Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Gardens At Aldersgate during CMS and state inspections, most recent first.
A resident with a history of stroke and hemiplegia, cognitively intact and fully dependent on staff for ADLs including showering, did not receive scheduled showers as care-planned and listed on the shower schedule. Over a review period, only a portion of the scheduled showers were actually provided, with discrepancies between paper shower sheets and EMR task sign-offs. The resident reported not receiving her scheduled weekday showers for several weeks, stating she did not refuse care and was not offered a bed bath. CNAs and nursing staff described expectations to document all offered showers, baths, and refusals on shower sheets and in the EMR, but only a limited number of shower sheets could be located. Administrative nursing staff confirmed that the resident did not receive showers according to the established schedule, in conflict with the facility’s ADL policy requiring necessary services to maintain personal hygiene.
A resident stated that mail was not delivered on Saturdays. Staff gave differing accounts of who was responsible for mail delivery, and an admin staff member stated that residents' mail was not consistently delivered on Saturdays unless she happened to come in. The facility policy stated residents would be able to send and receive mail, letters, packages, and other materials delivered to the facility through a means other than a postal service.
Improper Food Labeling and Storage: Food items in the main kitchen and kitchenette refrigerators were found unlabeled, undated, uncovered, or not sealed, including prepared tuna salad, prepared salsa, solidified grease, Mighty Shakes, an open box of cereal, and frozen hamburger patties. Surveyors also observed stains and debris in a kitchenette refrigerator and on its kick plate, while staff stated kitchen/dietary staff were responsible for cleaning, labeling, dating, and covering stored food items.
Infection control failures were identified when a resident with a suprapubic catheter had no EBP signage or PPE visible at the room, despite staff stating that residents with catheters, wounds, or stomas should be on EBP and that signs and PPE should be posted for care. The facility also left multiple residents’ respiratory devices and tubing in unsanitary locations, observed uncovered clean linen carts, and lacked a current Legionella tracking process after being unable to locate prior documentation.
A facility failed to secure an unlocked rehab therapy room with a broken closet lock and a turned-on hydrocollator, and surveyors also found an exterior door propped open with the alarm turned off. In addition, a resident with dementia and severe cognitive impairment did not have her special flat call light in place after a room transfer, and she later had a non-injury fall.
Missing Puree Recipes During Meal Prep: Dietary staff prepared pureed chicken pot pie without the puree recipe present, and the cook stated the facility normally added stock or milk to pureed foods to maintain flavor. A dietary staff member later confirmed the recipes for that week's menus were not in the binder and were on the lead dietary manager's desk, even though the facility policy required standard recipes for pureed foods to maintain quality, flavor, palatability, and maximum nutritive value.
Essential kitchen equipment was not maintained in working order. Surveyors observed a three-bin dishwashing sink with a dripping sanitizing faucet that would not fill with hot water, rusted support pipes, and a dish machine leaking hot water from inside. In a kitchenette, the ice machine was out of service, so dietary staff used bagged ice and a portable cooler, with the scoop stored outside the cooler.
A resident was transported to the shower on a shower chair with his lower body exposed while hospice staff moved him through the hallway, and facility staff observed but did not intervene. In a separate incident, a CMA assisted another resident with dressing while leaving the room door wide open, exposing the resident’s private areas.
Wheelchair Transports Without Foot Pedals: An LN and another staff member pushed two residents in wheelchairs without foot pedals. One resident with severe cognitive impairment placed his feet down several times during transport, and another resident with impaired mobility had her feet slide on the ground while being pushed. Staff stated foot pedals were expected to be used when pushing residents.
A facility failed to keep a resident’s PHI private when an unlocked laptop on a medication cart displayed medications, DOB, allergy information, and code status in a hallway. The facility also failed to provide privacy for another resident during peri-care when a CNA did not close the curtains, exposing the resident’s buttocks to an open window.
Failure to include required stop date for PRN clonazepam. A resident with multiple chronic conditions, moderately impaired cognition, and dependence for several ADLs had an order for clonazepam 0.5 mg PRN for anxiety, but the order lacked the required 14-day stop date and the EMR lacked a rationale for extended use. Staff interviews confirmed anti-anxiety meds should have a 14-day stop date and that the nurse entering the order was responsible for ensuring it was documented correctly.
