Inspection Reports for Wg Hearthstone West Sh LLC
3515 SW 6TH AVE, KS, 66606-1900
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 23, 2025, found that all previously cited deficiencies had been corrected. Earlier inspections showed a pattern of deficiencies related mainly to medication management, resident safety including neglect and elopement risks, incomplete negotiated service agreements, and emergency preparedness. Complaint investigations in recent years were mostly unsubstantiated, with one substantiated case in April 2024 involving verbal abuse and neglect by a staff member. No fines, immediate jeopardy findings, or license suspensions were listed in the available reports, although the August 2025 inspection did note immediate jeopardy related to resident neglect and elopement risks that were later corrected. The facility’s record shows improvement over time, with the most recent inspection confirming resolution of prior issues.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% better than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
34 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 23, 2025
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Celebration Villa of Hearthstone West have been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with each correction documented and completed.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 22, 2025
Visit Reason
The document represents the findings of a complaint investigation conducted at the assisted living facility on 09/22/2025.
Findings
The complaint investigation conducted on 09/22/2025 resulted in no citations.
Complaint Details
Complaint investigation 196941 conducted with no citations issued.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation at the assisted living facility.
Findings
The complaint investigation conducted on 09/22/2025 resulted in no citations or deficiencies.
Complaint Details
Complaint investigation number 196941 was conducted and resulted in no citations.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 15
Aug 25, 2025
Visit Reason
The inspection was a resurvey with attached complaints conducted on 08/18, 08/20, 08/21, and 08/25/2025 at Celebration Villa of Hearthstone West, an assisted living facility.
Findings
The facility was found deficient in multiple areas including failure to notify family of medication changes, failure to protect residents from elopement and neglect, incomplete negotiated service agreements, failure to provide services as specified, improper medication administration, unlabeled over-the-counter medications, failure to follow up on pharmacy recommendations, inadequate emergency preparedness, unsafe food storage and temperature control, unsanitary environment, and noncompliance with tuberculosis screening guidelines.
Complaint Details
The resurvey included attached complaints numbered 187638, 188778, 188876, 189258, 190169, 192119, 193461, 194007, 196278, 194725, 195684, and 196432.
Severity Breakdown
SS=D: 3
SS=J: 1
SS=E: 7
SS=F: 5
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to notify legal representative or family of medication changes for Resident 6. | SS=D |
| Failure to protect residents from neglect and elopement, placing residents 2 and 7 in immediate jeopardy. | SS=J |
| Failure to fully develop negotiated service agreements for residents 1, 3, and 6 based on functional capacity screening and service needs. | SS=E |
| Failure to revise negotiated service agreement when facility staff assumed management of Resident 6's medications. | SS=D |
| Failure to provide or coordinate services as specified in negotiated service agreements for residents 1, 3, 5, 6, and 12. | SS=E |
| Failure to complete bed assist device assessments for residents 1 and 3 to ensure safe use and prevent entrapment. | SS=E |
| Failure to administer medications to Resident 3 in accordance with provider's orders. | SS=D |
| Failure to label over-the-counter medications with resident's full name by pharmacist or licensed nurse. | SS=E |
| Failure to follow up on pharmacist medication regimen review recommendations for residents 1, 2, and 3. | SS=E |
| Failure to ensure quarterly review of the facility's emergency management plan with all employees and residents. | SS=F |
| Failure to ensure food items were served at proper temperatures and food temperature logs were incomplete. | SS=F |
| Failure to ensure food items were stored under safe and sanitary conditions including undated and unsealed food items. | SS=F |
| Failure to provide a safe, sanitary, and comfortable environment for residents including stained carpets, unclean toilets, and strong odors. | SS=F |
| Failure to comply with infection control policies including employee health screening and tuberculosis guidelines. | SS=F |
| Failure to ensure compliance with tuberculosis screening guidelines for residents and new employees. | SS=F |
Report Facts
Census: 34
Medication administration count: 26
Missing food temperature documentation days: 15
TB screening delay days: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in findings related to medication notification, negotiated service agreements, medication administration, and pharmacy follow-up |
| Administrative Staff A | Administrative Staff | Named in findings related to elopement, emergency preparedness, housekeeping, and tuberculosis screening |
| Certified Medication Aide F | Certified Medication Aide | Named in findings related to medication administration and unlabeled OTC medications |
| Unlicensed Staff P | Unlicensed Staff | Named in findings related to elopement risk resident list and door alarm response |
| CMA Q | Certified Medication Aide | Named in elopement incident for Resident 2 |
| CMA K | Certified Medication Aide | Named in elopement incident for Resident 7 |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 18, 2025
Visit Reason
The document represents the findings of a resurvey with attached complaints at the assisted living facility conducted on 08/18, 08/20, 08/21, and 08/25 of 2025.
