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
Occupancy
Latest occupancy rate
72% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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 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.
Inspection Report
Re-Inspection
Census: 80
Deficiencies: 10
Date: Jun 23, 2025
Visit Reason
Re-Licensure survey with complaint investigations conducted on 06/16/25, 06/17/25, 06/18/25, and 06/23/25 at Cedarhurst of Topeka Assisted Living Facility.
Complaint Details
The visit was a re-licensure survey combined with complaint investigations numbered 188631, 191173, 193433, and 193760.
Findings
The facility had multiple deficiencies including inaccurate functional capacity screenings, incomplete negotiated service agreements, failure to review and revise service agreements after significant changes, inadequate monitoring of outside service providers, delayed response to call lights, incomplete medication self-administration assessments, missing documentation of medication administration responsibilities, lack of resident incident documentation, and non-compliance with tuberculosis screening guidelines for new employees.
Deficiencies (10)
26-41-201 (d) Functional Capacity Screen Accurate: Facility staff failed to accurately complete functional capacity screens for residents R6 and R7 reflecting their true functional abilities and risks.
26-41-202 (a) Negotiated Service Agreement: Facility failed to develop complete negotiated service agreements for five sampled residents that included all required service descriptions, providers, and payment sources.
26-41-202 (d) Negotiated Service Agreement Revisions: Facility failed to review and revise negotiated service agreements for residents R5 and R6 following significant changes in condition or service needs.
26-41-202 (j) Negotiated Service Agreement Outside Resource: Facility failed to monitor and advocate for resident R6 receiving outside therapy services due to lack of communication and documentation.
26-41-204 (i) Health Care Services Standards of Practice: Facility staff failed to respond timely to call lights, placing residents at risk for delayed assistance and increased risk of incontinence and falls.
26-41-205 (a)(1) Self Administration of Medication: Licensed nurse failed to complete assessment for resident R8 prior to self-injection of insulin.
26-41-205 (b) Administration of Selected Medications: Resident R8's negotiated service agreement did not identify selected medications she self-administers, including insulin.
26-41-205 (g)(3) Over The Counter Drugs: Facility failed to label all over-the-counter medications with resident's full name on both original packaging and medication containers.
26-41-105 (f)(11) Resident Record Documentation of Incidents: Facility failed to document incidents, symptoms, actions taken, and results for residents R3, R4, R5, R6, and R7.
26-41-207 (b)(5-6)(c) Infection Control Policies: Facility failed to comply with tuberculosis screening guidelines for five newly hired employees, missing key screening questions.
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
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 16, 2025
Visit Reason
The document is a Plan of Correction related to a Re-Licensure survey with complaint investigations conducted at an Assisted Living Facility on 06/16/25, 06/17/25, 06/18/25, and 06/23/25.
Findings
The Plan of Correction addresses findings from the Re-Licensure survey and complaint investigations conducted over multiple days in June 2025 at the facility.
Inspection Report
Follow-Up
Deficiencies: 2
Date: May 7, 2024
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiencies identified in the prior survey have been corrected as of the revisit date. Specific regulations cited include 26-41-101 (f)(1) and 26-41-205 (d)(1-2), with corrections completed on 05/07/2024.
Deficiencies (2)
Regulation 26-41-101 (f)(1) deficiency was corrected as of 05/07/2024.
Regulation 26-41-205 (d)(1-2) deficiency was corrected as of 05/07/2024.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 18, 2024
Visit Reason
The document is a Plan of Correction responding to findings from an Abbreviated Licensure Survey with complaint investigations conducted on 04/18/24 and 04/22/24 at an assisted living facility.
Findings
The Plan of Correction addresses citations resulting from the abbreviated licensure survey and complaint investigations identified by event IDs 186280, 186967, 185062, and 185088.
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 2
Date: Apr 18, 2024
Visit Reason
The inspection was an Abbreviated Licensure Survey combined with complaint investigations for an assisted living facility conducted on 04/18/2024 and 04/22/2024.
Complaint Details
The visit included complaint investigations numbered 186280, 186967, 185062, and 185088. The allegation of neglect related to delayed response to call lights was substantiated, and failure to supervise a resident at risk for elopement was confirmed.