Failure to provide written transfer notifications: Two residents had multiple unplanned hospital transfers with return anticipated, but the facility lacked documentation that written notice of transfer and bed-hold information was provided to the residents and/or their representatives as required. EMR review showed the notices were not completed as soon as practicable after each transfer, despite facility policy requiring written notification at transfer or within 24 hours.
Failure to provide scheduled bathing assistance. A resident with an unstageable sacral pressure ulcer, DM, HTN, CHF, and dependence for toileting and bathing was observed wearing a dirty shirt and smelling of sweat after stating he had not been getting his showers. His care plan directed substantial to maximal help with showers, but the bathing record showed showers as not applicable over a period of time. Staff stated residents were to receive two showers weekly, though showers were sometimes missed due to call-ins, and an admin nurse stated showers should be rescheduled if missed.
Inadequate catheter care was identified for a resident with an indwelling catheter, and the drainage bag was found resting on the floor. The resident had encephalitis, kidney disease, DM, and HTN, with moderately impaired cognition and dependence on staff for most ADLs. The care plan directed catheter care every shift, urinary output monitoring, and monitoring for discomfort and urinary frequency, and the resident also had a UTI and was receiving an antibiotic.
Missing dialysis orders and monitoring directions: A resident with ESRD, DM, CHF, COPD, and an indwelling catheter was receiving hemodialysis three times weekly, but the EMR lacked a physician order for dialysis and lacked directions for the dialysis location, transportation provider, and dialysis schedule. The chart also lacked direction for port site monitoring, while staff stated the dialysis order and port dressing checks should have been documented in the EMR.
Unsecured Treatment Carts Containing Medicated Ointments and Creams: Two treatment carts were found unlocked and unattended, one in an unlocked storage room and another in a hallway, each containing medicated ointments and creams. An LN stated the cart had not been locked because there was no key, and an Administrative Nurse stated medication and treatment carts should be locked when not in use. The facility policy required medications to be stored with proper security.
Failure to document influenza and PCV20 vaccine offers or declinations: a resident had no documented influenza declination and no PCV20 record, and two other residents also lacked documentation that PCV20 was offered or declined. Records showed prior pneumococcal vaccines for the residents, but no historical administration, consent, or physician-documented contraindication for PCV20 was available when requested by the surveyor.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety but does not provide further details about the specific events or individuals involved.
A resident with dementia and multiple diagnoses, including Parkinsonism and anxiety, exhibited wandering and disruptive behaviors. The facility failed to create an individualized care plan to address these behaviors, as required by their dementia care policy. Staff acknowledged the behaviors but did not consistently report incidents or update the care plan, placing the resident at risk for impaired psychosocial well-being.
A resident with multiple health conditions, including dementia and Parkinson's disease, suffered a dislocated shoulder and fractured humerus due to inadequate supervision and assistance during a transfer. The resident's care plan required two staff members for assistance, but a CNA attempted to assist the resident alone, leading to a fall from a recliner. The facility's policy on accident prevention was not followed, resulting in the resident's injuries.
A resident sustained avoidable injuries during a transfer using a Hoyer lift when two CNAs did not follow proper procedures, resulting in skin tears on both lower legs. The resident, who required extensive assistance with ADLs and had a history of lower leg pain, was not positioned correctly in a recliner, leading to significant pain and emotional distress.
A resident with a history of cerebral infarction, vascular dementia, and other medical conditions sustained serious injuries during a transfer using a Hoyer lift. Certified Nurse Aides (CNA) used a toileting sling instead of the appropriate sling, causing the resident to slip and fall, resulting in a head laceration, thoracic fracture, and intracranial hemorrhage. Interviews with involved staff and review of the resident's medical records revealed that the facility's policies on safe resident handling and transfers were not followed, leading to the incident.
