Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Lexington Park Nursing & Post Acute Center during CMS and state inspections, most recent first.
Wheelchairs Used Without Foot Pedals During Resident Transport: Staff were observed pushing multiple residents in wheelchairs without foot pedals, requiring one resident to hold her feet up and another to drag his feet on the floor. One resident had severe cognitive impairment and needed extensive assistance, another had intact cognition but needed help with longer wheelchair distances, and a third had dementia and poor safety awareness. Staff stated foot pedal use depended on resident preference or ability, and the facility reported it had no wheelchair safety policy.
Unattended Medication Cart Left Unlocked: Staff left the 100-hall med cart unlocked and unattended across from the nurse's station, with the keys resting on top of the cart and no staff in sight. A CMA, an LN, and an Administrative Nurse all stated the cart was supposed to remain locked when unattended, and facility policy required medications and biologicals to be stored safely and securely.
Incomplete Nurse Staffing Posting: The facility posted a daily nursing staffing sheet near the nursing station that listed employee numbers and hours but did not include the facility name or the daily nursing staff total hours. An Administrative Nurse stated he had not noticed the missing totals and was unaware the facility name had to be included on the daily staffing form.
The facility failed to provide three residents or their representatives with written information about the bed hold policy during hospital transfers, risking their ability to return to the facility. This oversight was confirmed through observations and staff interviews.
The facility failed to ensure nonpharmacological interventions and specified durations for PRN psychotropic medications for residents, leading to unnecessary medication use. One resident received lorazepam without prior nonpharmacological interventions, another had no gradual dose reduction for an antipsychotic, and a third lacked a 14-day stop date for PRN antipsychotic use.
Wheelchairs Used Without Foot Pedals During Resident Transport
Penalty
Summary
The facility failed to ensure an environment free from accident hazards when staff propelled residents in wheelchairs without foot pedals attached, requiring the residents to hold their feet up or allowing their feet to drag on the floor. Survey observations showed multiple residents being transported through hallways and to rooms in wheelchairs missing foot pedals, and the pedals were found placed separately in residents’ rooms or outside rooms rather than attached to the chairs. R49 had diagnoses of Alzheimer’s disease and polyosteoarthritis, a BIMS score of 4 indicating severe impairment, and required substantial to maximum assistance for transfers and other ADLs. Her care plan directed staff to propel her in her wheelchair and use a sit-to-stand lift if she was weaker than usual or if a transfer seemed unsafe. Despite this, staff were observed pushing R49 in her wheelchair without foot pedals, and she had to hold her feet in the air. Staff later stated they were allowed to push residents without foot pedals if the resident could hold their feet up, while nursing staff also stated that resident preference and cognition influenced whether foot pedals were used. R29 had diagnoses including sciatica, sepsis, CHF, and anemia, and her MDS documented intact cognition but need for assistance with wheelchair mobility. Her care plan stated she could propel short distances but needed staff assistance for longer distances. She was observed being pushed to her room in a wheelchair without foot pedals, with her feet dragging on the floor. R24 had diagnoses including unspecified dementia, restlessness and agitation, and restless leg syndrome, with a BIMS score of 5 and a care plan noting poor safety awareness and assistance with wheelchair propulsion. R24 was also observed being pushed in a wheelchair without foot pedals, with the foot pedals sitting on the floor outside the room. The facility stated it did not have a policy related to wheelchair safety.
Unattended Medication Cart Left Unlocked
Penalty
Summary
The facility failed to adequately store medications and biologicals when staff left the 100-hall medication cart unlocked and unattended. On 04/28/2026 at 08:47 AM, the medication cart was observed sitting across from the nurse's station with no staff present at the nurse station or within sight of the cart, and the keys were resting on top of the cart. During interviews, a CMA stated the cart was supposed to be locked when unattended and the key was never to be left on the cart, a LN stated the cart was never supposed to be left unlocked and unattended, and an Administrative Nurse stated facility policy directed staff to never leave the cart unlocked and to always have the key on them. The facility policy stated that medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.
Incomplete Nurse Staffing Posting
Penalty
Summary
The facility failed to display accurate posted nurse staffing information that included all required data. On 04/27/2026 at 07:43 AM, an observation found a daily staffing sheet posted near the nursing station that listed the number of employees and hours but did not include the facility name or the daily nursing staff total hours. On 04/29/26 at 09:15 AM, Administrative Nurse D stated he had not noticed the staffing sheet was missing the total numbers and said he knew it should be posted on the daily nursing staffing sheet; he also stated he was unaware the facility name needed to be included. The facility’s Daily Nurse Staff Posting policy, revised 11/28/17, stated the facility will post the full-time equivalent number of nursing personnel responsible for providing direct care daily for each shift and that the posting should include the number of licensed nurses and unlicensed personnel on duty for that day and shift.
Failure to Provide Bed Hold Policy Information
Penalty
Summary
The facility failed to provide three residents or their representatives with written information regarding the facility's bed hold policy when they were transferred to the hospital. This deficiency was identified during a survey that included a sample of 19 residents out of a census of 77. The lack of communication regarding the bed hold policy placed these residents at risk of not being permitted to return and resume residence in the nursing facility. One resident, who had a diagnosis of malignant neoplasm, anxiety, atherosclerotic heart disease, and COPD, was transferred to the hospital after experiencing severe respiratory distress. Despite the transfer, there was no evidence in the resident's clinical record that the bed hold policy was provided to the resident or their representative. Observations and interviews with facility staff confirmed that the policy was not communicated as required. Another resident with diagnoses including congestive heart failure, COPD, and sepsis was transferred to the hospital on two separate occasions. Similarly, the clinical record lacked documentation that the bed hold policy was provided. A third resident, diagnosed with anxiety disorder, dementia, schizoaffective disorder, and bipolar disorder, was also transferred to a behavioral health hospital without receiving the necessary bed hold policy information. Interviews with administrative staff confirmed the oversight in all cases.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure nonpharmacological symptom management and a specified duration of use for a resident's PRN psychotropic antianxiety medication. The resident, who had severe cognitive impairment and was receiving hospice care, was administered lorazepam multiple times without documentation of nonpharmacological interventions being attempted prior to administration. The physician's response to the consultant pharmacist's review lacked a specified duration of use and a clinical rationale for the continued use of the medication. Another resident, who had severe cognitive impairment and was receiving an antipsychotic medication, did not have a gradual dose reduction (GDR) attempted, and the physician did not provide a clinical rationale for the continued use of the medication at the same dose. The consultant pharmacist had recommended a trial reduction to ensure the lowest effective dose was being utilized, but the physician disagreed without providing a rationale that addressed the benefits of continued use despite the risks. Additionally, a third resident's PRN antipsychotic medication lacked the required 14-day stop date, and the physician did not provide a rationale for the extended use of another PRN medication. The facility's policy on unnecessary medications was not adhered to, as the medications were used without adequate indications for use or specified durations, placing the residents at risk of receiving unnecessary psychotropic medications.
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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) |
|---|---|---|---|---|
| Topeka Presbyterian Manor | 0.9 mi | ★★★★★ | 2 | 0 |
| Brighton Place West | 1.2 mi | ★★★★★ | 1 | 1 |
| Plaza West Healthcare And Rehab | 1.9 mi | ★★★★★ | 0 | 0 |
| The Healthcare Resort Of Topeka | 2.3 mi | ★★★★★ | 8 | 0 |
| Tanglewood Nursing & Rehabilitation | 2.3 mi | ★★★★★ | 0 | 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.