1/5
CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
1/5
CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
The Gardens at Aldersgate LLC is a 175-bed nursing facility located in downtown Topeka, Kansas. Operated by Betten End Snf Realty LLC and managed by administrator Morgan Morris, the five-year-old community accepts Medicare, Medicaid, and private pay. The resident demographic is composed of 59 percent Medicare admissions, 38 percent private-pay individuals, and 3 percent Medicaid recipients, with an average overall stay length of 112 days.
Clinical operations include an on-staff physician and an average of 3 hours and 43 minutes of direct daily nursing care per resident. The facility features on-site specialty care, including dietary, podiatry, audiology, dental, and psychiatric services, alongside physical rehabilitation equipment and respite care.
The downtown location holds a walkability score of 78 out of 100, indicating most daily errands are manageable on foot. Everyday amenities consist of three daily meals, a beauty salon, a barber shop, a whirlpool tub, bathing assistance, housekeeping, and scheduled transportation. In terms of oversight, state regulatory inspections have reviewed medication delivery, infection control, and charting documentation, with recent records indicating the correction of past deficiencies and compliance with state guidelines.
Prospective representatives can communicate with the admission office directly to obtain detailed pricing schedules, evaluate specialized therapy programs, or arrange a walkthrough of the downtown campus.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
|
38m per day | ▼ 11% State avg: 43m per day · National avg: 41m per day |
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LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
|
52m per day | ▲ 31% State avg: 40m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
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2h 29m per day | ▼ 8% State avg: 2h 42m per day · National avg: 2h 21m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
|
3h 45m per day | ▲ 5% State avg: 3h 35m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
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3m per day | ▲ 30% State avg: 2m per day · National avg: 4m per day |
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Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
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26m per day | ▼ 11% State avg: 29m per day · National avg: 29m per day |
Lower than the Kansas average: 79.5%
The Gardens at Aldersgate LLC is administered by Morgan Morris.
Key information about the people who lead and staff this community.
In Kansas, the Department for Aging and Disability Services, Survey and Certification Commission performs the unannounced inspections required for facility licensing and federal certification.
This scorecard compares key inspection, deficiency, and complaint metrics at this facility against the Kansas state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies
|
This Facility | KS Average | vs. KS Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
|
297 | 100 | This facility has 197% more total deficiencies than a typical Kansas nursing home (297 vs. KS avg 100).↑ 197% worse |
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Deficiencies per year
Average deficiencies per year since 2012.
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21.2 | 7.1 | This facility has 199% more deficiencies per year than a typical Kansas nursing home (21.2 vs. KS avg 7.1).↑ 199% worse |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
Kansas average 4.5
Last Health inspection on Jul 2025
Kansas average 26.9
Kansas average 6.07
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
10 of 40 citations resulted from standard inspections; 6 of 40 resulted from complaint investigations; and 24 of 40 came from combined inspections (standard and complaint).
11% worse than Kansas average
Kansas average: 0.9
233% worse than Kansas average
Kansas average: 0.9
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
8% more staff per resident than Kansas average
8% better than Kansas average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
48 total: 34 full-time employees and 14 contractors.
48
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.2 hours
Assists with medical care and medications.
73 total: 44 full-time employees and 29 contractors.
73
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.1 hours
Helps with daily care and mobility.
166 total: 124 full-time employees and 42 contractors.
166
Average shift length. Calculated as total hours divided by days worked and average staff per day.
8.2 hours
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
8,454 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 124 | 42 | 166 | 29,231 | 92 | 100% | 8.2 |
| Licensed Practical Nurse | 44 | 29 | 73 | 13,082 | 92 | 100% | 9.1 |
| Registered Nurse | 34 | 14 | 48 | 7,933 | 92 | 100% | 9.2 |
| Medication Aide/Technician | 28 | 5 | 33 | 7,646 | 92 | 100% | 8.1 |
| Speech Language Pathologist | 0 | 10 | 10 | 1,875 | 71 | 77% | 6.2 |
| Other Dietary Services Staff | 4 | 0 | 4 | 1,727 | 89 | 97% | 8.2 |
| Mental Health Service Worker | 3 | 0 | 3 | 1,387 | 69 | 75% | 7.5 |
| Clinical Nurse Specialist | 2 | 0 | 2 | 1,053 | 66 | 72% | 9.1 |
| Physical Therapy Aide | 0 | 5 | 5 | 884 | 80 | 87% | 6.1 |
| Administrator | 2 | 0 | 2 | 872 | 66 | 72% | 8 |
| Physical Therapy Assistant | 0 | 5 | 5 | 867 | 78 | 85% | 5.9 |
| Dietitian | 1 | 0 | 1 | 751 | 75 | 82% | 10 |
| Respiratory Therapy Technician | 0 | 2 | 2 | 647 | 67 | 73% | 7.4 |
| Nurse Practitioner | 1 | 0 | 1 | 521 | 66 | 72% | 7.9 |
| Qualified Social Worker | 0 | 2 | 2 | 393 | 61 | 66% | 6 |
| Nurse Aide in Training | 1 | 0 | 1 | 318 | 43 | 47% | 7.4 |
Includes penalties issued in 2024
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database (Data as of Jan 2026)
29% higher than Kansas average
Kansas average: $44K
24% more fines than Kansas average
Kansas average: 2.4
Serious action where Medicare and/or Medicaid temporarily stops payments for new residents until issues are fixed.
