TOPEKA, KS - Federal inspectors documented multiple infection control violations at Plaza West Healthcare and Rehab where staff repeatedly failed to follow enhanced barrier precautions for residents with medical devices.
Staff Ignore Required Safety Protocols
During a March 19, 2025 inspection, federal surveyors observed nursing staff caring for residents with feeding tubes and urinary catheters without wearing required protective equipment. The violations occurred despite facility policies requiring enhanced barrier precautions for residents with indwelling medical devices.
The inspection revealed that staff members lacked proper training on enhanced barrier precautions (EBP), which are infection control interventions designed to reduce transmission of resistant organisms through targeted gown and glove use during high-contact care.
Feeding Tube Care Violations
Inspectors observed a certified nurse aide providing care to a resident with a feeding tube without wearing a gown, despite facility policies requiring full protective equipment. The aide assisted the resident with transfers and dressing while having direct contact with the resident's clothing.
When questioned about enhanced barrier precautions, the aide stated she "did not know" about the requirements and "had not been trained about EBP." This occurred despite the resident's care plan specifically documenting the need for enhanced precautions due to the feeding tube.
The facility's policy clearly states that residents with feeding tubes require enhanced barrier precautions during high-contact activities including dressing, bathing, transferring, and device care.
Catheter Care Safety Failures
In a separate incident, inspectors observed a licensed nurse emptying a urinary catheter bag without wearing a gown and without properly disinfecting the drainage ports. The nurse placed the catheter bag on the floor and allowed it to touch the ground before placing it back on the resident's bed.
When asked about disinfecting the drainage ports, the nurse stated she "had not been trained to do that." The nurse also confirmed she was unaware of any residents requiring enhanced barrier precautions on her assigned unit.
Medical Device Infection Risks
Residents with indwelling medical devices face significantly higher risks for healthcare-associated infections. Feeding tubes and urinary catheters create direct pathways for bacteria to enter the body, making proper infection prevention protocols essential.
Multi-drug resistant organisms (MDROs) pose particular dangers to nursing home residents, who often have compromised immune systems and underlying health conditions. These bacteria resist treatment with multiple antibiotics, making infections more difficult to treat and potentially life-threatening.
Required Safety Standards
Enhanced barrier precautions represent standard practice in healthcare facilities for residents with medical devices. The protocols require staff to wear gloves and gowns during all high-contact care activities, including:
- Dressing and bathing - Transferring residents - Providing hygiene care - Changing linens and briefs - Device care for catheters and feeding tubes - Wound care and dressing changes
Proper technique also requires disinfection of catheter ports before and after use to prevent bacterial contamination. Allowing catheter bags to contact floors creates additional infection risks by introducing environmental pathogens.
Training and Oversight Gaps
The violations revealed systemic training failures at Plaza West Healthcare. Multiple staff members demonstrated lack of knowledge about facility infection control policies and proper protective equipment use.
An administrative nurse confirmed expectations for enhanced barrier precautions and noted that required supplies were available. However, the gap between policy and practice indicated insufficient staff education and supervision.
Quality Assurance Concerns
The inspection also identified broader quality assurance failures. Surveyors noted that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to identify multiple care issues affecting all 130 residents.
QAPI programs are required to maintain comprehensive, data-driven oversight of care quality and resident outcomes. The program's failure to detect infection control violations suggests inadequate monitoring systems.
Regulatory Response
The Centers for Medicare & Medicaid Services classified the infection control violations as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the violations placed residents at unnecessary risk for serious infections.
Federal regulations require nursing homes to maintain effective infection prevention and control programs to protect resident health and safety. Facilities must ensure all staff receive proper training on infection control procedures and follow established protocols consistently.
The facility must submit a plan of correction addressing the training deficiencies and implement measures to ensure compliance with enhanced barrier precaution requirements. Continued violations could result in additional enforcement actions including financial penalties or termination from Medicare and Medicaid programs.
Plaza West Healthcare and Rehab serves 130 residents in Topeka and must demonstrate sustained compliance with federal infection control standards to maintain its certification for government-funded healthcare programs.
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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