Inspection Reports for
Topeka Presbyterian Manor

The complaint investigation found that Resident 1 eloped on 06/01/25 by following a visitor out the door before the lock engaged. The Wanderguard alarm alerted staff who found the resident outside with no injuries. The facility was found deficient in supervision practices related to wandering and elopement risks.

The facility failed to provide adequate supervision for Resident 1, who eloped from the facility by following a visitor out before the door locked. The resident was found outside with no injuries and was redirected back inside. The facility implemented corrective actions including staff education, signage, audits, and communication with designated power of attorneys prior to the inspection.

The facility had multiple deficiencies including failure to ensure proper wheelchair foot pedal use, inadequate assistance with resident grooming, inconsistent weekend activities, improper pressure ulcer prevention, unsecured hazardous areas, inadequate supervision and fall prevention, incomplete safety assessments for bed rails, incomplete staff performance evaluations, improper use of psychotropic medications, unsanitary food service practices, lack of coordinated hospice care, failure to implement infection control precautions, incomplete immunization administration, and insufficient training for agency staff.

The facility failed to ensure Resident 1 remained free from avoidable accident hazards during transfers, resulting in bilateral ankle fractures. The investigation revealed staff did not use the required number of personnel or proper equipment for safe transfers, placing the resident at risk for increased pain and impaired well-being.

The investigation was triggered by a complaint regarding Resident 1's fall on 01/10/24. The fall was unwitnessed but documented by staff and resulted in actual harm. The complaint was substantiated based on findings of inadequate supervision and failure to assess the resident's ability to safely use the recliner footrest.

The facility failed to provide a safe environment and adequate supervision for Resident 1, who fell from a manual recliner with the footrest raised, resulting in a fractured sternum and left fourth rib. The investigation revealed lack of assessment of the resident's ability to lower the footrest and insufficient monitoring prior to the fall.

The complaint investigation substantiated that CNA M physically abused Resident 1 by slapping her arms twice during care on 11/08/23. The facility substantiated the abuse and took disciplinary action by suspending CNA M. Education on abuse, neglect, and exploitation was conducted but not on behavior management.

The facility failed to protect Resident 1 from physical abuse when CNA M slapped the resident on her arms after Resident 1 exhibited physical behaviors. The facility also failed to provide appropriate dementia care by not ensuring CNA M followed care-planned interventions, placing the resident at risk for ongoing abuse.

The facility failed to update care plans for residents leading to risks of falls and injuries, failed to provide appropriate post-fall assessments and treatments, failed to ensure appropriate use and documentation of psychotropic medications, had medication administration errors, failed to maintain sanitary dietary standards, and failed to follow proper infection control practices.

The investigation was complaint-driven, focusing on Resident 14's bathing assistance and medication management, expired medications in storage, and food sanitation practices. The complaints were substantiated with findings of minimal harm and risk to residents.

The facility failed to provide Resident 14 with preferred bathing frequency, failed to discontinue unnecessary PRN psychotropic medication without a stop date, failed to remove expired medications from use, and failed to maintain sanitary food storage, preparation, and serving conditions, placing residents at risk for poor hygiene, medication side effects, ineffective medication, and foodborne illness.