Findings
This plan of correction addresses multiple complaints and findings from the resurvey conducted on the specified dates at the assisted living facility.
Complaint Details
The resurvey was conducted with attached complaints numbered 187638, 188778, 188876, 189258, 190169, 192119, 193461, 194007, 196278, 194725, 195684, and 196432.
Report Facts
Complaint numbers: 12
Inspection Report
Re-Inspection
Deficiencies: 0
May 9, 2024
Visit Reason
An offsite revisit survey was conducted on 05/09/24 for all previous deficiencies cited on 04/16/24 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 05/03/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 04/16/24 corrected by 05/03/24
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 15, 2024
Visit Reason
The document is a Plan of Correction addressing findings from a Re-Licensure Survey with Complaint Investigations conducted on 04/15/24 and 04/16/24 at an Assisted Living Facility.
Findings
The Plan of Correction corresponds to deficiencies identified during the Re-Licensure Survey and multiple complaint investigations at the facility on the specified dates.
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 7
Apr 15, 2024
Visit Reason
The inspection was a Re-Licensure Survey with Complaint Investigations conducted on 04/15/24 and 04/16/24 at an Assisted Living Facility.
Findings
The survey identified multiple deficiencies including failure to prevent resident abuse, failure to report allegations of abuse promptly, inaccurate functional capacity screenings, failure to revise negotiated service agreements after significant changes, lack of self-administration medication assessments, incomplete emergency preparedness reviews, and missing required paperwork for authorized electronic monitoring.
Complaint Details
The visit included complaint investigations related to allegations of verbal abuse and neglect by a Certified Nurse Aide towards resident R6, including withholding the call pendant and telling the resident to get her own drink. The complaints were substantiated based on interviews and notarized statements.
Severity Breakdown
D: 3
E: 2
F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure one resident was not subjected to abuse by a Certified Nurse Aide who was verbally abusive and withheld the call pendant. | D |
| Failure to report allegations of abuse and neglect to the administrator as soon as staff were aware of the allegation. | F |
| Failure to accurately complete Functional Capacity Screens for residents, including identifying fall risks and mobility needs. | E |
| Failure to review and revise Negotiated Service Agreements following significant changes in resident condition or services. | E |
| Failure to complete a licensed nurse assessment for self-administration of medication prior to resident self-administering medications. | D |
| Failure to ensure quarterly reviews of the facility's emergency management plan with all residents and employees. | F |
| Failure to ensure required paperwork for authorized electronic monitoring was completed and in the resident's record. | D |
Report Facts
Deficiency count: 7
Resident census: 38
Dates of complaint investigations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide G | Certified Nurse Aide | Named in findings related to verbal abuse and neglect of resident R6. |
| Administrative Staff A | Interviewed resident R6 and reported on abuse allegations. | |
| Certified Medication Aide F | Certified Medication Aide | Provided notarized witness statement regarding abuse by CNA G. |
| Certified Nurse Aide H | Certified Nurse Aide | Provided notarized statement about verbal abuse by CNA G. |
| Certified Medication Aide I | Certified Medication Aide | Provided notarized statement about verbal abuse by CNA G. |
| Certified Medication Aide J | Certified Medication Aide | Provided notarized statement about verbal abuse by CNA G. |
| Administrative Licensed Nurse B | Administrative Licensed Nurse | Reported on coding errors in functional capacity screens and self-administration assessments. |
| Maintenance Staff C | Maintenance Staff | Provided information on emergency management plan reviews. |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 14, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-08-23.