Findings
The survey found neglect related to inadequate supervision and response to resident needs, including an elopement incident and delayed call light responses. Additionally, medication administration errors resulted in a resident receiving anticoagulant therapy improperly, causing excessive bleeding and hospitalization.
Deficiencies (2)
KAR 26-41-101(f)(1)(B) Staff Treatment of Residents: The executive director failed to prevent neglect when a resident eloped and was unaccounted for 30 minutes, and when staff failed to respond promptly to another resident's call light causing discomfort.
KAR 26-41-205(d)(1-2) Facility Administration of Medications: The executive director failed to ensure medications were administered according to physician orders, resulting in a resident receiving warfarin despite contraindications, causing excessive bleeding and hospitalization.
Report Facts
Resident census: 69
Call light responses: 228
Call light delayed responses: 114
Call light delayed responses > 30 minutes: 11
Warfarin doses administered: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA H | Certified Medication Aide | Named in finding for failing to respond timely to resident R3's call light, resulting in termination |
| Administrative Staff A | Provided information on elopement plan and medication administration errors | |
| CMA C | Certified Medication Aide | Reported on failure to respond to door alarm during resident R5's elopement |
| CMA D | Certified Medication Aide | Reported resident R5 wandering behavior |
| Certified Medication Aide F | Reported on care provided to resident R3 | |
| Certified Nurse Aide G | Reported on care provided to resident R3 | |
| Maintenance Staff E | Reported on door alarm functionality |
Inspection Report
Re-Inspection
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
Initial survey with complaint #184407 and #184702 conducted on 12/20/23, 12/21/23, and 12/26/23 at Cedarhurst of Topeka Assisted Living facility.
Complaint Details
The inspection was conducted as an initial survey with complaints #184407 and #184702.
Findings
The facility was found deficient in multiple areas including failure to post required notices, incomplete negotiated service agreements for residents, improper medication labeling and storage, inadequate disaster preparedness, unsafe food storage practices, and failure to maintain sanitary conditions in food service.
Deficiencies (11)
KAR 26-41-101(g): The operator failed to post a notice of availability of policies and procedures related to resident services in a place readily accessible to residents.
KAR 26-41-101(k): The facility failed to post ombudsman contact information in a common area accessible to residents and the public.
KAR 26-41-202(a)(1): The facility failed to fully develop negotiated service agreements for residents R102 and R103 based on their functional capacity screening triggers.
KAR 26-41-202(h): The negotiated service agreements for residents R102 and R103 were not signed by all individuals involved in their development.
KAR 26-41-204(d): The negotiated service agreements for residents R102, R103, and R104 did not identify the licensed nurse responsible for implementation and supervision of the health care services plan.
KAR 26-41-205(g)(3): The facility failed to ensure licensed pharmacist or nurse placed the full name of the resident on original packages of over-the-counter medications for four residents.
KAR 26-41-205(g)(2): Prescription medication containers were not labeled with a dispensing pharmacist's label as required.
KAR 26-41-205(h): Resident medications were not stored according to manufacturer recommendations; an opened vial of Tuberculin solution was not dated.
KAR 26-41-104(d): The facility failed to perform quarterly reviews of the emergency management plan with employees and residents as required.
KAR 26-41-206(e): Food items in the dietary kitchen were not stored under safe and sanitary conditions; multiple items were uncovered or undated.
KAR 26-41-207(b)(4): The facility failed to ensure sanitary conditions for food service by not documenting hot water temperatures and chemical sanitizer strengths daily.
Report Facts
Resident census: 54
Undated food items: 14
Dates missing hot water and sanitizer documentation: 18
Residents with medication labeling issues: 4
Residents sampled for NSA review: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Provided statements regarding deficiencies in negotiated service agreements and medication storage. | |
| Dietary Staff C | Reported missing November 2023 Temperature/Sanitizer Log. | |
| Administrative Staff A | 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 responding to findings from an initial survey with complaints #184407 and #184702 conducted on December 20, 21, and 26, 2023, at an assisted living facility.
Complaint Details
The inspection was triggered by complaints #184407 and #184702.
Findings
The plan of correction addresses citations resulting from the initial survey and complaint investigations conducted on the specified dates.
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