0
100% fewer payment denials than Kansas average
Kansas average: 0.3
Penalties are imposed by CMS for violations of federal nursing home regulations.
3 penalties in the past 3 years
Multiple penalties were reported in the last 3 years.
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
Oct 2, 2024
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
May 9, 2024
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
Feb 22, 2024
Last updated: Jan 2026
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
9.4
10% better than Kansas average
Kansas average: 10.5
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
15.6
25% better than Kansas average
Kansas average: 20.7
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
10.4%
45% better than Kansas average
Kansas average: 19.0%
Percent of long-stay residents whose ability to move independently worsened
20.5%
6% worse than Kansas average
Kansas average: 19.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
15.9%
33% better than Kansas average
Kansas average: 23.8%
Percent of long-stay residents experiencing one or more falls with major injury
4.9%
11% worse than Kansas average
Kansas average: 4.4%
Percent of long-stay high risk residents with pressure ulcers
6.9%
48% worse than Kansas average
Kansas average: 4.6%
Percent of long-stay residents with a urinary tract infection
1.6%
49% better than Kansas average
Kansas average: 3.1%
Percent of long-stay residents who lose too much weight
4.4%
14% better than Kansas average
Kansas average: 5.1%
Percent of long-stay residents who have depressive symptoms
0.0%
100% better than Kansas average
Kansas average: 5.2%
Percent of long-stay residents who received an antipsychotic medication
22.5%
33% worse than Kansas average
Kansas average: 16.9%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
96.9%
5% better than Kansas average
Kansas average: 91.9%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
93.7%
In line with Kansas average
Kansas average: 95.5%
Number of hospitalizations per 1,000 long-stay resident days.
1.38
25% better than Kansas average
Kansas average: 1.84
Number of outpatient emergency department visits per 1,000 long-stay resident days.
1.45
33% better than Kansas average
Kansas average: 2.16
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
94.5%
25% better than Kansas average
Kansas average: 75.6%
Percent of short-stay residents who newly received an antipsychotic medication
1.7%
20% better than Kansas average
Kansas average: 2.2%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
84.6%
15% better than Kansas average
Kansas average: 73.5%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
26.8%
17% worse than Kansas average
Kansas average: 23.0%
Percentage of short-stay residents who had an outpatient emergency department visit.
11.4%
In line with Kansas average
Kansas average: 11.7%
Percentage of SNF residents who experience falls with major injury during their stay.
0.9%
16% worse than Kansas average
Kansas average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
67.8%
26% better than Kansas average
Kansas average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
64.1%
27% better than Kansas average
Kansas average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
59% of new residents, usually for short-term rehab.
38% of new residents, often for short stays.
3% of new residents, often for long-term daily care.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
148
Residents meet regularly to discuss policies, care quality, and activities
Family members meet regularly to discuss policies, care quality, and activities
State-approved Nurse Aide Training and Competency Evaluation Program on-site
Organized group of family members that meets regularly to discuss facility policies, resident care, and activities.
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for The Gardens at Aldersgate LLC from 2011–2023, based on CMS SNF Cost Reports.
Based on CMS SNF Cost Report for fiscal year ending in 12/2023.
Net patient revenue — what the home actually collects for resident care, after contractual allowances, bad debt and discounts are subtracted from its gross charges (CMS cost report, Worksheet G-3). It covers resident care only; money the home earns from other sources is shown separately as "Other income."
Net patient income: net patient revenue minus the home's total operating expenses. A positive figure means it earns more from resident care than it spends to deliver it; a negative figure means the opposite. It excludes non-operating "other income."
Net patient revenue — what the home actually collects for resident care, after contractual allowances, bad debt and discounts are subtracted from its gross charges (CMS cost report, Worksheet G-3). It covers resident care only; money the home earns from other sources is shown separately as "Other income."
