Plaza West Healthcare And Rehab
PLAZA WEST HEALTHCARE AND REHAB in TOPEKA, KS — inspection on March 19, 2025.
Found 22 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The facility failed to provide a safe, comfortable environment.
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The facility failed to address the resident's history of sexually aggressive behavior.
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The facility failed to complete comprehensive assessments in a timely manner for R13, R98, and R112.
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The facility failed to complete baseline care plans for R13, R78, R98, and R295.
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The facility failed to revise care plans for R78 and R117.
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The facility failed to provide consistent bathing for R48, R71, R92, R99, R117, R121, and R125.
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The facility failed to complete nursing assessments prior to a discharge to the hospital for R35 and R142.
The facility failed to complete a nursing assessment following admission for R128.
The facility failed to implement intervention to prevent a skin tear for R117, and implement intervention related to R13s back brace.
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The facility failed to implement preventative interventions for R78, who had a pressure ulcer.
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The facility failed to obtain an order for oxygen therapy and failed to store oxygen tubing in a bag for R346.
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The facility failed to obtain orders for R295, who received Dialysis Services.
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The facility failed to ensure adequate daily nursing staff were always available to meet the needs of the residents who resided in the facility.
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The facility failed to ensure staff possessed the competencies and skill sets necessary to provide nursing and related services for R128 and R142.
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F-F726.
175255
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 175255 B.
Wing 03/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Plaza West Healthcare and Rehab 1570 SW Westport Drive Topeka, KS 66604
F-F742.
F-F755. potential for actual harm
The facility failed to ensure the Consultant Pharmacist identified and reported to the facility R29's
The facility failed to notify the physician for Accu-check outside of physician-ordered parameters for R29.
The facility failed to document in the Medication Administration Record after administering medication for R295.
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The facility failed to prevent medication administration errors for R29, who received the wrong dosage of a medication supplement for six out of six administrations.
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The facility failed to store and label biologicals as required in one of seven medication carts when staff failed to place a stop date on R31's Humalog Insulin) Kwik pen.
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The facility failed to provide, at regular times comparable to normal mealtimes for two dining room and room meal trays.
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The facility failed to provide a plan of care for R112, who was on hospice.
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The facility failed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections.
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Based on observation, record
development and transmission of communicable diseases and infections when staff failed to provide enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 8 and R88.
This deficient practice placed the residents at risk for possible exposure to infection for R8 and R88.
Findings included:
- R8's Electronic Medical Record (EMR) documented that R8 had a diagnosis of dysphagia (swallowing difficulty).
R8's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R8 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment.
The MDS documented R8 had a feeding tube.
R8's Care Plan, revised 03/03/25, documented R8 required supervision with eating, she was on Enhanced Barrier Precautions due to the she had an internal feeding tube.
The plan instructed staff to don personal protective equipment while providing care to the affected area.
On 03/18/25 at 08:40 AM, Certified Nurse Aide (CNA) Q applied gloves, entered R8's room, and failed to don on gown. CNA Q assisted the resident in standing, using a gait belt, and pivot transferred to a wheelchair, during transfer touched her clothes against R8's clothes. CNA Q assisted R8 in transferring from the wheelchair to the toilet, took off her pajama top, and placed a new blouse on R8.
On 03/18/25 at 09:00 AM, CNA Q when asked if R8 was on EBP, replied she did not know, she had not been trained about EBP.
On 03/18/25 at 11:19 AM, Administrative Nurse D stated he expected staff to follow the EBP precautions for R8.
Administrative Nurse D stated the door had an EBP sign on the side of the entrance room door and supplies were on the back of the R8's entrance door.
The facility's EBP policy, implemented 06/14/23, documented EBP referred to the use of gloves and gown for use during high contact resident care activities for residents known to be colonized or infected with a Multi-Drug Resistant Organism (MDRO - bacteria that resist treatment with more than one antibiotic) as well as those at increased risk of MDRO acquisition (residents with a wound or indwelling medical device.
High-contact resident care activities included the following:
a. dressing,
b. bathing
175255
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 175255 B.
Wing 03/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Plaza West Healthcare and Rehab 1570 SW Westport Drive Topeka, KS 66604