Plaza West Healthcare and Rehab: Care Failures - KS
Federal inspectors who visited the facility on March 19, 2025 documented the lapses in a report that cited five residents across four separate failures, all falling under a single federal standard governing basic nursing care. The violations ranged from missing paperwork before emergencies to a resident left without an intervention to prevent a skin tear.
The two residents sent to the hospital without completed nursing assessments were identified in the report as Resident 35 and Resident 142. What those assessments would have captured, and whether either resident's condition worsened in transit or at the hospital, the report does not say. What the report does say is that the assessments were not done.
A nursing assessment before a hospital transfer is the moment staff document what they know about a resident's condition, what changed, what was communicated, and what the receiving facility needs to understand. Without it, a record gap opens at exactly the moment a resident is most vulnerable.
Resident 128 arrived at the facility and did not receive a nursing assessment after admission. That assessment, completed after a new resident comes through the door, is how staff learn what they are dealing with, what risks exist, and what care the person needs from the start. Resident 128's went undone.
Two other residents were left without interventions that staff had apparently identified as necessary. Resident 117 sustained a skin tear, and no intervention to prevent it had been put in place. Skin tears are painful, slow to heal in elderly residents, and can become infected. They are also largely preventable when staff act on what they know about a resident's fragile skin.
Resident 13 needed a back brace. The inspection report states that an intervention related to that back brace was not implemented. The report does not describe what the intervention was, how long it went unimplemented, or what the resident experienced in the meantime.
Five residents. Four failures. One inspection.
Plaza West Healthcare and Rehab is a skilled nursing facility in Topeka. The violations cited in this inspection fall under F677, a federal tag covering activities of daily living and the basic nursing care residents require to maintain their health and prevent deterioration. The citation does not indicate whether any of the five residents suffered lasting harm, and the report reviewed for this article does not include the full investigative findings that would typically accompany a formal citation.
What the report does make clear is a pattern. These are not isolated incidents involving a single resident or a single lapse. Inspectors found the same category of failure repeated across multiple residents in multiple forms: assessments skipped before discharge, an assessment skipped after admission, interventions not carried out for a skin injury, interventions not carried out for a back brace. The through line is the same in each case. Someone identified what needed to happen. It did not happen.
Nursing assessments are not paperwork for their own sake. They are the mechanism by which a facility tracks what it knows about a person, communicates that knowledge when the person moves to a different care setting, and creates accountability for what was done and when. When they are skipped before a hospital transfer, the hospital receives a resident without a documented clinical picture from the people who knew that resident best. When they are skipped after admission, a new resident enters a facility and nobody has formally recorded what that person needs.
Resident 117's skin tear and Resident 13's back brace represent a different kind of failure, one step further down the chain. In those cases, the problem had been identified. An intervention had been deemed necessary. The intervention still did not happen.
The inspection report does not name the staff involved, does not describe what explanations were offered, and does not indicate whether any of the five residents or their families were notified of the lapses. Resident 13 needed a back brace. Whether they got one, and when, is not recorded in what inspectors released.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
PLAZA WEST HEALTHCARE AND REHAB in TOPEKA, KS was cited for violations during a health inspection on March 19, 2025.
The violations ranged from missing paperwork before emergencies to a resident left without an intervention to prevent a skin tear.
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.