Net patient income: net patient revenue minus the home's total operating expenses. A positive figure means it earns more from resident care than it spends to deliver it; a negative figure means the opposite. It excludes non-operating "other income."
Money the home earns outside of resident care — such as investments, grants, rentals and other non-operating sources (CMS cost report, Worksheet G-3). It is tracked separately from net patient revenue: it is not part of that figure, and it is not included in net patient income.
Staff salaries plus wage-related costs — benefits such as payroll taxes, health insurance and retirement — from the home's own accounting records (CMS cost report, Worksheet A). Contract or agency labor is counted separately, under other operating costs.
Payroll as a share of revenue: staff salaries and wage-related benefits divided by net patient revenue. A higher figure means more of each revenue dollar goes to staff pay.
Everything it costs to run the home apart from payroll — food, utilities, supplies, maintenance, contract labor and administration. Calculated as total operating expense minus payroll (staff salaries and wage-related benefits).
The home's total operating expense for the year — all the costs of running it, salaries included (CMS cost report, Worksheet G-3).
Most residents typically stay for a few weeks or months before returning home or moving on.
Most new residents arrive under Medicare (59% of admissions), and a typical Medicare stay runs around 24 days.
Coverage residents most often arrive under.
Coverage residents most often leave under.
0.0 miles from city center
Estimated distance in miles from Topeka's city center to The Gardens at Aldersgate LLC's address, calculated via Google Maps.
Add your location
The information below is reported by the Kansas Department for Aging and Disability Services.
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| Lexington Park Assisted Living |
NH
AL
IL
|
Topeka (West Southwest 2) |
60
Facility
60
KS AVG
69
Rank
#94 / 224
| 83.9% | +6% | 4.49 | -50% | -3% | $0 | 8 | 2.7 | - | 80 | A+ |
60
Facility
60
KS AVG
46
Rank
#99 / 363
| Floyd Eaton | $8.4M | $4.3M | 51.3% | 175154 | ||||
| Brewster Place |
NH
AL
IL
MC
RC
|
Topeka (South/Southeast 1) |
141
Facility
141
KS AVG
69
Rank
#10 / 224
| 74.3% | -7% | 6.62 | -64% | +43% | $0 | 19 | 6.3 | - | 76 | A+ |
56
Facility
56
KS AVG
46
Rank
#124 / 363
| Melissa Reynolds | $20.7M | $13.6M | 65.8% | 175044 | ||||
| Sabetha Manor |
NH
HC
|
Sabetha |
40
Facility
40
KS AVG
69
Rank
#193 / 224
| 65.0% | -18% | 5.64 | -34% | +22% | $0 | 18 | 3.6 | - | 27 | - |
8
Facility
8
KS AVG
46
Rank
#342 / 363
| Sabetha Nursing LLC | $2.2M | $1.2M | 54.5% | 175241 | ||||
| Protected: Rolling Hills Retirement Community |
NH
AL
RC
|
Topeka (Southwest Topeka) |
70
Facility
70
KS AVG
69
Rank
#83 / 224
| 60.9% | -23% | 3.87 | -30% | -17% | $14.2k | 44 | 8.8 | 1 | 43 | - |
33
Facility
33
KS AVG
46
Rank
#248 / 363
| Floyd C Eaton III Trust 2012 | $4.6M | $2.3M | 51.1% | 175165 | ||||
| The Gardens at Aldersgate LLC |
NH
HC
MC
PC
RC
|
Topeka (Downtown) |
175
Facility
175
KS AVG
69
Rank
#4 / 224
| 65.1% | -18% | 3.72 | +32% | -20% | $56.6k | 40 | 4.4 | 4 | 114 | B- |
78
Facility
78
KS AVG
46
Rank
#25 / 363
| - | $19.2M | $7.8M | 40.5% | 175340 |
The Gardens at Aldersgate LLC is located in TOPEKA, Kansas.
Here are the financial assistance programs available to residents in Kansas.
The Gardens at Aldersgate LLC is in the Downtown neighborhood of TOPEKA.
The Gardens at Aldersgate LLC is legally operated by Betten End Snf Realty Llc, and administered by Morgan Morris.
The Gardens at Aldersgate LLC has a walk score of 78. Very walkable. Most errands can be accomplished on foot, and many essentials are within a short walk.
According to KS state health department records, The Gardens at Aldersgate LLC's license number is 175340.
The Gardens at Aldersgate LLC's occupancy is 65%.
The Gardens at Aldersgate LLC is registered as a for-profit in KS.
Morgan Morris is the administrator of The Gardens at Aldersgate LLC.
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