Inspection Report Summary
The most recent inspection on July 14, 2025, found no deficiencies and confirmed that all previously cited issues had been corrected. Prior inspections showed multiple deficiencies related mainly to documentation accuracy, medication management, and timely response to resident needs, including incomplete service agreements and labeling errors. Earlier complaint investigations substantiated neglect involving delayed call light responses and inadequate supervision, which led to resident harm and hospitalization, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaints were substantiated, particularly those involving resident care and medication administration, while some issues involved food safety and infection control. The facility appears to have made improvements over time, as recent inspections show correction of prior deficiencies and compliance with regulations.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
80 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 14, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-06-23.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 2025-07-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 80
Deficiencies: 10
Date: Jun 23, 2025
Visit Reason
Re-Licensure survey with complaint investigations for an Assisted Living Facility conducted on 06/16/25, 06/17/25, 06/18/25, and 06/23/25.
Complaint Details
The survey included complaint investigations numbered 188631, 191173, 193433, and 193760.
Findings
The facility was found deficient in multiple areas including inaccurate functional capacity screenings, incomplete negotiated service agreements, failure to monitor outside service providers, delayed response to call lights, incomplete medication self-administration assessments, improper labeling of over-the-counter medications, incomplete documentation of incidents and symptoms, and non-compliance with tuberculosis screening guidelines for new employees.
Deficiencies (10)
Failure to accurately complete Functional Capacity Screens for residents R6 and R7.
Failure to complete Negotiated Service Agreements accurately for five residents (R3, R4, R5, R6, R7) including missing service descriptions and payment responsibilities.
Failure to review and revise Negotiated Service Agreements following significant changes in condition for residents R5 and R6.
Failure to monitor outside resource services and advocate for resident R6 to ensure professional standards of practice.
Failure to provide health care services in accordance with acceptable standards of practice, including delayed response to call lights.
Failure to complete licensed nurse assessment for self-administration of medication for resident R8.
Failure to include selected medications resident R8 chose to self-administer in the Negotiated Service Agreement.
Failure to label over-the-counter medications with resident's full name on both original packaging and medication containers.
Failure to document incidents, symptoms, actions taken, and results in medical records for residents R3, R4, R5, R6, and R7.
Failure to comply with tuberculosis screening guidelines for five newly hired employees; TB screening forms lacked required components.
Report Facts
Resident census: 80
Call light delays: 81
Call light delays: 280
Call light delays: 393
Call light delays: 126
Call light delays: 70
Call light delays: 57
Call light delays: 91
Falls documented: 52
Residents requiring physical assistance: 39
Residents requiring physical assistance: 21
Newly hired employees reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Provided multiple interviews confirming deficiencies and findings related to functional capacity screens, negotiated service agreements, monitoring of outside services, call light response, medication assessments, documentation, and TB screening compliance. |
| Certified Medication Aide E | Certified Medication Aide | Interviewed regarding residents' medication management and functional abilities. |
| Certified Medication Aide C | Certified Medication Aide | Observed unlocking medication cart and noted labeling deficiencies. |
| Certified Medication Aide D | Certified Medication Aide | Observed unlocking medication carts and noted labeling deficiencies. |
| Certified Nurse Aide J | Certified Nurse Aide | Interviewed about staffing shortages and night shift issues. |
| Certified Nurse Aide K | Certified Nurse Aide | Interviewed about staffing and float staff. |
| Certified Medication Aide L | Certified Medication Aide | Interviewed about staffing and night shift conditions. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 16, 2025
Visit Reason
The document is a Plan of Correction addressing findings from a Re-Licensure survey with complaint investigations conducted on 06/16/25, 06/17/25, 06/18/25, and 06/23/25 at the Assisted Living Facility.
Complaint Details
The visit included complaint investigations with case numbers 188631, 191173, 193433, and 193760.
Findings
The Plan of Correction responds to citations identified during the Re-Licensure survey and complaint investigations at the facility over multiple days in June 2025.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: May 7, 2024
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies at Cedarhurst of Topeka have been corrected.
Findings
The report confirms that the deficiencies previously cited under regulation numbers 26-41-101 (f)(1) and 26-41-205 (d)(1-2) have been corrected as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 26-41-101 (f)(1)
Deficiency related to regulation 26-41-205 (d)(1-2)
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
The document is a Plan of Correction addressing findings from an Abbreviated Licensure Survey with complaint investigations conducted on 04/18/24 and 04/22/24 at an assisted living facility.
Complaint Details
The visit included complaint investigations numbered 186280, 186967, 185062, and 185088.