Failure to Provide Scheduled Showers and Proper ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled ADL assistance with personal hygiene, specifically showers, to a dependent resident. The resident had diagnoses of cerebral infarction and hemiplegia and was documented on both annual and quarterly MDS assessments as cognitively intact with a BIMS score of 15, having no rejection of care during the observation period, and being dependent on staff for most ADLs, including showering. Care plans documented that the resident was dependent on staff for showers/baths and that she would often refuse bathing/showers, with directions to continue to offer bathing/showers and remind her of the importance of hygiene. The shower schedule listed the resident for showers on Tuesday and Friday day shifts. Review of shower sheets from early February through early April showed only five completed shower sheets, while EMR shower tasks showed staff sign-offs for several dates. In total, 16 showers were scheduled during the review period, but documentation showed the resident received only nine. During observation and interview, the resident reported she had not received her scheduled Tuesday showers for the past three weeks, stating she only received Friday baths, did not know why she was not offered showers, did not refuse showers, and was not offered a bed bath. A CNA reported that shower sheets were to be completed on paper each time a shower or bed bath was offered, including documentation of refusals, and that refusals were also to be documented in the EMR and reported to the charge nurse. A nurse stated the shower schedule was last updated in early February and that CNAs were expected to document all offered baths/showers and refusals both on shower sheets and in the EMR. Administrative nursing staff confirmed their expectation that staff complete or offer showers as scheduled, document all showers, baths, or refusals, and that only a limited number of shower sheets for the resident could be located. It was confirmed that the resident did not receive showers according to her scheduled shower days, contrary to the facility’s ADL policy requiring provision of necessary services, including bathing, to maintain good grooming and personal hygiene.
Inconsistent Saturday Mail Delivery
Penalty
Summary
The facility failed to consistently deliver residents' mail on Saturdays. During the resident council meeting, a resident stated that the facility did not deliver residents' mail on Saturdays. Administrative Staff B stated that she was responsible for delivering mail to residents, sorting the mail for each unit and delivering it to the unit manager during the week, and delivering it to residents if unit staff were busy; she also stated that residents' mail did not get delivered consistently on Saturdays unless she happened to come in. An Administrative Nurse stated that the admission receptionist should deliver residents' mail during the week and the unit nurse manager should deliver it on Saturday. The facility's Communications Within and External to the Facility Policy stated that the facility would ensure the resident had the ability to send and receive mail, letters, packages, and other materials delivered to the facility for the resident through a means other than a postal service.
Improper Food Labeling and Storage
Penalty
Summary
Food was not properly labeled, dated, covered, or stored in refrigerated areas in the facility’s main kitchen and kitchenette areas. During an initial tour of the main kitchen walk-in refrigerator, a plastic vat container that appeared to contain prepared tuna salad was observed sitting on a cart without any label, date, or cover, and with a scoop inside. The same refrigerator also contained a clear lidded container that appeared to contain prepared salsa but was not labeled or dated, and a metal storage container in a food prep and serving refrigerator that was unlabeled, undated, uncovered, and contained what looked like solidified grease. In the 400-hall dining room kitchenette, the black side-by-side refrigerator/freezer had a yellowish stain in the bottom drawer, red dried stains under the bottom shelf glass, and a kick plate lying on the floor with grayish fuzzy substances on it. The refrigerator contained eight undated 4-ounce vanilla Mighty Shakes, and the cabinet held an open 27.1-ounce box of Raisin Bran with the plastic not sealed. In the Mulvane Unit refrigerator, eight frozen hamburger patties were found in the ice tray of the freezer without being dated, labeled, or kept in a sealed package. Staff interviews stated that kitchen staff were responsible for cleaning, labeling, and dating food items in the kitchenette refrigerators, and dietary staff stated that all stored food should be labeled, dated, and covered or sealed.
Infection Control Failures With EBP, Respiratory Equipment, Linen, and Legionella Surveillance
Penalty
Summary
The facility failed to implement its infection prevention and control program by not consistently using Enhanced Barrier Precautions (EBP) indicators and PPE for a resident with a suprapubic catheter. During a walkthrough, R113’s room had no EBP signage or PPE visible in or around the room related to the catheter. Staff interviews indicated that residents with open wounds, stomas, or catheters should be on EBP, that signs should be posted outside the rooms, and that PPE should be available during care. Administrative staff also stated that EBP signage should be placed outside each room when a resident is admitted and requires EBP. The facility also failed to store respiratory equipment in a sanitary manner for R11, R63, R14, R104, R43, and R9. Observations showed R11’s nasal cannula laying directly in a trash can, R63’s CPAP and nebulizer unbagged on a bedside table, R14’s CPAP on a bedside table, R104’s nasal cannula and oxygen tubing wrapped around a wheelchair, R43’s nebulizer on a walker seat, and R9’s CPAP and mask not contained in a sanitary manner on a bedside table. In addition, uncovered clean linen carts were observed next to utility closets without a protective barrier, and the maintenance supervisor stated the facility had previously had a Legionella process but could not locate the documentation and did not have a current process to track Legionella.