Findings
All deficiencies have been corrected as of the compliance date of 2022-09-07, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2022-08-23
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 22, 2022
Visit Reason
The document is a plan of correction responding to a resurvey with complaint investigation 155889 conducted at the assisted living facility on 08/22/2022 - 08/23/2022.
Findings
The citations represent findings from the resurvey and complaint investigation conducted at the facility during the specified dates.
Complaint Details
The visit was complaint-related as it involved complaint investigation 155889.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for plan of correction assistance | |
| Mary Tegtmeier | Submitted and modified the plan of correction |
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 1
Aug 22, 2022
Visit Reason
The inspection was a resurvey with complaint investigation 155889 conducted at the assisted living facility to assess compliance with medication regimen review requirements for residents who self-administer medications.
Findings
The facility failed to ensure that designated staff offered two residents who self-administered their medications an opportunity to have a medication regimen review conducted by a licensed pharmacist, as required by regulation.
Complaint Details
The visit was complaint-related under investigation number 155889.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to offer medication regimen review by a licensed pharmacist to residents who self-administer medications. | SS=E |
Report Facts
Census: 36
Sample size: 3
Focused record review: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse | Provided pharmacy notebook lacking evidence of medication regimen review | |
| Administrative staff A | Acknowledged failure to offer pharmacy review to resident R825 | |
| Administrative staff B | Provided information about resident medication management and pharmacy review process |
Inspection Report
Re-Inspection
Deficiencies: 1
Oct 7, 2020
Visit Reason
This is a revisit inspection conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency related to regulation 26-41-206(d) was corrected as of 10/07/2020. No other deficiencies or findings are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-41-206(d) |
Inspection Report
Re-Inspection
Census: 33
Deficiencies: 1
Sep 16, 2020
Visit Reason
The inspection was a resurvey with attached complaints conducted at an assisted living facility to evaluate compliance with food preparation and serving temperature regulations.
Findings
The facility failed to ensure that food was served at safe and proper temperatures, with multiple observations of hot foods served below the required 135 degrees Fahrenheit and cold foods above 41 degrees Fahrenheit. Staff did not pre-heat serving boxes or check food temperatures immediately prior to serving, and meals were often left in resident rooms to be reheated later.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure food was served at a safe and proper temperature. | SS=F |
Report Facts
Census: 33
Food temperature: 102
Food temperature: 89.4
Food temperature: 143
Food temperature: 150
Food temperature: 148.6
Food temperature: 155.3
Food temperature: 170.2
Food temperature: 148.7
Food temperature: 94.7
Food temperature: 104
Food temperature: 90.1
Food temperature: 50.5
Food temperature: 104.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) | Administered medication and reheated meal for resident #916 | |
| Dietary Supervisor | Confirmed dietary staff do not pre-heat reusable serving boxes or check food temperature immediately prior to serving | |
| Dietary Staff | Prepared reusable food boxes with meals |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 17, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 2020-06-17.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Renewal
Deficiencies: 0
Jul 3, 2018
Visit Reason
A survey for re-licensure with attached complaint was conducted at the assisted living facility in Topeka, KS on 7/3/18.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 26, 2017
Visit Reason
This document is a plan of correction form indicating completion of corrections for cited deficiencies.
Findings
The form shows that corrections for all cited deficiencies have been completed, with no outstanding issues noted.
Deficiencies (1)
| Description |
|---|
| Regulation 26-41-101 (f) (1) |
Report Facts
Correction completion date: Jan 26, 2017
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 1
Jan 26, 2017
Visit Reason
The inspection was a revisit resulting from a Correction Order 17-1, Notice of Assessment 17-1, and Ban on Admission 17-1 at the assisted living facility.
