under regulation 483.25(d)
Deficiency identified under regulation 483.25(h)
Deficiency identified under regulation 483.25(m)(1)
Deficiency identified under regulation 483.30(a)
Deficiency identified under regulation 483.65
Report Facts
Deficiencies corrected: 10
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Dec 13, 2013
Visit Reason
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.
Findings
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.
Deficiencies (11)
Care plan updates to include previous life roles, interventions for wandering behaviors, agitation, pain, and toileting needs
Staff training/retraining on engaging residents in meaningful experiences and managing difficult behaviors
Implementation of hydration program and monitoring compliance
Tissue tolerance testing and pressure ulcer prevention interventions including Braden assessments
Training on pericare and incontinence management procedures
Fall prevention interventions and installation of magnetic door locks with keypad
Counseling on medication administration and med pass observation audits
Assignment of additional direct caregivers and review of call light response times
Infection control education and audits of linen delivery
Installation of new call lights with audible signals and additional pull stations
Securing wireless call system to prevent disconnection
Report Facts
Training dates: Dec 7, 2013
Training dates: Dec 9, 2013
Training dates: Dec 5, 2013
Audit frequency: 2
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcia Stecklein | VP of Clinical Services | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 186
Deficiencies: 4
Date: Nov 21, 2013
Visit Reason
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.
Findings
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.
Deficiencies (4)
Failed to provide an audible call signal in 2 soiled and 1 clean utility rooms on 1 of 8 units for 1 of 4 days onsite.
Failed to provide emergency call system in resident showers for 1 of 8 units for 4 of 4 days onsite.
Failed to ensure the wireless call system functioned for 27 residents on Westminster unit for 1 of 4 days onsite.
Failed to ensure if a wireless call signal went unanswered for 3 minutes, the signal progressed to another workstation not designated to receive the original call.
Report Facts
Census: 186
Residents affected: 27
Units affected: 1
Days observed: 4
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 21, 2013
Visit Reason
The inspection was a licensure resurvey conducted to assess compliance for renewal of the facility's license.
Findings
The licensure resurvey at Aldersgate Village resulted in no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 22, 2013
Visit Reason
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.
Findings
The revisit confirmed that the deficiency identified under regulation 483.25(h) with ID prefix F0323 was corrected as of 07/22/2013.
Deficiencies (1)
Deficiency under regulation 483.25(h) previously cited
Report Facts
Deficiency correction date: Jul 22, 2013
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 1
Date: Jun 26, 2013
Visit Reason
The inspection was conducted as a complaint investigation related to allegations identified by complaint investigation numbers #KS00063467 and #KS00066230.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to implement effective interventions to prevent falls for a resident who fell and sustained a nose fracture.
Report Facts
Census: 169
Sample size: 7
Fall risk assessments: 3
Date of fall: May 25, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff D | Interviewed and observed not staying within arm's reach of resident while toileting. | |
| Administrative nursing staff A | Interviewed regarding staff education and expectations for resident care. | |
| Direct care staff C | Interviewed stating he/she stayed with the resident at all times during toileting. | |
| Licensed care staff B | Interviewed stating expectation for staff to stay with resident at all times. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 7, 2013
Visit Reason
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.
Findings
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.
Deficiencies (2)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(h)
Report Facts
Correction completion date: Jun 7, 2013
Follow-up survey completion date: May 17, 2013
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 17, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Aldersgate Village.
Complaint Details
This Plan of Correction is related to a complaint investigation identified by event ID SDCG11 and complaint ID 051713.
Findings
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.
Deficiencies (2)
Resident #1 and #3 care plan has been updated to ensure correct mechanical lift and sling size.
The hygiene lift sling was removed from resident #1's room and care plans updated to use the small lift sling for transfers.
Report Facts
Complete Date: Jun 12, 2013
Complete Date: Jun 7, 2013
Training Dates: 42526
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcia Stecklein | VP of Clinical Services | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added Plan of Correction on 05/20/2013 | |
| Mary Jane Kennedy | Modified Plan of Correction on 05/28/2013 |
Inspection Report
Complaint Investigation
Census: 180
Deficiencies: 2
Date: May 17, 2013
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to revise care plans for residents to reflect changes in transfer methods and sling sizes.
