Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Topeka Presbyterian Manor during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, depression, and chronic kidney disease returned from the ER with a right wrist fracture in a sugar‑tong splint and written instructions for the facility to call an orthopedic clinic for prompt follow‑up. Staff did not attempt to schedule the appointment for many days, then encountered an out‑of‑network issue and faxed a referral to another orthopedic provider but failed to verify receipt or follow up in a timely manner, resulting in the resident remaining in the original splint for an extended period without orthopedic oversight. At the eventual orthopedic visit, the provider documented that the facility had not followed the ER order for follow‑up and that a pressure sore had developed at the base of the thumb from the splint; a later wound note identified this as a Stage 3 pressure ulcer. Subsequent observation found the resident’s hand swollen and discolored, with the ordered dressing for the thumb wound not in place, and nursing leadership acknowledged that staff had missed the AVS instruction to call for the appointment and had delayed follow‑up after learning of network and referral issues.
A resident with Alzheimer's disease and a history of wandering exited the facility unsupervised by following a visitor out the main entrance before the door's lock engaged. Although the resident wore a Wanderguard bracelet and had a care plan identifying elopement risk, staff did not prevent the resident from leaving, and the alarm system was only triggered after the exit. The resident was found outside and returned safely, but the incident revealed a lapse in supervision and exit monitoring.
The facility failed to provide consistent weekend activities on Saturdays, as revealed by a review of the Activity Calendar for October, November, and December 2024. The Resident Council reported long and boring weekends, with residents often staying in their rooms watching TV. Staff interviews confirmed the lack of activities, with efforts underway to recruit volunteers. The facility's Life Enrichment Programs policy was not adhered to, placing residents at risk for decreased psychosocial well-being.
The facility failed to secure hazardous areas and materials, placing residents at risk for accidents. Unsecured closets and rooms contained cleaning chemicals and unlocked electrical panels. A resident with Alzheimer's fell in an unsecured shower room due to inadequate supervision, while another resident's wheelchair was not placed as per their care plan, increasing fall risk. Staff interviews confirmed these areas should have been locked and care plans followed.
The facility did not complete a yearly performance evaluation for a CNA who had been employed for over 12 months. This was confirmed by an administrative staff member who admitted the facility was behind on evaluations. The facility also lacked a policy for yearly staff performance reviews, placing residents at risk for inadequate care.
The facility failed to maintain sanitary standards in the dining room, with dirty plates left from previous meals and an uncovered food thickener container. A CNA placed dome covers directly on food and did not perform hand hygiene between tasks. Staff interviews confirmed inconsistent adherence to hand hygiene protocols, contrary to the facility's policy on maintaining clean food service areas.
The facility failed to implement an effective system for alerting staff and visitors about Enhanced Barrier Precautions (EBP) needs, with PPE stored in rooms without visible signage. Staff interviews revealed a lack of awareness about EBP indicators. Additionally, proper hand hygiene was not followed during wound care, and oxygen equipment was improperly stored, increasing infection risk.
The facility failed to ensure agency staff received required resident rights training, as revealed by a review of training records for CNAs and LNs. Interviews with agency staff indicated inconsistent training practices, and Administrative Nurse D admitted there was no system to verify training completion. This deficiency placed residents at risk for impaired care and decreased quality of life.
The facility failed to ensure agency staff received required infection control training, risking resident care quality. Training records lacked documentation for agency CNAs and an LN, and there was no system to verify training completion. Some agency staff reported completing in-services through their agencies, but the facility relied on agencies to ensure training, contrary to its education policy.
The facility failed to ensure the use of foot pedals during wheelchair transport for three residents, leading to their feet sliding on the floor. Staff interviews confirmed the expectation for foot pedals to be used, but no policy was provided. This oversight placed residents at risk for preventable accidents.
A resident with severe cognitive impairment and multiple health conditions was not properly assisted with grooming, resulting in matted and unkempt hair. Despite staff acknowledging their responsibility to ensure residents are presentable, the facility lacked a policy for ADLs, and the resident's consistent refusals for showering were documented without adequate intervention.
A resident with multiple health conditions, including hemiplegia and obesity, was at high risk for pressure ulcers. The facility failed to set the resident's low air-loss mattress at the correct weight, as specified in the care plan, which was crucial for pressure ulcer prevention. Observations showed the mattress was set at 320 pounds instead of the required 190-210 pounds. Staff interviews revealed inconsistent monitoring and documentation practices, despite the facility's policy emphasizing preventative measures for skin integrity.
