Inspection Reports for
The Gardens at Aldersgate LLC

The complaint investigation substantiated an incident of staff-to-resident physical abuse involving Licensed Nurse G and Resident 1. The staff member was immediately suspended and terminated. The resident was assessed with no injuries. Law enforcement and the state agency were notified.

The facility failed to prevent an episode of staff-to-resident physical abuse involving a cognitively impaired resident. The staff member involved was terminated, and corrective actions including staff education and resident screening were implemented.

The investigation focused on Resident 1's dementia care. The complaint was substantiated as the facility did not adequately address the resident's dementia-related behaviors or update care plans accordingly.

The facility failed to develop an individualized dementia treatment plan to address Resident 1's dementia-related behaviors, which placed the resident at risk for impaired psychosocial well-being and quality of life. Multiple skilled and behavior notes documented disruptive behaviors, wandering, anxiety, agitation, and hallucinations without adequate staff response or care plan updates.

The investigation was triggered by concerns from Resident 1's representative about inconsistent use of mechanical lifts and inadequate staff assistance. The complaint was substantiated as the resident sustained injuries from a fall when only one staff member assisted her, contrary to care plan requirements.

The facility failed to ensure Resident 1 remained free from avoidable accidents, resulting in a dislocated right shoulder and fractured right humerus. Staff did not consistently provide the required two-person assistance during transfers, leading to the resident's fall and injury.

The complaint investigation found that Resident 1 was injured during transfer when staff pushed on her legs, contrary to her request to be guided using her heels. The injury was substantiated with documented lacerations requiring 15 sutures.

The facility failed to ensure an environment free from accident hazards, resulting in R1 sustaining a laceration to her leg requiring sutures. Staff improperly pushed on R1's legs during transfer with a Hoyer lift, causing injury and pain.

The investigation was triggered by a complaint regarding Resident 1's fall during transfer with a Hoyer lift. The complaint was substantiated as the facility failed to use the correct sling, leading to immediate jeopardy to the resident's health and safety.

The facility failed to ensure a safe environment free from preventable accidents when staff used the wrong sling during a mechanical lift transfer, resulting in Resident 1 falling from the sling and sustaining serious injuries including a head laceration, spinal fracture, and brain hemorrhage. The facility retrained staff and updated resident sling information to prevent recurrence.

The facility had multiple deficiencies including failure to maintain resident dignity, notify physicians of medication refusals, investigate falls, develop and revise care plans, provide adequate bathing and skin care, prevent pressure ulcers and falls, follow toileting care plans, monitor fluid restrictions, coordinate dialysis care, ensure staff training, provide behavioral health services, manage medications properly, maintain sanitary food service, and follow infection control protocols.

The facility had multiple deficiencies including failure to maintain resident dignity, notify physicians of medication refusals, investigate falls, develop and revise care plans, provide adequate bathing and skin care, prevent falls, follow toileting care plans, monitor fluid restrictions, coordinate dialysis care, ensure staff training, provide behavioral health services, manage medications properly, maintain sanitary food service, implement infection control, and offer pneumococcal vaccinations.

The facility failed to provide appropriate care and services for a resident with dementia by not identifying and implementing resident-centered interventions to address wandering and behavioral issues. This deficiency affected the resident's ability to maintain his highest practicable level of physical, mental, and psychosocial well-being.

The facility was found to have 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 consultant pharmacist recommendations for psychotropic medications, and failure to coordinate hospice care plans.

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 to the State Agency, failure to implement fall prevention interventions, failure to adequately monitor nutritional status, failure to reconcile controlled substances accurately, failure to follow up on pharmacist recommendations for psychotropic medications, and failure to coordinate hospice care plans.

The facility identified multiple deficiencies related to resident care practices including blood sugar monitoring, weight monitoring, fall interventions, medication management, and hospice care documentation. Corrective actions and monitoring plans were outlined to address these issues and prevent recurrence.

The facility reviewed policies related to medication storage and management. Nurses received mandatory training on medication identification, storage, and distribution, and insulin pens were replaced for two residents. Compliance checks will be conducted weekly by Unit Managers, with oversight by the Director of Nursing.

The facility failed to date insulin pens when opened or expired for two residents, placing them at risk for use of ineffective medications. Observations and interviews confirmed that insulin pens lacked required date labeling on medication carts.

The visit included complaint investigations #159625, #160205, #160634, and #160358.

The facility failed to date insulin pens when opened or expired for two residents, placing them at risk for use of ineffective medications.

