TOPEKA, KS - Federal inspectors documented multiple assessment and care failures at Plaza West Healthcare and Rehab during a March 2025 complaint investigation.
Missing Critical Assessments
The facility failed to complete mandatory nursing assessments for three residents during crucial care transitions. Two residents were discharged to hospitals without proper pre-transfer evaluations, while another resident did not receive the required assessment following admission to the facility.
These assessment lapses represent serious breaks in the continuity of care chain. Pre-discharge assessments are essential for ensuring hospitals receive complete medical information about a resident's condition, current treatments, and care needs. Similarly, admission assessments establish baseline health status and identify immediate care requirements.
Care Implementation Failures
Beyond assessment problems, inspectors found the facility failed to implement necessary interventions for two additional residents. One resident did not receive proper prevention measures for skin tears, while another resident's back brace intervention was not properly implemented.
Skin tear prevention is particularly critical for elderly residents, whose fragile skin requires specific protective measures including proper positioning, gentle handling techniques, and environmental modifications to prevent injury during routine care activities.
Medical Significance of Assessment Gaps
Nursing assessments serve as the foundation for all resident care planning. These evaluations document vital signs, mental status, pain levels, medication effects, and changes in condition that directly impact treatment decisions.
When facilities skip these assessments, healthcare providers lose essential information needed to make informed decisions about medications, treatments, and care interventions. This creates dangerous information gaps that can lead to inappropriate treatments or missed medical changes.
Regulatory Standards
Federal regulations require nursing facilities to conduct comprehensive assessments at specific intervals and following significant changes in resident condition. These assessments must be completed by qualified nursing staff and documented according to established protocols.
The assessment requirements exist because elderly nursing home residents often experience rapid health changes that require immediate attention. Regular evaluations help identify problems before they become serious complications requiring emergency intervention.
Facility Response and Oversight
Plaza West Healthcare and Rehab must develop corrective action plans addressing each identified deficiency. The facility's compliance with these requirements will be monitored through follow-up inspections and ongoing regulatory oversight.
The inspection findings highlight the importance of systematic assessment protocols that ensure no resident falls through gaps in the care process, particularly during vulnerable periods like admissions and pre-discharge preparations.
These violations underscore the critical role that proper documentation and care implementation play in maintaining resident safety and ensuring appropriate medical decision-making throughout the healthcare system.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Plaza West Healthcare and Rehab from 2025-03-19 including all violations, facility responses, and corrective action plans.
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