A facility failed to ensure a resident had a safety assessment for side rails used with a low air-loss mattress. The resident, with severe cognitive impairment and a history of falls, was fully dependent on staff for transfers and ADLs. The facility's policy required an assessment of risks associated with side rails and low air-loss mattresses, but staff did not conduct this assessment, placing the resident at risk for uninformed decisions and impaired safety.
A facility failed to ensure a resident had a CMS-approved indication or required physician-documented rationale, including risk versus benefits, for the use of Zyprexa. The resident, with severe dementia and other conditions, was receiving hospice services and had a severely impaired cognition. Despite the facility's policy requiring documentation and monitoring of psychoactive medications, the EMR lacked documentation of nonpharmacological interventions attempted and failed, placing the resident at risk for unnecessary medication administration and possible adverse side effects.
The facility failed to coordinate hospice services for two residents, leading to inadequate end-of-life care. The care plans lacked specific instructions on hospice services, causing confusion among staff. Interviews revealed staff uncertainty about hospice services, highlighting a gap in care coordination.
A resident consented to receive the PCV20 pneumococcal vaccine in August 2024 but did not receive it until December 2024, despite the facility's policy requiring timely vaccination. The delay was confirmed through EMR review and staff interviews, with no explanation provided for the oversight.
A resident with multiple health conditions, including osteoporosis and COPD, sustained fractures to both ankles due to improper transfer methods by staff. The resident's care plan required a sit-to-stand lift with two staff members, but an unsafe arm-in-arm transfer was used instead. The facility's investigation was inadequate, failing to identify all involved staff and not adhering to the policy on safe transfers.
Failure to Arrange Timely Orthopedic Follow‑Up Leading to Stage 3 Thumb Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow‑up care and services for a resident’s fractured wrist as ordered, which led to prolonged use of a non‑removable splint without physician oversight and the development of a Stage 3 pressure ulcer on the resident’s thumb. The resident’s EMR showed diagnoses including Alzheimer’s disease, depression, chronic kidney disease, and later a Stage 3 pressure ulcer. A quarterly MDS documented intact cognition with a BIMS score of 13 and identified the resident as at risk for pressure ulcers but without any pressure areas at that time. After the resident fell and sustained a right wrist fracture and fractured tailbone, the hospital emergency room applied a sugar‑tong splint and provided an AVS instructing the facility to call an orthopedic surgery clinic for a follow‑up visit as soon as possible, keep the splint dry and intact, and monitor for numbness, tingling, or worsening pain. The resident returned to the facility with a documented referral to a named orthopedic clinic, including its address and phone number, and instructions to follow up the next week. However, the facility’s progress notes showed no evidence of attempts to schedule the orthopedic follow‑up until many days later, with the first documented attempt occurring nine business days after the ER visit, when staff learned the resident was not in network with the original orthopedic provider and then faxed a referral to another surgeon’s office. The EMR then lacked evidence of further contact with the orthopedic provider for an extended period, with the next documented action occurring over a month after the splint was applied, when an appointment was finally scheduled. At the orthopedic visit, the provider documented that the facility had failed to follow up on the ER order for orthopedic consultation, that the resident had remained in the sugar‑tong splint since the ER visit, and that a pressure sore had developed at the base of the thumb from the splint. A subsequent skin and wound note documented a Stage 3 pressure ulcer on the right thumb with specific measurements and slough present. Later observation found the resident’s hand swollen and discolored, with the ordered dressing for the thumb wound not in place. Facility nursing leadership acknowledged that staff did not recognize the AVS instruction that the facility must call to schedule the orthopedic appointment, did not follow up promptly when told the resident was out of network, and allowed additional delays when a faxed referral was not received and when it was later learned that a referral was not required.