Findings
The Administrator failed to ensure that all medications administered to resident #2219 were in accordance with written physician orders and professional standards of practice, with discrepancies found between the medication administration record and physician orders.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure all medications administered to resident #2219 were in accordance with written physician orders and professional standards of practice. | SS=D |
Report Facts
Census: 32
Residents with facility managed medications: 22
Sampled residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Company Compliance Nurse | Interviewed and confirmed discrepancies in medication administration record |
Inspection Report
Abbreviated Survey
Census: 30
Deficiencies: 3
Dec 22, 2016
Visit Reason
The inspection was a licensure abbreviated survey conducted at an assisted living facility in Topeka, Kansas on multiple dates in December 2016 to assess compliance with state regulations.
Findings
The survey identified multiple deficiencies including failure to provide independent direct access to residents' electronic records, medication administration errors placing residents at immediate jeopardy, failure to reconcile medication orders, and improper administration of PRN medications by certified staff without nurse instruction.
Severity Breakdown
SS=F: 1
SS=J: 1
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure independent direct access to each resident's electronic records for inspection and failed to provide facility monitored direct access to each resident's electronic record by a representative of the department. | SS=F |
| Failed to ensure residents were not subjected to neglect when medication was administered by unlicensed staff and failed to properly obtain accurate medication records and physician confirmation orders, resulting in immediate jeopardy for resident #1218. | SS=J |
| Failed to ensure medications and treatments were administered in accordance with professional standards of practice, including PRN medications administered by certified staff without nurse instruction. | SS=E |
Report Facts
Census: 30
Residents sampled: 6
Closed chart reviews: 2
PRN medication administrations: 17
PRN medication administrations: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facility operator #Z | Denied access to electronic resident records during inspection | |
| Certified staff #X | Administered narcotic medication without nurse instruction | |
| Certified staff #W | Administered narcotic medication without nurse instruction | |
| Certified staff #V | Administered controlled narcotic medication 8 times without notifying nurse prior to administration | |
| Licensed staff #Y | Confirmed certified staff do not seek nurse instructions prior to PRN medication administration |
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 4
Oct 31, 2016
Visit Reason
The inspection was a licensure re-survey with an attached complaint conducted at the assisted living facility on 10/26/16, 10/27/16, and 10/31/16.
Findings
The facility was found deficient in multiple areas including failure to provide access to resident records for inspection, incomplete negotiated service agreements lacking required signatures and payment responsibility identification, improper medication administration by unlicensed outside provider staff without proper documentation, and failure to maintain resident records according to professional standards.
Complaint Details
The inspection included an attached complaint investigation as indicated by the report stating it was a licensure re-survey with attached complaint.
Severity Breakdown
SS=C: 1
SS=E: 2
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure access to each resident's records for inspection and photocopying by any representative of the department. | SS=C |
| Failed to ensure the Negotiated Service Agreement (NSA) was completed in collaboration with the resident or legal representative and contained identification of each party responsible for payment if outside resources provide a service. | SS=E |
| Failed to ensure all medications and treatments were administered in accordance with professional standards and only licensed nurses and medication aides administered medications; unlicensed outside provider staff administered medications without documentation. | SS=E |
| Failed to maintain resident records in accordance with accepted professional standards and practices, including lack of admission physical assessment and incomplete documentation. | SS=D |
Report Facts
Residents present: 29
Residents in sample: 3
Focus review residents: 1
Medications listed: 18
Residents with outside provider medication assistance: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff #A | Denied access to resident electronic records | |
| Licensed staff #B | Confirmed nursing progress notes on electronic system and provided interviews regarding medication administration and resident records | |
| Licensed nurse #C | Participated in development of Negotiated Service Agreement | |
| Licensed agency staff #Q | Preset medications for resident #128 in pill minder box | |
| Agency staff #P | Delivered pill minder box to resident #128 and assisted with medication administration |
Inspection Report
Re-Inspection
Deficiencies: 1
Jul 24, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected as of the revisit date.