Failure to ensure resident environment was free of accident hazards and provide adequate supervision and devices to prevent accidents, specifically related to mechanical lift sling use.
Report Facts
Census: 180
Residents using full body slings: 16
Residents sampled for transfers: 3
Resident #1 MDS date: Mar 27, 2013
Resident #3 MDS date: Feb 12, 2013
Fall assessment scores: 14
Fall assessment scores: 16
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 9, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
The report shows that deficiencies previously cited under regulations 483.10(b)(11) and 483.65 were corrected as of 02/09/2013.
Deficiencies (2)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 16, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Aldersgate Village.
Complaint Details
This Plan of Correction is related to a complaint investigation identified by Event ID P30811 and Complaint ID 011113.
Findings
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.
Deficiencies (2)
Failure to notify physician and family of change in condition for residents #1 and #2, and inadequate physician notification procedures.
Housekeeping staff did not follow proper cleaning procedures for resident room #4 in contact isolation (C.diff).
Report Facts
Deficiency completion dates: Feb 9, 2013
Deficiency completion date: Feb 1, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcia Stecklein | VP of Clinical Services | Submitted the Plan of Correction to KDADS |
Inspection Report
Complaint Investigation
Census: 181
Deficiencies: 2
Date: Jan 11, 2013
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers #62923, #62939, and #62387.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to promptly notify the resident's physician regarding loose stools and failed to notify family when a resident was transferred to a hospital.
Failed to establish and maintain an infection control program that performed surveillance and investigation to prevent infection spread and failed to effectively clean the room of a resident in isolation.
Report Facts
Resident census: 181
Residents on Mulvane unit: 24
Residents with loose stools/diarrhea on Mulvane unit: 12
Prothrombin time: 46.1
INR: 4.8
Coumadin dosage: 7.5
Coumadin dosage: 5
Imodium dosage: 2
Imodium max tablets: 8
Inspection Report
Follow-Up
Deficiencies: 10
Date: Oct 4, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the prior survey were corrected as of the revisit date.
Findings
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.
Deficiencies (10)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(e)(2)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.55(b)
Deficiency related to regulation 483.60(b), (d), (e)
Report Facts
Deficiencies corrected: 10
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Sep 1, 2012
Visit Reason
This document is a Plan of Correction submitted by Aldersgate Village in response to deficiencies cited in a prior inspection report.
Findings
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.
Deficiencies (10)
Care plan for resident #194 to include lower extremities range of motion program and audit of restorative services.
Care plan for resident #1 updated to include individualized approaches addressing personal preferences.
Individualized hygiene program developed for resident #1 including therapy baths and grooming approaches.
Direct care staff educated on toileting assistance and peri-care; audits on incontinence and toileting programs.
Audit of restorative programs for residents; screening by skilled therapy for restorative needs.
Fall prevention measures including audits of shift change logs, placement of alarms, and non-skid bath mats.
Behavior monitoring sheets updated for psychoactive medications; staff training scheduled.
Mandatory inservice for dining services staff on food handling, sanitation, and hair/beard restraints.
Dental appointment scheduled and oral hygiene audits to identify dental needs; weekly risk assessments.
Procedure added for checking dates on open medication vials; staff training and audits for compliance.
Report Facts
Date of mandatory inservice: Aug 27, 2012
Date of dental appointment: Aug 17, 2012
Date of fall prevention inservice: Aug 30, 2012
Date of dining services inservice: Aug 14, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcia Stecklein | VP of Clinical Services | Submitted the Plan of Correction to KDADS |
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 10
Date: Aug 13, 2012
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (10)
Failed to develop a comprehensive care plan regarding restorative services for a resident with decreased range of motion.
Failed to individualize the care plan to reflect resident preferences for oral care, shaving, and catheter bag placement.