Unsafe Areas and Missing Call Light Supervision
Penalty
Summary
The facility failed to secure potentially hazardous cleaning chemicals and other unsafe areas in a safe, locked location and out of reach of 16 cognitively impaired, independently mobile residents. During a walkthrough, surveyors found an unlocked rehab therapy room with an unsecured closet containing a hydrocollator that was turned on, and the closet lock was broken and did not function. A consultant confirmed the lock had been broken for a while. Surveyors also found an exterior door in Transitional Care propped open about five inches with a weighted dumbbell, with the door alarm turned off; staff later stated the door was not to be propped open and should have remained locked. The facility’s Accident and Supervision policy stated it would provide an environment that implements adequate supervision, interventions, and assessment to minimize hazards, accidents, preventable injuries, and falls. The facility also failed to ensure a resident’s specialized call light remained in place after a room transfer, resulting in a non-injury fall. The resident had dementia, chronic kidney disease, and major depressive disorder, and her MDS showed a BIMS score of five, indicating severe cognitive impairment. Her care plan documented that staff were to anticipate her care needs and ensure her call light remained within reach; after prior falls, her call light had been replaced with a special flat call light. Records showed she was transferred to an acute medical facility, and when surveyed shortly afterward, her flat call light was found resting beside her in bed rather than in place. Staff stated all staff were responsible for ensuring fall interventions were in place after room moves and that call lights were to be within reach and functional each time they entered rooms.
Missing Puree Recipes During Meal Preparation
Penalty
Summary
The facility failed to ensure dietary staff had and used the provided recipe to specify instructions on the preparation of pureed foods for nine residents. During observation on 01/06/26 at 09:20 AM, Dietary CC prepared pureed chicken pot pie for the lunch meal using a Robo Coupe machine, but did not have the puree recipe present while scooping the chicken pot pie mixture into the container and starting the machine. At 09:25 AM, Dietary CC stated the facility normally added chicken or beef stock or milk to foods they pureed to maintain flavor, described the pureed food as needing to be a pudding consistency with no liquid separation, and said the menu/recipe binder normally contained the puree recipe but did not know why it was missing for that week's meals. On 01/07/26 at 10:30 AM, Dietary BB stated the cook should normally follow the recipe for pureed diets, but the recipes for that week's menus were not in the binder and were on the lead dietary manager's desk. Dietary BB stated the recipes should be followed to ensure nutritional value and flavor were preserved. The facility's Puree Food Preparation policy stated all pureed food would be prepared using standard recipes to maintain quality, flavor, palatability, and maximum nutritive value.
Essential Kitchen Equipment Not Maintained
Penalty
Summary
Essential kitchen and kitchenette equipment was not kept in proper working condition for a facility with a census of 161 residents. During the initial tour of the main kitchen, the three-bin dishwashing sink in the dishwashing room was observed with a dripping faucet for the sanitizing sink bin, and the faucet was not functional to fill the sink with hot water. The support pipes for the three-bin sink also had numerous rusted-out areas, and the main dishwashing machine had dripping hot water from a pipe spigot on the inside of the machine. In the 100-hall kitchenette area, the ice machine was not working, so dietary staff obtained ice from a portable chest cooler in the kitchenette area. The scoop was stored in a separate container outside of the cooler. Dietary staff stated that work orders had been placed for the sanitizer sink faucet, the dishwashing machine leak, and the ice machine, but the equipment remained out of service at the time of observation. A policy for essential equipment was requested but was not received.