Findings
The report confirms that the deficiency identified under regulation 26-41-104 (d) with ID prefix S3280 was corrected by 07/24/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 26-41-104 (d) |
Inspection Report
Renewal
Census: 31
Deficiencies: 4
Jun 23, 2015
Visit Reason
The inspection was a Licensure Resurvey conducted at the Assisted Living Facility on 6/17/15, 6/18/15, 6/22/15, and 6/23/15, including investigation of Complaint #86148.
Findings
The facility was found deficient in multiple areas including inaccurate functional capacity screening for residents, failure to provide health care services according to standards, lack of licensed nurse assessment for self-administration of medication, and failure to conduct quarterly reviews of the emergency management plan with employees and residents.
Complaint Details
Complaint #86148 was investigated during the resurvey.
Severity Breakdown
SS=E: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure designated facility staff completed a functional capacity screen (FCS) that accurately reflected residents' functional capacity, with incorrect coding in the cognition section. | SS=E |
| Failure to ensure all health care services, including interventions for blood sugar test results, were provided by qualified staff in accordance with acceptable standards of practice. | SS=E |
| Failure to ensure a licensed nurse performed an assessment of the resident's ability to safely and accurately self-administer medications. | SS=E |
| Failure to ensure disaster and emergency preparedness by conducting quarterly reviews of the facility's emergency management plan with employees and residents. | SS=F |
Report Facts
Census: 31
Employees hired since last resurvey: 44
Residents with self-administered medications: 6
Residents with facility-managed medications: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #H | Interviewed regarding functional capacity screen training and coding. | |
| Licensed Nurse #J | Completed an inaccurate functional capacity screen before May 2015. | |
| Resident Service Director #G | Confirmed inaccuracies in functional capacity screen coding and lack of physician notification for blood sugar results. | |
| Operator | Interviewed regarding medication self-administration and emergency preparedness documentation. | |
| Maintenance Director | Confirmed lack of documentation for disaster plan reviews. |
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 4
Mar 4, 2014
Visit Reason
The inspection was a resurvey conducted on 2014-02-26, 2014-02-27, and 2014-03-04 to assess compliance with previously identified deficiencies at the assisted living facility.
Findings
The facility was found deficient in multiple areas including failure to ensure licensed nurse assessments following functional capacity screenings indicating need for health care services, incomplete negotiated service agreements lacking provider and payment information, inadequate medication disposition records, and failure to conduct quarterly reviews of the emergency management plan with employees and residents.
Severity Breakdown
E: 1
D: 1
F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure a licensed nurse assessed residents whose functional capacity screening indicated the need for health care services. | E |
| Failure to ensure the negotiated service agreement included a description of services, identification of providers, and payment responsibilities. | D |
| Failure to maintain records of receipt and disposition of all medications managed by the facility in sufficient detail for accurate reconciliation. | F |
| Failure to ensure disaster and emergency preparedness by performing quarterly review of the facility's emergency management plan with employees and residents. | F |
Report Facts
Census: 39
Medications for discharged residents: 127
Medications for current residents: 73
Narcotics for discharged residents: 6
Narcotics for current residents: 3
Over the counter medications to be destroyed: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Interviewed confirming deficiencies related to licensed nurse assessments and medication destruction procedures | |
| Certified Medication Aide E | Accompanied observation of medication cabinet and confirmed medication destruction procedures | |
| Administrative Staff C | Interviewed regarding emergency management plan reviews with residents | |
| Administrative Staff B | Interviewed confirming lack of documentation for emergency management plan reviews with employees and residents |
Inspection Report
Plan of Correction
Deficiencies: 5
Mar 4, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report for Atria Hearthstone West.
Findings
The Plan of Correction indicates that no corrective actions were required for the listed deficiencies as of the completion date 03/04/2014.
Deficiencies (5)
| Description |
|---|
| S0000 |
| S3080-E |
| S3085-D |
| S3216-F |
| S3280-F |
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