Failed to provide adequate grooming and oral care for a dependent resident.
Failed to offer toileting to a resident and failed to provide complete perineal care after incontinence for another resident.
Failed to provide restorative services to the lower extremities of a dependent resident as planned.
Failed to utilize fall interventions as planned for a resident resulting in a hip fracture and failed to ensure safe bathing environment with non-skid surfaces in showers.
Failed to monitor behavioral medications effectively for a resident receiving antipsychotic and anti-anxiety medications.
Failed to maintain a clean and sanitary food preparation area, failed to assure foods were labeled and stored under sanitary conditions, and failed to maintain hair restraints in kitchen food service areas.
Failed to provide a dental consultation as ordered by the physician for a resident with poor dental health.
Failed to label open multi-use insulin vials with an open date in a medication room.
Report Facts
Residents sampled: 29
Residents sampled for restorative care: 3
Residents sampled for urinary incontinence: 5
Residents sampled for falls: 4
Residents sampled for behavioral medications: 10
Minutes of occupational therapy: 303
Minutes of physical therapy: 269
Insulin vial expiration days: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse L | Licensed Nurse | Reported falsification of fall alarm check records and acknowledged failure to keep resident safe |
| Licensed nurse U | Licensed Nurse | Nurse on duty at time of fall, failed to check chair alarm |
| Licensed nurse N | Licensed Nurse | Acknowledged resident and room odor, lack of individualized care plan interventions, and behavioral medication monitoring |
| Licensed nurse E | Administrative Nursing Staff | Acknowledged failure to label insulin vials and failure to clean resident after incontinence |
| Licensed nurse F | Administrative Nurse | Acknowledged resident odor and lack of individualized care plan interventions |
| Licensed nurse Q | Licensed Nurse | Expected staff to clean all skin in contact with incontinence brief |
| Licensed nurse S | Licensed Nurse | Reported rounds to ensure resident safety and interventions |
| Licensed nurse T | Licensed Nurse | Reported medication administration and behavioral monitoring |
| Pharmacy consultant NN | Pharmacy Consultant | Recommended behavioral monitoring for psychotropic medications |
| Direct care staff FF | Direct Care Staff | Reported resident grooming and care refusals |
| Direct care staff Y | Direct Care Staff | Reported toileting practices and perineal care |
| Dietary staff SS | Dietary Staff | Acknowledged kitchen cleaning schedule and hair restraint policy |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N089021 POC QK2311
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Aldersgate Village.
Complaint Details
This Plan of Correction is linked to a complaint investigation at Aldersgate Village.
Findings
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.
Deficiencies (1)
Direct care staff for resident #1 will receive written and verbal education on the intervention to prevent falls on resident #1.
Report Facts
Complete Date for F0000 deficiency review: Jul 10, 2013
Complete Date for F323-D deficiency correction: Jul 22, 2013
Staff inservice dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcia Stecklein | VP of Clinical Services | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: N089021 POC QNCL11
Visit Reason
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.
Findings
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.
Deficiencies (8)
Allegation of abuse on resident #11 with investigation completed and reporting procedures established.
MDS for resident #49 corrected to include presence of surgical wound; audits to ensure skin issues are identified.
Pressure ulcer on resident #49 managed by wound care physician; audits and training on skin monitoring under medical devices.
Correct procedure on administration of enteral tube medication for resident #247 reviewed with licensed staff.
All outdated/undated food items discarded; training on labeling/dating and cross-contamination provided to dining services staff.
Policy on monitoring of behaviors updated; behavior monitoring sheets reviewed for accuracy with staff training.
All residents requiring blood glucose monitoring provided with individual machines; audits and staff training on disinfection.
Hydrocollator plugged into ground fault circuit interrupter; policy updated and equipment monitored for compliance.
Report Facts
Employees trained: 308
Employees total: 318
Cleaning inspections per week: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marcia Stecklein | VP of Clinical Services | Submitted the Plan of Correction |
Viewing
Loading inspection reports...