Elopement Due to Inadequate Supervision and Exit Monitoring
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, moderate cognitive impairment, and a history of wandering was able to elope from the facility. The resident's care plan identified him as being at risk for elopement, required the use of a Wanderguard bracelet, and instructed staff to check its placement and functionality regularly. The care plan also noted that the resident would often wait by the facility entrance for his wife and required redirection and supervision. Despite these interventions, the resident was able to exit the facility by following a visitor out the main entrance before the door's lock could engage. The Wanderguard alarm system was triggered, and staff found the resident outside the main entry, leaning against a brick wall. The resident was assessed and found to have no injuries before being redirected back inside. Interviews with staff confirmed that the resident's Wanderguard was checked each shift and that he was known to be confused and required supervision when outside. The facility's policy required close monitoring of residents at risk for elopement and adherence to individualized care interventions, but the resident was able to leave the building unsupervised due to a lapse in monitoring at the entrance.
Inconsistent Weekend Activities for Residents
Penalty
Summary
The facility failed to provide consistent weekend activities on Saturdays, which are essential for promoting socialization among residents. The review of the facility's Activity Calendar for October, November, and December 2024 revealed a lack of scheduled activities on several Saturdays. Specifically, no activities were recorded on 10/19/24, 10/26/24, 11/02/24, 11/09/24, 11/30/24, and throughout December. This inconsistency in providing activities was confirmed by the Resident Council, which reported that weekends were long and boring, with residents often staying in their rooms watching TV. Interviews with facility staff further corroborated the deficiency. Activities Staff Z acknowledged the absence of consistent weekend activities and mentioned efforts to recruit volunteers from churches and staff to address this issue. CNA Q was unaware of any weekend activities, indicating a lack of communication or implementation of such programs. Administrative D stated that while volunteers were available on Sundays, the nursing staff could facilitate weekend activities, but there was no evidence of this occurring. The facility's Life Enrichment Programs policy emphasizes the importance of group activities for residents' well-being, yet the facility failed to adhere to this policy, placing residents at risk for decreased psychosocial well-being, boredom, and isolation.
Failure to Secure Hazardous Areas and Supervise Residents
Penalty
Summary
The facility failed to secure hazardous areas and materials, placing residents at risk for preventable accidents and injuries. During a walk-through, it was observed that housekeeping and linen closets in the 580's hallway were unsecured, containing cleaning chemicals with warning labels and unlocked electrical panels marked with high voltage warnings. Additionally, a storage closet in the 560's hallway and the Spa room were found unsecured, with the latter containing unsecured sanitary bleach wipes. Staff interviews confirmed that these areas should have been locked to prevent resident access, especially for the ten cognitively impaired, independently mobile residents. Resident 33, diagnosed with Alzheimer's disease and other conditions, was at risk for falls due to cognitive and physical impairments. Despite a care plan indicating the need for extensive assistance and supervision, R33 was found in a shower room after a fall, which should have been locked. The facility's investigation revealed that R33 attempted to toilet herself, leading to the fall. Staff interviews highlighted that R33 was impulsive and required supervision, yet the necessary precautions were not consistently implemented, resulting in her accessing the unsecured shower room. Resident 43, with multiple diagnoses including anxiety and Parkinson's disease, was also at risk for falls. The care plan required R43's wheelchair to be placed next to her to prevent falls. However, it was observed that R43's wheelchair was folded and out of reach, contrary to the care plan. Staff interviews indicated that while care plans were accessible, they were not always reviewed or followed, leading to R43's fall. The facility's failure to adhere to the care plan and ensure proper supervision and equipment placement contributed to the risk of falls and injuries for R43.
Failure to Complete Yearly Performance Evaluation for CNA
Penalty
Summary
The facility failed to complete a yearly performance evaluation for one of the five Certified Nurse Aides (CNA) reviewed, specifically CNA N, who had been employed for over 12 months. This oversight was identified during a review of the facility's staffing list and confirmed through an interview with Administrative Staff A. The staff member acknowledged that CNA N's performance evaluation had not been completed, citing that the facility was behind in conducting these evaluations. Additionally, the facility was unable to provide a policy related to yearly staff performance reviews. This deficiency placed the residents at risk for inadequate care.