Failure to Maintain Resident Dignity During Personal Care and Transport
Penalty
Summary
The facility failed to preserve Resident 7’s dignity during transport to the shower when an unidentified hospice staff member pushed him from his room down the hallway on a shower chair with a hospital gown tied at the neck, leaving his lower extremities, back, and buttocks exposed. Resident 7 was turned backwards through the double doors into the unit while still not completely covered. Facility staff, including a CMA and an unidentified male CNA standing in the hallway, observed that he was not fully covered but did not intervene or stop the transport to ensure his private areas were covered. The facility also failed to maintain Resident 16’s dignity during dressing assistance when a CMA entered his room, found him sitting on the bedside in his underwear with his lower back, buttocks, and extremities exposed, and left the room door wide open while assisting him with putting on his pants. The CMA later verified that she had left the door open and stated she should have closed it. Administrative staff stated that residents should be fully covered during transfers and that the room door should be closed when assisting a resident with dressing.
Wheelchair Transports Without Foot Pedals
Penalty
Summary
The facility failed to utilize foot pedals during wheelchair transports for two residents. On 01/05/26 at 09:15 AM, a severely cognitively impaired resident was in the dining room when an LN informed him that he had a phone call at the nurse’s station and pushed him there in his wheelchair without foot pedals. During transport, the resident placed his feet down several times. On 01/06/26 at 07:54 AM, a resident with impaired mobility and weakness wheeled herself into a common area near the Sunflower Unit and told an unknown staff member that she was tired and asked to be pushed. The staff member pushed her to her room while her wheelchair had no foot pedals, and her feet slid on the ground during the transport. The resident wore slip-on shoes. Staff interviews stated wheelchairs were expected to be used with foot pedals when pushing residents, and the facility’s Accident and Supervision policy indicated it would use appropriate assistive devices to prevent falls and injuries.
Failure to Protect Resident Privacy and Confidential Information
Penalty
Summary
The facility failed to keep Resident 24’s protected health information private when a medication cart was observed parked in the Elmhurst hallway with a laptop computer on top of it. The computer screen was unlocked and open, and Resident 24’s PHI was visible to anyone passing by the cart. The information seen included the resident’s medications, date of birth, allergy information, and code status, and no nursing staff were in view of the medication cart at the time of the observation. The facility also failed to provide privacy for Resident 113 during personal care. A CNA entered the resident’s room to assist with personal hygiene and did not close the curtains while providing peri-care, exposing the resident’s buttocks to the open window. Staff interviews reflected that curtains should be closed during personal hygiene and dressing, and administrative staff stated they would expect the window curtains to be closed during personal care.
Failure to Include Required Stop Date for PRN Clonazepam
Penalty
Summary
The facility failed to ensure Resident 9’s as-needed clonazepam order had a 14-day stop date. Resident 9 had diagnoses including hypertension, DM, COPD, CHF, urinary retention, ESRD, and major depressive disorder. The admission MDS documented a BIMS score of 11, indicating moderately impaired cognition, along with dependence for toileting and bathing, need for set-up or clean-up assistance with eating, and impairment of both sides of the lower body. The psychotropic use CAA documented that Resident 9 was a new admission after a hospital stay, required oxygen at baseline, needed substantial-dependent assistance with ADLs, had bowel incontinence, received hemodialysis three times weekly, and was receiving clonazepam. The care plan identified use of anti-anxiety medication related to an anxiety disorder and directed staff to administer anti-anxiety medications as ordered and monitor for side effects and effectiveness every shift. The physician order dated 12/18/25 was for clonazepam 0.5 mg by mouth as needed for anxiety twice daily, but the order lacked a 14-day stop date and the EMR lacked a rationale for extended use beyond 14 days. During interview, Resident 9 stated that starting dialysis had made him very anxious. Staff interviews confirmed that anti-anxiety medication orders should have a 14-day stop date and that it was the nurse’s responsibility entering the order to ensure it was documented correctly.