The facility failed to maintain standard transmission-based precautions for COVID-19 prevention, including improper use of PPE, inadequate hand hygiene, and failure to sanitize a mechanical lift after use, increasing the risk of COVID-19 spread.

The facility reviewed and updated policies related to Infection Control, focusing on PPE use, hand hygiene, and equipment sanitization. Staff were trained and monitored to ensure compliance, with ongoing oversight by nursing leadership.

The facility reviewed and updated policies and procedures related to infection control, focusing on PPE use, chemical dwell times, and high-risk areas. Staff received training and monitoring to ensure compliance, with ongoing oversight by the Director of Nursing and infection control experts.

The survey included an abbreviated complaint investigation for complaint #KS00155013 conducted on 08/13/2020.

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 follow manufacturer's directions for disinfectant wet time. These deficiencies posed a risk for transmission of COVID-19 and other communicable diseases.

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

The facility reviewed policies related to medication administration and monitoring after a cited resident had no further adverse effects. Staff involved were educated and competency was restored, with ongoing monitoring by the Director of Nursing.

Complaint investigation conducted with findings of multiple deficiencies including environmental, care planning, restorative services, medication administration, infection control, and accident prevention issues.

The facility had multiple deficiencies including failure to maintain a safe, clean, and homelike environment, incomplete resident assessments, inadequate care plan revisions, failure to provide restorative services, medication administration errors, unsanitary food preparation areas, infection control lapses, and failure to prevent accidents including falls and elopement.

The Plan of Correction addresses multiple deficiencies related to safe and homelike environment, comprehensive assessments, care plans, restorative programs, activities administration, accident prevention, individualized toileting plans, medical equipment sanitization, medication procurement, and infection control. The facility has revised policies, provided staff training, and implemented monitoring procedures for each cited deficiency.

The report is based on complaint investigations KS00143262, KS00142684, KS00142293, and KS00139974. The medication error was substantiated as the resident required emergency care and hospitalization due to the overdose.

The facility failed to prevent a significant medication error when a narcotic pain medication order was incorrectly transcribed, resulting in a resident receiving an increased dose that required emergency care and hospitalization. The investigation revealed errors in transcription and administration of morphine sulfate to a cognitively impaired resident.

The report confirms that all previously cited deficiencies identified by regulation numbers 26-41-204(d), 26-41-205(g)(3), and 26-41-104(d) have been corrected as of the dates listed.

The facility was found deficient in multiple areas including failure to include the licensed nurse's name in negotiated service agreements, improper medication administration practices, inadequate labeling of over-the-counter medications, incomplete documentation of incidents, and insufficient disaster and emergency preparedness.

The plan addresses multiple areas including posting of survey results, notification of the State Ombudsman, completion of neuro checks after falls, physician notification and treatment documentation for skin issues, and medication management. The facility describes policy reviews, staff education, and monitoring responsibilities to achieve substantial compliance.

The survey found an isolated 'D' level deficiency constituting 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 2018-08-08.

The survey found an isolated 'D' level deficiency that constitutes no actual harm but has potential for more than minimal harm without 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.

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

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 notify the State Ombudsman of resident transfers, failure to perform neurological checks as per policy after a resident's fall, failure to notify a physician and monitor a resident's skin issue, and failure to ensure a resident's drug regimen was free from unnecessary medications.

The plan addresses deficiencies related to weight monitoring, meal intake documentation, and care plan updates. The facility has implemented education for dietitians and direct care staff and updated policies to ensure compliance.

The inspection was triggered by complaint investigations #111980, #111264, #112188, and #112410. The findings confirmed the facility failed to notify the physician of critical lab results and failed to prevent pressure ulcers for one resident.

The facility failed to timely notify the physician of abnormal lab results for one resident, which led to 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.

This plan of correction is in response to a complaint investigation identified as Aldersgate complaint 03092017.

The plan addresses issues related to physician notification and skin assessments under medical devices. The facility outlines corrective actions including re-education of licensed nurses and ongoing monitoring by the Director of Nursing.

The survey found a most serious deficiency at F314, 'G', indicating actual harm that is not immediate jeopardy. The facility was found noncompliant with pressure ulcer prevention and care requirements, leading to enforcement remedies including denial of payment for new Medicare and Medicaid admissions.

The plan addresses deficiencies including the posting of the Policy and Procedures manual location and the proper dating of insulin pens for residents. The facility outlines education and monitoring plans to ensure ongoing compliance and prevent recurrence.