Sanitary Standards Violation in Dining Room
Penalty
Summary
The facility failed to maintain a sanitary environment for food storage and meal service, as observed in the Cedar View dining room. Dirty plates were left on a table next to the kitchenette's serving window from the previous evening's meal service. A large, uncovered container of instant food thickener was found on the condiment shelf, with residue covering the countertop. Despite being moved, the thickener container remained uncovered at various times, indicating a lack of adherence to sanitary standards. Additionally, a CNA was observed placing dome covers directly on food, pushing it downward, and delivering it to residents without proper hand hygiene between tasks. Staff interviews revealed that hand hygiene protocols were not consistently followed, as CNAs were expected to sanitize hands before, during, and after assisting residents with meals. The facility's policy on equipment storage, cleaning, and sanitizing emphasized the importance of maintaining clean and sanitary food service areas, yet these standards were not met. The failure to adhere to these protocols placed residents at risk of food-borne illnesses and compromised food safety.
Inadequate Infection Control and EBP Signage
Penalty
Summary
The facility failed to develop and implement an effective system to alert staff and visitors of Enhanced Barrier Precautions (EBP) needs for residents identified as requiring such precautions. During inspections, it was observed that personal protective equipment (PPE) was stored in residents' rooms without any visible signage or indicators for EBP, leaving staff and visitors unaware of the necessary precautions. Interviews with staff revealed a lack of awareness regarding the indicators for EBP, with some staff members unaware of the blue dots on door plates meant to signify EBP rooms. This lack of clear communication and signage compromised the facility's ability to effectively manage infection control. Additionally, the facility failed to adhere to proper hand hygiene protocols during wound care and did not ensure the sanitary storage of oxygen therapy equipment. Observations showed that a licensed nurse did not change gloves or perform hand hygiene between handling soiled and clean dressings during a resident's wound care. Furthermore, oxygen equipment, such as nebulizer masks and nasal cannulas, were found improperly stored on surfaces like coffee tables and beds, rather than in clean storage bags as required by the facility's policy. These practices increased the risk of infectious disease transmission among residents.
Deficiency in Resident Rights Training for Agency Staff
Penalty
Summary
The facility failed to ensure that agency staff received the required resident rights training, which is essential for providing proper care and maintaining the quality of life for residents. The deficiency was identified during a review of training records for agency staff, including Certified Nurses Aids (CNAs) and Licensed Nurses (LNs). Specifically, the credentialing files for CNA O and LN I lacked documentation of completed resident rights training. Although LN I's file indicated she had received training on abuse, neglect, and exploitation, the absence of resident rights training was noted. Interviews with agency staff, such as CNA Q and LN H, revealed that while some in-services were completed through their staffing agencies, there was no consistent system in place at the facility to ensure all agency staff had completed the necessary training. Administrative Nurse D acknowledged the expectation that the staffing agency would ensure their staff completed the required in-services. However, she admitted there was no system in place at the facility to verify that agency staff had received the necessary training. The facility's education policy, dated August 2022, outlined the goal of ensuring all staff received appropriate training to guarantee resident safety and well-being, utilizing an electronic learning management system and other educational resources. Despite this policy, the lack of documented resident rights training for agency staff placed residents at risk for impaired care and decreased quality of life.
Failure to Ensure Infection Control Training for Agency Staff
Penalty
Summary
The facility failed to ensure that agency staff received the required infection control training, which placed residents at risk for impaired care and decreased quality of life. During a review of training records, it was found that the credentialing files for agency CNAs and a Licensed Nurse lacked documentation of completed infection control training. Although some agency staff reported completing in-services through their staffing agencies, there was no system in place at the facility to verify that these trainings were completed. Interviews with agency staff revealed that while some had attended in-services at the facility, there was an expectation from the Administrative Nurse that the staffing agency would ensure the completion of required in-services. The facility's education policy aimed to ensure all staff received appropriate training for resident safety and well-being, utilizing an electronic learning management system and other educational resources. However, the lack of documented infection control training for agency staff indicated a failure to meet this goal.
Failure to Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure the appropriate use of foot pedals during wheelchair transports for three residents, placing them at risk for preventable accidents and injuries. On multiple occasions, staff were observed transporting residents without foot pedals in place, causing the residents' feet to slide along the floor. Specifically, a resident with upper and lower extremity impairments was wheeled without foot pedals to the medication cart, and two other residents, one severely cognitively and physically impaired, were transported in similar conditions. Interviews with staff, including a Licensed Nurse and a Certified Nurse Aide, confirmed that the expectation was for foot pedals to be in place during transport. However, the facility did not provide a policy related to the accommodation of needs or assistive devices for wheelchairs, indicating a lack of procedural guidance. This oversight in ensuring the proper use of assistive devices during resident transport was identified as a deficiency by the surveyors.