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to ensure that Resident 7 and Resident 90, and their representatives, were provided written notification of transfer as soon as practicable after transfer to the hospital. Resident 7 had multiple unplanned discharges to an acute hospital with return anticipated, as documented by Discharge MDS records dated 04/28/25, 06/12/25, and 08/07/25, followed by re-entry MDS records dated 05/08/25, 06/19/25, and 08/14/25. For each of these hospital transfers, the facility lacked the required written notification of transfer during the period between the discharge and re-entry dates. Resident 90 also had multiple unplanned discharges to an acute hospital with return anticipated, as documented by Discharge MDS records dated 08/14/25, 09/04/25, and 12/30/25, with corresponding re-entry MDS records dated 08/19/25, 09/09/25, and 01/03/26. Review of the EMR showed no written notification of transfer was provided to Resident 90's representative as soon as practicable when the resident was transferred to the hospital on those occasions. The facility's Bed Hold policy and Transfer and Discharge policy required written notice of bed-hold and transfer information to be provided at the time of transfer or within 24 hours, but the record lacked documentation that this occurred for these residents.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure staff assisted Resident 8 with bathing as needed and as scheduled. Resident 8 had diagnoses including an unstageable sacral pressure ulcer, DM, HTN, and CHF. The admission MDS documented intact cognition with a BIMS score of 15, and also documented that the resident was dependent on staff for toileting and required substantial to maximal assistance for bathing. The CAA documented the resident was a new admission after hospitalization, had recurring falls at home, required substantial-dependent assistance with ADLs, was incontinent of bowel and bladder, and had multiple wounds to the feet, a skin tear, and coccyx wounds. The care plan directed staff to provide substantial to maximal assistance with showers and also documented partial to moderate assistance for all toilets and showers. The bathing record showed bathing was marked not applicable from 12/16/25 through 01/05/26. During observation, Resident 8 was sitting in a recliner wearing a dirty shirt and smelled of sweat, and stated he had not been getting his showers. He said he was unsure whether he was supposed to ask staff for a shower on his shower day, identified his shower days as Tuesday and Saturday, and stated staff told him he could not shower because there was not enough staff. A CNA stated residents were to have two showers a week, that showers could be missed due to pain or behaviors, and that some Saturdays had call-ins so showers were not given. An administrative nurse stated she was not aware of showers not being given, said the facility had enough staff to give showers, and stated missed showers should be rescheduled for the next day or the following day.
Inadequate Catheter Care and Drainage Bag Placement
Penalty
Summary
Appropriate care was not provided for a resident with an indwelling catheter, and the resident’s drainage bag was allowed to rest on the floor. The resident had diagnoses of encephalitis, kidney disease, diabetes mellitus, and hypertension. The Significant Change MDS documented a BIMS score of 11, indicating moderately impaired cognition, and showed the resident was dependent on staff for all ADLs except eating and needed assistance with cleanup or setup. The resident’s CAA documented cognitive impairment and the presence of an indwelling catheter. The resident’s care plan identified urinary retention with an indwelling catheter and directed staff to provide catheter care every shift and as needed, monitor urinary output every shift, and monitor for signs and symptoms of discomfort and frequency of urination. The care plan also documented that the resident had a UTI and would be on an antibiotic for seven days. During interview, the Administrative Nurse stated the catheter bag should be off the floor and below the bladder. The facility’s catheter care policy stated catheter care was to be provided to residents with an indwelling catheter to reduce bladder and kidney infections.
Missing dialysis orders and monitoring directions
Penalty
Summary
The facility failed to provide standards of care related to a resident receiving dialysis. The resident had diagnoses including hypertension, DM, COPD, CHF, urinary retention, ESRD, and major depressive disorder. The admission MDS documented a BIMS score of 11, impairment of both sides of the lower body, dependence on staff for toileting and bathing, and need for assistance with set-up and clean-up with eating. The CAA documented the resident was a new admission after a hospital stay, required substantial to dependent assistance with ADLs, had an indwelling catheter, and received hemodialysis three times a week. The resident’s care plan documented a history of renal disease with dialysis, that dialysis would start on 12/19/25, and that the dialysis chair time would be 02:05 PM on Monday, Wednesday, and Friday, with staff to plan rest periods. However, the EMR under physician orders lacked direction for staff to monitor the resident’s port site, lacked a physician order for dialysis, and lacked direction for dialysis location, transportation provider, and the date and times dialysis was received. Staff interviews confirmed the absence of these orders and documentation, with one nurse stating an order for dialysis should have been in the chart when the resident was admitted or became dependent on dialysis, and another stating the dialysis port dressing should be checked every shift.
