ALDERSGATE VILLAGE

Nursing Home Inspector

3220 SW ALBRIGHT DRIVE
TOPEKA, KS 66614
Shawnee County
Phone: 785-478-9440
Provider Number: 175340
Last Inspection: 08/01/2016

About the Nursing Home

Number of Beds: 196
Number of Residents: 174
Beds Available: 22
Percent Occupancy: 89%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

14

Facility
31

County
29

KS
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

14

2016
26

2015
33

2013

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

8/1/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 8/19/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 8/19/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 8/19/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 8/19/2016
 

3/13/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 3/27/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 4/3/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 4/3/2015
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 4/3/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 3/27/2015
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 4/3/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 4/3/2015
 

11/21/2013 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide activities to meet the interests and needs of each resident. Isolated : Minimal 3 12/13/2013
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 12/13/2013
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 12/13/2013
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 12/13/2013
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 12/13/2013
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 12/13/2013
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 12/13/2013
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 12/13/2013
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Isolated : Minimal 3 12/13/2013
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 12/13/2013
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

8/23/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Actual 4 9/10/2017
 

3/9/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 3/24/2017
 

9/6/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 9/23/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 9/23/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 9/23/2016
 

4/19/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Actual 4 4/20/2016
 

2/22/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 3/12/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Actual 5 3/12/2016
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Widespread : Minimal 5 3/12/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 3/12/2016
 

12/3/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 1/1/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 1/1/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 1/1/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg KS State Avg
Number of Residents 174 74.88 52.13
Registered Nurses 0.85 0.55 0.82
Licensed Practical / Vocational Nurses 0.91 0.67 0.65
Certified Nursing Assistants 2.79 2.25 2.63
Total Staff Hours 4.55 3.47 4.10

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% KS State Avg%
of high risk long-stay residents with pressure ulcers 3 5 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 87 88 93
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 95 91 95
of long-stay residents experiencing one or more falls with major injury 6 2 4
of long-stay residents who have depressive symptoms 4 5 6
of long-stay residents who lose too much weight 10 6 7
of long-stay residents who received an antianxiety or hypnotic medication 27 30 24
of long-stay residents who received an antipsychotic medication 25 34 19
of long-stay residents who self-report moderate to severe pain 7 6 8
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 17 18 19
of long-stay residents whose need for help with daily activities has increased 15 16 16
of long-stay residents with a catheter inserted and left in their bladder 1 2 2
of long-stay residents with a urinary tract infection 7 2 5
of low risk long-stay residents who lose control of their bowels or bladder 60 39 39
of short-stay residents assessed and appropriately given the pneumococcal vaccine 80 77 78
of short-stay residents who had an outpatient emergency department visit 8 12 11
of short-stay residents who made improvements in function 86 71 70
of short-stay residents who newly received an antipsychotic medication 4 1 2
of short-stay residents who self-report moderate to severe pain 12 22 19
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 82 66 74
of short-stay residents who were rehospitalized after a nursing home admission 17 19 19
of short-stay residents who were successfully discharged to the community 65 62 55
of short-stay residents with pressure ulcers that are new or worsened 1 0 1