Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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 August 2026) and official state health department websites.