Unsecured Treatment Carts Containing Medicated Ointments and Creams
Penalty
Summary
The facility failed to properly store medications in two of eight treatment carts. During the initial tour, a treatment cart on the Transitional Care Unit was found unlocked and unattended in an unlocked storage room, and it contained medicated ointments and creams. The next day, an unattended and unlocked treatment cart was observed on the Sunflower hallway, also containing medicated ointments and creams. A LN stated they never locked that treatment cart because they did not have a key to unlock it, and acknowledged that the cart should be locked. An Administrative Nurse stated she would expect all medication and treatment carts to be locked when not being used. The facility's Medication Storage policy stated medications on the premises would be stored in medication carts or medication rooms according to manufacturer recommendations and in a manner sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Failure to Document Influenza and PCV20 Vaccine Offers or Declinations
Penalty
Summary
The facility failed to offer or obtain an informed declination for influenza vaccination for R72 and failed to offer or obtain an informed declination for the Pneumococcal Conjugate Vaccine (PCV20) for R72, R16, and R4. Review of R72's clinical record showed no documented PCV20, a last documented influenza vaccine on 12/14/22, and no documentation that PCV20 was offered or declined, no historical administration record, and no physician-documented contraindication. Review of R16's record showed PCV13 was administered on 03/10/13 and PSV23 on 03/17/17, but there was no documentation that PCV20 was offered or declined and no historical administration or physician-documented contraindication. Review of R4's record showed PCV13 was administered on 01/18/16 and PSV23 on 11/17/03 and 03/13/17, but there was no documentation that PCV20 was offered or declined and no historical administration or physician-documented contraindication. On 01/07/26, Administrative Nurse E stated she would investigate the PCV20 declinations and stated R72 was on the next list for influenza vaccines to be given in the facility, but she was unable to provide declinations or consents for PCV20 or influenza when requested.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop an individualized dementia treatment plan for a resident, referred to as R1, who displayed dementia-related behaviors. R1's medical record indicated diagnoses of metabolic encephalopathy, Parkinsonism, anxiety, restlessness, and agitation, with a severely impaired cognition score. Despite these conditions, the care plan lacked specific interventions to address R1's behaviors, such as wandering and disruptive actions, which were documented in various skilled and behavior notes. These notes frequently lacked detailed descriptions of R1's behaviors and the staff's responses to manage or prevent further episodes. R1's care plan included general directives for engagement activities and monitoring due to wandering and elopement risk, but it did not provide comprehensive strategies tailored to R1's specific needs. Observations and interviews revealed that R1 frequently wandered into other residents' rooms, causing discomfort and potential safety issues. Staff members, including a licensed nurse and a certified nurse aide, acknowledged R1's behaviors but did not consistently report incidents to management or update the care plan accordingly. The facility's dementia care policy emphasized the importance of individualized care plans developed through an interdisciplinary team approach, involving the resident and their family. However, the facility did not adhere to this policy, as evidenced by the lack of a detailed and effective care plan for R1. This oversight placed R1 at risk for impaired psychosocial well-being and quality of life, as the facility did not adequately address or document interventions for R1's dementia-related behaviors.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure that a resident remained free from avoidable accidents, resulting in a dislocated right shoulder and a fractured right humerus. The resident, who had diagnoses including polyosteoarthritis, Parkinson's disease, dementia, anxiety disorder, and fibromyalgia, was dependent on staff for assistance with activities of daily living and transfers. The resident's care plan required the maximum assistance of two staff members for all bed mobility and showering, and interventions were in place to ensure care was provided in pairs to make the resident feel safe. On the day of the incident, a Certified Nurse Aide (CNA) was assisting the resident in changing clothing while the resident was in a recliner. The CNA was aware that the resident required a Hoyer lift for transfers but did not obtain assistance from another staff member, as the CNA was not getting the resident up. During the process, the resident jerked forward and fell out of the recliner onto the floor, resulting in injuries. The CNA reported that sometimes access to the resident's care information was delayed, which may have contributed to the lack of adherence to the care plan. The facility's policy on accidents and supervision emphasized the need for a resident environment free of accident hazards and adequate supervision to prevent accidents. Despite this policy, the facility did not ensure that the resident received the required supervision and assistance, leading to the accident. The incident highlighted a failure to follow the care plan and ensure staff were adequately informed and prepared to provide the necessary care, as evidenced by the CNA's lack of awareness and the subsequent fall and injuries sustained by the resident.