Findings
The Plan of Correction references findings from an abbreviated licensure survey combined with complaint investigations identified by numbers 186280, 186967, 185062, and 185088 for the assisted living facility.
Report Facts
Complaint investigations: 4
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 2
Date: Apr 18, 2024
Visit Reason
The inspection was an Abbreviated Licensure Survey with complaint investigations for the assisted living facility conducted on 04/18/24 and 04/22/24.
Complaint Details
The visit included complaint investigations numbered 186280, 186967, 185062, and 185088. The allegation of staff neglect related to delayed response to resident needs was substantiated, including failure to respond promptly to call lights and inadequate supervision leading to elopement.
Findings
The survey found neglect related to elopement risk and inadequate staff response to resident needs, resulting in immediate jeopardy for one resident who eloped and was unaccounted for 30 minutes. Another resident experienced neglect due to delayed response to call lights causing pain. Additionally, medication administration failures led to excessive bleeding and hospitalization of a resident on anticoagulant therapy.
Deficiencies (2)
Failure to ensure residents were not subjected to neglect, including inadequate supervision and response to elopement risk and call light response delays.
Failure to administer medications according to physician orders resulting in excessive bleeding and hospitalization.
Report Facts
Census: 69
Residents at risk for elopement: 13
Call light responses: 228
Call light delayed responses: 114
Call light delayed responses > 15 minutes: 68
Call light delayed responses > 20 minutes: 22
Call light delayed responses > 30 minutes: 11
Call light delayed responses > 45 minutes: 4
Longest call light response time: 1.91
Warfarin administration: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA H | Certified Medication Aide | Named in finding for failing to respond timely to resident R3's needs, resulting in neglect substantiation and termination. |
| Administrative Staff A | Provided information on elopement plan, call light response goals, and medication administration investigation. | |
| CMA C | Certified Medication Aide | Reported failure to respond properly to door alarms related to resident R5's elopement. |
| Certified Medication Aide F | Reported on care provided to resident R3. | |
| Certified Nurse Aide G | Reported on care provided to resident R3. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 16, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-12-26.
Findings
All deficiencies have been corrected as of the compliance date of 2024-01-15, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 11
Date: Dec 26, 2023
Visit Reason
The inspection was conducted as an initial survey with complaints #184407 and #184702 at an assisted living facility.
Complaint Details
The inspection was triggered by complaints #184407 and #184702.
Findings
The inspection identified multiple deficiencies including failure to post required notices, incomplete negotiated service agreements for residents, improper medication labeling and storage, inadequate disaster preparedness reviews, unsafe food storage practices, and lapses in infection control procedures.
Deficiencies (11)
Failure to post a notice of availability of policies and procedures related to resident services in a place readily accessible to residents.
Failure to post ombudsman contact information in a common area accessible to residents and the public.
Negotiated Service Agreements (NSA) were not fully developed to include all triggered items from the Functional Capacity Screen for residents R102 and R103.
NSA for residents R102 and R103 were not signed by all individuals involved in their development.
NSA did not identify the licensed nurse responsible for implementation and supervision of the health care services plan for residents R102, R103, and R104.
Over-the-counter medications were not labeled with the full name of the resident on the original package for four residents.
Prescription medication containers stored in original packaging were not labeled with the resident's full name.
Resident medications were not stored in accordance with each manufacturer's recommendations; an opened vial of Tuberculin solution was not dated.
Failure to perform quarterly review of the facility's emergency management plan with employees and residents as required.
Food items in the dietary kitchen were not stored under safe and sanitary conditions; several items were uncovered or not dated/labeled.
Failure to ensure sanitary conditions for food service by not documenting hot water temperatures and chemical sanitizer strengths daily.
Report Facts
Census: 54
Deficiencies with severity F: 6
Deficiencies with severity E: 5
Dates missing documentation: 17
Number of residents in NSA sample: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Provided statements regarding deficiencies in Negotiated Service Agreements and medication storage. |
| Dietary Staff C | Dietary Staff | Reported missing November 2023 Temperature/Sanitizer Log. |
| Administrative Staff A | Administrative Staff | Provided documentation of emergency management plan reviews. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
The document is a plan of correction addressing findings from an initial survey with complaints #184407 and #184702 conducted on 12/20/23, 12/21/23, and 12/26/23 at an assisted living facility.
Complaint Details
The visit was complaint-related involving complaints #184407 and #184702.
Findings
The plan of correction corresponds to deficiencies identified during the initial survey and complaint investigations conducted on the specified dates.
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