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

The plan addresses deficiencies related to individualized care plans for toileting and pressure ulcer prevention, wound care assessments, antibiotic treatment monitoring, and infection control practices including proper glove use. The facility outlines staff re-education, ongoing monitoring, and reporting to the Quality Assurance and Assessment Committee to prevent recurrence.

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

The survey found a serious deficiency at F314 "G", CFR 483.25(c) related to pressure ulcers causing actual harm without immediate jeopardy. Enforcement remedies include denial of payment for new Medicare and Medicaid admissions effective September 27, 2016, until substantial compliance is achieved.

The deficiency cited was related to a complaint investigation and was reviewed through an Independent Informal Dispute Resolution process.

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

The inspection was triggered by complaint investigation #104353.

The facility failed to develop individualized care plans for toileting and pressure ulcer care, failed to update care plans after new pressure ulcers developed, failed to provide timely and effective interventions to prevent and treat pressure ulcers, and failed to prevent the spread of infection through improper glove use during care.

The plan addresses multiple deficiencies including fall investigations, environmental cleanliness, care plan updates for dialysis, fall prevention interventions, chemical storage security, and patio door alarm functionality. The facility outlines corrective actions, staff education, and ongoing monitoring to ensure compliance and prevent recurrence.

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

The facility failed to provide a functioning door monitoring system on patio doors for two cognitively impaired and independently mobile residents. Maintenance and nursing staff did not routinely check or document checks of the patio door alarms.

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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

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 effective August 19, 2016.

The report confirms that the previously identified deficiencies, including one under regulation 483.25(m)(2), have been corrected as of 04/20/2016. No uncorrected deficiencies remain at the time of this revisit.

The complaint investigation #98558 found that a cognitively impaired resident was given another resident's medications without physician orders, leading to emergency transfer and ICU admission.

The facility failed to provide adequate supervision and orientation to new licensed staff, resulting in the wrong administration of another resident's medications to a cognitively impaired resident. This error caused the resident to be transferred to an acute care hospital and admitted to the intensive care unit for treatment.

The facility identified issues with medication administration by a nurse during orientation and the need to improve the orientation process and medication cart functionality. Corrective actions include re-education of staff, redefinition of orientation procedures, and audits to ensure compliance.

The survey found the most serious deficiencies at the facility to be at 'F' level, indicating no harm but with potential for more than minimal harm that is 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.

The survey found the most serious deficiencies at the facility to be at 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.

This Plan of Correction responds to deficiencies cited during a complaint investigation at Aldersgate Village. The document does not state substantiation status explicitly.

The plan outlines corrective actions for deficiencies related to care plan revisions, fall prevention and management, staffing schedule accuracy, and Quality Assurance and Assessment processes. It notes that several residents involved in the deficiencies are no longer at the facility and describes education and monitoring efforts to prevent recurrence.

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

The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to the facility's history of noncompliance, no opportunity to correct deficiencies before remedies are imposed was given.

The report confirms that the previously cited deficiency with regulation number 26-40-305 (3) was corrected as of 03/20/2015. No other deficiencies are listed as outstanding.

The report documents that all previously identified deficiencies listed on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected with specified completion dates.

The report documents that all previously cited deficiencies identified by regulation or LSC provision numbers were corrected by specified dates in March and April 2015.

The facility failed to have a hydrocollator plugged into a ground-fault circuit interrupter (GFCI) outlet as required by electrical safety regulations. Observations and interviews confirmed the hydrocollator was plugged into a standard electrical outlet during the survey.

The survey found deficiencies at a level of actual harm that is not immediate jeopardy. Due to the facility's history of noncompliance, no opportunity to correct deficiencies was given before enforcement remedies were imposed, including denial of payment for all new Medicare admissions effective April 5, 2015.

The report confirms that all previously cited deficiencies identified on the CMS-2567 have been corrected by the revisit date of 2015-01-01.

The survey found a most serious deficiency at an 'F' level indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The inspection was triggered by complaint investigations #73647, 75580, 75852, 77422, and 78789. The findings were substantiated as evidenced by observations, interviews, and record reviews.

The facility failed to promote dignity and respect during meal service, ensure adequate supervision and safety to prevent accidents, and maintain sanitary food storage and preparation conditions on the Eastminister unit.

This Plan of Correction is related to deficiencies cited during a complaint investigation at the facility.

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.

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. A plan of correction was required to address these deficiencies.

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. A plan of correction was required to address these deficiencies.