Failure to Ensure Safe Transfer Procedures
Penalty
Summary
The facility failed to ensure an environment free from accidents for a resident, resulting in an avoidable injury. The resident, who had diagnoses including Bell's palsy, localized edema, chronic pain, and anemia, required extensive assistance with activities of daily living (ADLs) and transfers. During a transfer using a Hoyer lift, two CNAs did not follow proper procedures, leading to the resident sustaining skin tears on both lower legs. The resident's care plan specified the need for two staff members to assist with transfers using a Hoyer lift and a full-body sling, but the CNAs deviated from this protocol by pushing on the resident's legs to position her in a recliner, causing the injuries. The resident's medical record documented a history of lower leg pain and a preference for being guided by her heels rather than her legs during transfers, which the CNAs ignored. The incident occurred when the resident was being transferred from her wheelchair to a recliner. One CNA pulled on the sling while the other pushed on the resident's legs to position her further back in the recliner. This action resulted in skin tears on both of the resident's lower legs, which were assessed and treated by the facility's licensed nurse. The resident was subsequently sent to the emergency room, where she received sutures for a laceration on her right lower leg. The resident expressed that the transfer caused her significant pain and emotional distress because the staff did not listen to her instructions to use her heels instead of her legs. Interviews with staff members revealed that the proper procedure for using a Hoyer lift involves one staff member pulling on the sling from behind while the other lowers the sling with the Hoyer controls. Pushing on a resident's legs is not an approved method and can cause injuries. The facility's policy on mechanical lifts directs staff to use the lever to gently raise and move the resident to the destination and to position the resident comfortably once lowered. The facility acknowledged that the CNAs involved had received transfer training, but the training was not yet completed at the time of the incident.
Improper Sling Use During Hoyer Lift Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from preventable accidents for Resident (R) 1 during a staff-assisted transfer using a Hoyer lift. On the day in question, Certified Nurse Aides (CNA) M and O attempted to transfer R1 from his bed to his chair using the Hoyer lift with a toileting sling. Unfortunately, R1 slipped out of the opening in the sling and fell to the floor, hitting his head on the metal leg of the Hoyer lift. This incident resulted in R1 sustaining a head laceration, a thoracic fracture, and an intracranial hemorrhage, leading to his admission to the Intensive Care Unit (ICU). The facility's failure to ensure the correct sling was used during the mechanical lift transfer placed R1 in immediate jeopardy. Various documents, including R1's Electronic Medical Record (EMR), Annual Minimum Data Set (MDS), Falls Care Area Assessment (CAA), and Care Plan, highlighted R1's medical history and care needs. R1 had diagnoses of cerebral infarction, vascular dementia, lumbar region spondylosis, epilepsy, and paroxysmal atrial fibrillation. His cognitive status varied from moderately impaired to intact, and he required extensive assistance with most activities of daily living, including transfers due to weakness on his left side and poor balance. Despite these documented needs and previous falls, the facility did not ensure the correct sling was used for R1's transfers, leading to the preventable accident. Interviews with staff members involved in the incident, including CNA M, CNA N, and Licensed Nurse G, provided insights into the events leading up to the deficiency. Both CNAs acknowledged using the wrong sling for R1's transfer, leading to him falling through the sling and sustaining injuries. Nurse G noted the use of the toileting sling as the root cause of the accident, emphasizing the importance of using the correct equipment for transfers. Administrative Nurse E and D acknowledged the error in sling selection and highlighted the need for staff education on safe transfer practices. The facility's policies and guidelines on safe resident handling and transfers were not followed, contributing to the deficiency identified during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Topeka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rolling Hills Health Center | 1.1 mi | ★★★★★ | 9 | 1 |
| Excel Healthcare And Rehab Topeka | 1.7 mi | — | 0 | 0 |
| Plaza West Healthcare And Rehab | 2.5 mi | ★★★★★ | 0 | 0 |
| Tanglewood Nursing & Rehabilitation | 2.7 mi | ★★★★★ | 0 | 0 |
| The Healthcare Resort Of Topeka | 3.5 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.