Plaza West Healthcare: Infection Control Failures - KS
She said so herself, minutes after it happened.
On the morning of March 18, inspectors watched CNA Q enter the room of a resident identified in the report as Resident 8, a woman with moderate cognitive impairment and a feeding tube. CNA Q put on gloves. She did not put on a gown. She helped the woman stand using a gait belt, pivoted her into a wheelchair, transferred her to the toilet, removed her pajama top, and dressed her in a new blouse, her own clothing pressing against the resident's throughout.
When asked, at 9:00 a.m., whether the resident was on enhanced barrier precautions, CNA Q said she did not know. She had not been trained about them.
Enhanced barrier precautions, known in infection control as EBP, require staff to wear both gloves and a gown during any high-contact care for residents who have wounds, feeding tubes, catheters, or other indwelling medical devices, and for residents known to carry drug-resistant bacteria. The point is to keep resistant organisms from moving between a staff member's clothing and a resident's body, or from one room to the next. Resident 8's care plan, revised just two weeks earlier on March 3, specifically required EBP. The facility's own policy, in place since June 2023, listed transferring, dressing, and hygiene as exactly the kinds of care that required a gown.
Administrative Nurse D, interviewed at 11:19 a.m. that same day, said he expected staff to follow EBP for Resident 8. He noted the sign on the door and the supplies behind it.
Neither of those things had reached CNA Q.
Less than three hours later, inspectors watched a licensed nurse make the same mistake with a different resident.
At 11:50 a.m., Licensed Nurse Q entered the room of Resident 88, a woman with intact cognition and a urinary catheter placed because she could not empty her bladder on her own. LN Q put on gloves, asked the resident's permission to empty the catheter bag, and then did not put on a gown.
What followed was, by the inspection report's account, a cascade of errors. LN Q retrieved a graduated cylinder from the bathroom and placed it on the floor. She drained both ports of the catheter bag into it without disinfecting either port before or after. She placed the catheter bag, uncovered, back on the bed, near the head, where it then touched the floor. When inspectors asked whether she would normally wipe the drainage ports with a disinfectant wipe or alcohol pad, LN Q said she had not been trained to do that.
At 1:15 p.m., when asked whether anyone in the 600 hall was on enhanced barrier precautions, LN Q said she was unaware of anyone being on EBP. She confirmed she had not worn a gown during Resident 88's catheter care.
Resident 88's care plan, revised February 24, required EBP because of her indwelling medical device. The requirement was documented. The gowns were available. The nurse providing direct catheter care did not know the protocol existed.
Catheter-associated urinary tract infections are among the most common infections acquired in healthcare settings, and they are a particular concern for residents with drug-resistant organisms. The facility's EBP policy was designed specifically to interrupt that transmission, targeting residents whose medical devices create a direct pathway for bacteria.
The broader inspection found that Plaza West's Quality Assurance program failed to identify multiple ongoing care concerns across its 130 residents, placing all of them at risk for undetected problems. Administrative Staff A, interviewed on the afternoon of March 19, said the team meets monthly and had been making changes for the good of residents.
What the inspection documented was two staff members, working the same hall on the same day, providing hands-on care to residents with documented infection risks, neither one knowing that a gown was required. The sign was on the door. The training was not in the building.
Resident 88, mentally sharp and largely independent, could tell the nurse had come to help her. She gave her permission. She did not know the bag would end up touching the floor.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
PLAZA WEST HEALTHCARE AND REHAB in TOPEKA, KS was cited for violations during a health inspection on March 19, 2025.
She said so herself, minutes after it happened.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.