TOPEKA, KS - Federal inspectors cited Plaza West Healthcare and Rehab for failing to implement proper preventative interventions for a resident with pressure ulcers during a March 2025 complaint investigation.
Critical Wound Care Violations
The facility received a citation under F684, which addresses the federal requirement for nursing homes to provide proper treatment and services to prevent new pressure ulcers and promote healing of existing ones. The inspection revealed that staff failed to establish adequate preventative measures for a resident identified as R78 who had developed a pressure ulcer.
Pressure ulcers, also known as bedsores, are preventable injuries that occur when prolonged pressure reduces blood flow to the skin and underlying tissues. These wounds can develop within hours in vulnerable residents and, if left untreated, can progress to life-threatening infections affecting bone and surrounding tissues.
Standard Prevention Protocols
Federal regulations require nursing facilities to assess each resident's risk factors for pressure ulcers and implement individualized prevention plans. These typically include regular position changes every two hours, specialized support surfaces like pressure-relieving mattresses, proper nutrition and hydration, and daily skin inspections.
Effective prevention protocols should include: - Systematic risk assessments using validated tools - Individualized turning and repositioning schedules - Appropriate support surfaces and cushioning - Nutritional interventions to support skin integrity - Staff education on proper positioning techniques
Medical Consequences of Prevention Failures
When facilities fail to implement proper preventative care, residents face serious health risks. Pressure ulcers can progress through four stages, with advanced wounds potentially exposing bone and creating pathways for dangerous infections. Stage 3 and 4 pressure ulcers often require surgical intervention and can lead to sepsis, a potentially fatal bloodstream infection.
The failure to prevent these wounds particularly impacts residents with limited mobility, diabetes, poor circulation, or compromised immune systems. These populations depend entirely on nursing staff to maintain their skin integrity through consistent, evidence-based care protocols.
Regulatory Requirements
The Centers for Medicare & Medicaid Services established these pressure ulcer prevention standards to ensure residents receive appropriate care. Facilities must demonstrate that they have assessed risk factors, implemented prevention strategies, and monitored outcomes for all residents susceptible to skin breakdown.
The citation indicates Plaza West Healthcare did not meet these basic care standards for at least one resident, suggesting potential gaps in staff training, care planning, or implementation of prevention protocols.
This violation reflects broader concerns about fundamental nursing care practices and the facility's commitment to preventing avoidable complications that can significantly impact resident quality of life and health outcomes.
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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