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

The complaint investigation (#77241) substantiated that the facility failed to notify the resident's legal representative after a medication error and failed to administer medication as ordered, resulting in hospitalization.

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

The report confirms that the deficiencies previously reported have been corrected as of the revisit date. No uncorrected deficiencies remain.

The plan addresses the use of protective coverings (geri-sleeves changed to tuba grip) for resident #7 to prevent skin injuries. It includes updates to resident care plans, physician orders, and development of a skin tear prevention policy with monitoring and reporting procedures.

The findings represent the results of complaint investigations #72220, 72586, 72952, and 74441.

The facility failed to prevent the development of multiple skin tears for one cognitively impaired resident who required extensive assistance. Staff did not consistently apply ordered protective Geri-sleeves, resulting in repeated skin tears despite care plans and physician orders.

The report documents that deficiencies previously cited under regulation 26-40-303 were corrected by 12/13/2013. No uncorrected deficiencies remain as of the revisit date.

The report confirms that all deficiencies previously reported on the CMS-2567 have been corrected as of 12/13/2013.

All deficiencies previously reported on the CMS-2567 were corrected by 12/13/2013, as verified during the revisit on 1/22/2014.

The plan addresses multiple deficiencies related to resident care plans, behavior management, hydration, pressure ulcer prevention, falls prevention, medication administration, infection control, and safety systems. The facility outlines corrective actions including staff training, audits, and implementation of new programs to ensure compliance.

The facility failed to provide audible call signals in soiled and clean utility rooms on one unit and failed to provide emergency call systems in resident showers on one unit. Additionally, the wireless call system did not function properly for 27 residents on the Westminster unit, with delays and incomplete signal transmission.

The report confirms that the deficiency identified under regulation 483.25(h) was corrected as of the revisit date.

The findings represent the results of complaint investigation #KS00063467 and #KS00066230. The complaint was substantiated based on failure to implement fall prevention interventions.

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 on the toilet, contributing to the fall.

The report confirms that the deficiencies previously reported on the CMS-2567 have been corrected as of the revisit date.

The complaint investigation (#65351) was substantiated with findings that the facility failed to revise care plans and failed to properly assess and communicate sling sizes for mechanical lifts, leading to a resident injury.

The facility failed to revise care plans for 2 of 3 sampled residents and did not properly assess or communicate the appropriate sling size for mechanical lifts, resulting in a resident falling through a sling and sustaining injury. Staff training and communication regarding sling use were inadequate.

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

The plan addresses deficiencies related to mechanical lift use, including updating care plans and 24-hour report sheets to reflect correct lift and sling sizes, staff training on mechanical lift use, and ongoing audits to ensure compliance.

The report confirms that deficiencies previously reported on the CMS-2567 have been corrected as of the revisit date.

The report confirms that deficiencies previously reported under regulations 483.10(b)(11) and 483.65 have been corrected as of February 9, 2013.

This Plan of Correction addresses deficiencies cited in a complaint investigation at Aldersgate Village.

Deficiencies involved failure to notify physician and family of resident condition changes and inadequate cleaning procedures for isolation rooms, specifically related to C. diff. Training and compliance audits were planned to address these issues.

The visit was complaint-related, investigating complaints #62923, #62939, and #62387. The investigation substantiated failures in timely physician and family notification and infection control practices.

The facility failed to promptly notify physicians and family members regarding significant changes and transfers of residents, and failed to maintain an effective infection control program including surveillance and proper cleaning to prevent the spread of infections such as Clostridium difficile.

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

The inspection was conducted as a Health Resurvey and Complaint Investigation under the Quality Indicator Survey process.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans, failure to provide adequate grooming and oral care, failure to provide restorative services, failure to prevent falls, failure to maintain sanitary food preparation areas, failure to provide dental consultation as ordered, and failure to properly label medications.

The plan addresses fall prevention interventions for resident #1 and all residents at risk for falls requiring staff assistance. It includes staff education, inservice training, role playing, and ongoing compliance audits with results reviewed at facility risk meetings and QA committee.

The plan addresses multiple deficiencies including abuse investigation, MDS documentation errors, pressure ulcer management, medication administration via enteral tube, food labeling and cross-contamination, behavior monitoring, blood glucose monitoring, and hydrotherapy equipment safety.

This Plan of Correction addresses deficiencies cited in a complaint investigation at Aldersgate Village.

Deficiencies involved failure to timely notify family or responsible parties about resident incidents requiring physician intervention and improper medication administration practices where medications were only given in residents' rooms instead of designated areas.