Failure to Assist Resident with Grooming
Penalty
Summary
The facility failed to ensure staff assisted a resident, identified as R4, with grooming, which placed the resident at risk for impaired dignity and a further decline in activities of daily living (ADL). R4's medical history included severe cognitive impairment, heart disease, kidney disease, and Alzheimer's disease, among other conditions. The resident's care plan indicated a need for staff assistance with grooming and other ADLs, but observations revealed that R4's hair was matted and unkempt, indicating a lack of proper grooming assistance. Interviews with facility staff, including a licensed nurse and a certified nurse's aide, confirmed that it was the responsibility of the staff to ensure residents were clean and presentable before leaving their rooms. However, the facility did not provide a policy for ADLs, and R4's medical record documented consistent refusals for showering. Despite these refusals, staff were expected to assist R4 with grooming, but failed to do so, as evidenced by the resident's appearance during observations.
Failure to Set Low Air-Loss Mattress Correctly for Resident
Penalty
Summary
The facility failed to ensure that a resident's low air-loss mattress was set at the appropriate weight setting, which is crucial for preventing pressure ulcers. The resident, identified as R32, had a range of medical conditions including hemiplegia, muscle wasting, obesity, and Alzheimer's disease, and was at high risk for pressure ulcers as indicated by a Braden Scale score of 10. Despite having a care plan that specified the mattress should be set between 190-210 pounds, observations revealed that the mattress was set at 320 pounds, which was not in accordance with the resident's weight of 201.8 pounds. This discrepancy was not documented or monitored in the resident's electronic medical record (EMR), and there was no evidence of regular checks to ensure the mattress was set correctly. Interviews with facility staff revealed a lack of consistent monitoring and documentation practices regarding the low air-loss mattress settings. A licensed nurse acknowledged that the mattress should be set according to the resident's current weight but was unable to find any record of monitoring in the EMR. Additionally, a certified nursing aide stated that she would notify a charge nurse if the pump was beeping but did not adjust the settings herself. The administrative nurse claimed that nursing staff checked each mattress daily and signed off on the Treatment Administration Record (TAR) each shift, but this was not reflected in the documentation. The facility's Skin Integrity policy emphasized the importance of evaluating skin integrity and implementing preventative measures, yet the failure to set the mattress correctly placed the resident at increased risk for pressure ulcer development.
Failure to Assess Side Rail Safety with Low Air-Loss Mattress
Penalty
Summary
The facility failed to ensure that a resident, identified as R33, had a safety assessment for the use of side rails that acknowledged the risks when used with a low air-loss mattress. R33's medical history included Alzheimer's disease, a history of fractures related to falls, hearing loss, age-related physical debility, fatigue, urinary retention, and age-related macular degeneration. The resident was severely cognitively impaired, fully dependent on staff for transfers and activities of daily living, and had a history of falls. Despite these conditions, the facility did not conduct a comprehensive safety assessment that considered the interaction between the side rails and the low air-loss mattress, which is crucial to prevent entrapment and ensure safety. Observations and interviews revealed that the facility's staff did not assess the side rails in relation to the low air-loss mattress, as required by the facility's policy. The Assistive Device for Bed Screening form completed for R33 failed to acknowledge the use of the low air-loss mattress, and the facility's policy indicated that such mattresses should be included in the evaluation of potential risks. Interviews with staff confirmed that while they checked for gaps in the bed rails, they did not assess the specific risks associated with the combination of side rails and low air-loss mattresses. This oversight placed R33 at risk for uninformed decisions and impaired safety related to the use of side rails.
