Topeka Presbyterian Manor

In the surveyor’s words

From the most serious findings on record at Topeka Presbyterian Manor, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 1, 2026

  Based on observation, interview, and record review, the facility failed to provide follow-up care and services for Resident (R) 1's fractured wrist when staff failed to make an appointment and take her to a surgeon as ordered by the physician. This resulted in a non-removable device existing for longer than intended without physician oversight, which caused a Stage 3(full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer on R1's thumb. Findings Included:- R1's Electronic Medical Record (EMR) revealed the following diagnoses: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), chronic kidney disease, and a… […]

• Actual harm, isolatedF689Sep 12, 2024

  The facility identified a census of 60 residents. The sample included three residents reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure Resident (R)1 remained free from avoidable accident hazards when staff failed to provide safe transfers using the required number of staff and the required equipment per the resident's plan of care. Subsequently, R1 sustained fractures to both her ankles/lower legs. This deficient practice also placed R1 at risk for increased pain and impaired well-being. […]

• Actual harm, isolatedF689Feb 1, 2024

  The facility identified a census of 62 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observation, the facility failed to provide an environment free from safety hazards when staff left Resident (R) 1 in a mechanical recliner, with the footrest raised, without assessing R1's ability to lower the footrest. On 01/10/24 R1 attempted to get out of the recliner by climbing over the footrest and fell . As a result, R1 sustained a fractured sternum (breastbone) and left fourth rib. […]

• Actual harm, isolatedF600Nov 27, 2023

  The facility identified a census of 62 residents. The sample included three residents. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from abuse when Certified Nurse Aide (CNA) M struck R1 on her arm after R1 had physical behaviors towards her. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for continued abuse. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and encounter for palliative care (treatment designed to relieve or reduce intensity of uncomfortable symptoms). […]

• Actual harm, isolatedF684Jul 26, 2023

  The facility identified a census of 63 residents. The sample included 16 residents with five residents reviewed for falls. Based on observation, interview, and record review the facility failed to respond to falls, assess, and identify injury, and apply standards of care for fall follow up for Resident (R)28. On 07/02/23 at 01:30 AM R28, who had severe cognitive impairment, had an unwitnessed fall in her room. Licensed Nurse (LN) K found R28 on the floor at which time R28 stated she was trying to get to her recliner. LN K assessed the resident and noted an abrasion to the left shoulder. R28 complained of left hip pain at that time. LN K assisted R28 to the recliner but failed to notify R28's physician and representative of the incident. […]