Failure to Document Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident, identified as R41, had a Centers for Medicare and Medicaid Services (CMS) approved indication or the required physician-documented rationale, including risk versus benefits and nonpharmacological attempts, prior to the use of the antipsychotic medication Zyprexa. R41's electronic medical record documented diagnoses of vascular dementia with irritation, depression, anxiety, and delirium. Despite these conditions, the facility did not complete a gradual dose reduction, and there was no physician documentation that a gradual dose reduction was contraindicated for R41. The resident was receiving hospice services and had a severely impaired cognition with a BIMS score of three. Observations and interviews revealed that R41 was at risk for unnecessary medication administration and possible adverse side effects due to the lack of documented rationale for the use of Zyprexa. The resident's care plan directed staff to monitor for side effects, but the EMR lacked documentation of nonpharmacological interventions attempted and failed. The facility's policy on psychoactive medications required that such medications not be used unless necessary to treat medical symptoms and that they be monitored by the interdisciplinary team. However, the facility did not ensure compliance with this policy, placing R41 at risk.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice providers for two residents, R43 and R38, who were receiving hospice services. For R43, the care plan lacked specific instructions on the services provided by hospice, including the frequency and type of support visits, supplies, medical equipment, medications covered by hospice, and hospice contact information. Despite being newly readmitted to hospice services, R43's care plan did not reflect the necessary coordination, leaving staff uncertain about the hospice services provided. Similarly, R38's care plan was deficient in detailing the services and medications provided by hospice. Although the care plan mentioned that hospice would provide durable medical equipment and that hospice staff would visit per the hospice plan of care, it did not specify the services hospice staff would provide or the medications covered. This lack of detailed information in the care plan led to confusion among staff about the hospice services available to R38. Interviews with facility staff, including a Licensed Nurse, a Certified Nursing Aide, and an Administrative Nurse, revealed a lack of clarity and communication regarding the hospice services provided to the residents. Staff members were unsure where to find information about hospice services if it was not included in the care plan, indicating a gap in the coordination of care. The facility's Care Management policy emphasized systematic and comprehensive management of resident care, yet the failure to coordinate care with hospice providers placed the residents at risk for inadequate end-of-life care.
Failure to Administer Pneumococcal Vaccine Timely
Penalty
Summary
The facility failed to ensure that a resident, identified as R51, received the pneumococcal vaccine after consenting to it. The resident had previously received pneumococcal vaccinations (PPSV23 in 2014 and PCV13 in 2016) but had not been offered or given the newer PCV20 or PCV21 vaccinations since his admission to the facility in 2023. Despite consenting to the PCV20 vaccination on August 28, 2024, the resident did not receive it until December 11, 2024. This delay in vaccination was confirmed through a review of the resident's electronic medical record (EMR) and interviews with the resident and facility staff. The deficiency was identified during a review of influenza and pneumococcal immunizations for a sample of residents, including R51. The facility's policy, revised in July 2024, required that all residents be screened for pneumococcal vaccinations, with assessments of each resident's history, health status, and preferences. However, the facility did not adhere to this policy, as evidenced by the lack of timely administration of the vaccine to R51. The administrative nurse was unable to provide an explanation for the delay in vaccination, which placed the resident at risk for complications from pneumococcal disease.
Failure to Ensure Safe Transfers Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as R1, remained free from avoidable accident hazards. The deficiency occurred when staff did not adhere to the resident's care plan, which required the use of a sit-to-stand lift with the assistance of two staff members for transfers. Instead, R1 was transferred using an unsafe arm-in-arm method without a gait belt, leading to fractures in both ankles and lower legs. R1's medical history included conditions such as malignant neoplasm of the lower right lung, COPD, osteoporosis, thrombocytopenia, long-term use of anticoagulants, and hypertension. R1 required substantial to maximal assistance for transfers and was assessed as having a moderate risk for falls. Despite these needs, the facility's staff did not follow the prescribed transfer procedures, resulting in significant injuries to R1. The facility's investigation into the incident was inadequate, as it failed to identify all staff involved in the transfer. The investigation relied solely on the account of one CNA, who reported that another unidentified CNA assisted in the transfer. However, other staff interviews contradicted this account, indicating that the transfer was conducted by only one CNA. The facility's policy on lifting and transferring residents was not followed, contributing to the accident and subsequent injuries sustained by R1.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 188 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Topeka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lexington Park Nursing & Post Acute Center | 0.9 mi | ★★★★★ | 10 | 0 |
| Brighton Place West | 1.4 mi | ★★★★★ | 1 | 1 |
| The Healthcare Resort Of Topeka | 1.5 mi | ★★★★★ | 8 | 0 |
| Plaza West Healthcare And Rehab | 1.7 mi | ★★★★★ | 0 | 0 |
| Excel Healthcare And Rehab Topeka | 2.8 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Topeka Presbyterian Manor.
100% money-back within 48 hours.
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.