Plaza West Healthcare And Rehab

F-F582.

The facility failed to provide a safe, comfortable environment. Refer to

F-F584.

The facility failed to address the resident's history of sexually aggressive behavior. Refer to

F-F600.

The facility failed to complete comprehensive assessments in a timely manner for Resident R13, Resident R98, and Resident R112. Refer to

F-F636.

The facility failed to complete baseline care plans for Resident R13, Resident R78, Resident R98, and Resident R295. Refer to

F-F655.

The facility failed to revise care plans for Resident R78 and Resident R117. Refer to

F-F657.

The facility failed to provide consistent bathing for Resident R48, Resident R71, Resident R92, Resident R99, Resident R117, Resident R121, and Resident R125. Refer to

F-F677.

The facility failed to complete nursing assessments prior to a discharge to the hospital for Resident R35 and Resident R142.

The facility failed to complete a nursing assessment following admission for Resident R128. The facility failed to implement intervention to prevent a skin tear for Resident R117, and implement intervention related to R13s back brace. Refer to

F-F684.

The facility failed to implement preventative interventions for Resident R78, who had a pressure ulcer. Refer to

F-F686.

The facility failed to obtain an order for oxygen therapy and failed to store oxygen tubing in a bag for Resident R346. Refer to

F-F695.

The facility failed to obtain orders for Resident R295, who received Dialysis Services. Refer to

F-F698.

The facility failed to ensure adequate daily nursing staff were always available to meet the needs of the residents who resided in the facility. Refer to

F-F725.

The facility failed to ensure staff possessed the competencies and skill sets necessary to provide nursing and related services for Resident R128 and Resident R142. Refer to

F-F726.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 53 175255 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The facility failed to ensure physician involvement for Resident R121, who had behaviors. Refer to

F-F742.

Level of Harm - Minimal harm or The facility failed to document signatures in the narcotic count boot. Refer to

F-F755. potential for actual harm

The facility failed to ensure the Consultant Pharmacist identified and reported to the facility Resident R29's Residents Affected - Some out-of-parameters accu-checks. Refer to

F-F756.

The facility failed to notify the physician for Accu-check outside of physician-ordered parameters for Resident R29.

The facility failed to document in the Medication Administration Record after administering medication for Resident R295. Refer to

F-F757.

The facility failed to prevent medication administration errors for Resident R29, who received the wrong dosage of a medication supplement for six out of six administrations. Refer to

F-F760.

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 Resident R31's Humalog Insulin) Kwik pen. Refer to

F-F761.

The facility failed to provide, at regular times comparable to normal mealtimes for two dining room and room meal trays. Refer to

F-F809.

The facility failed to provide a plan of care for Resident R112, who was on hospice. Refer to

F-F849.

The facility failed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections. Refer to

F-F880.

On 03/19/25 at 05:00 PM, Administrative Staff A stated the team meets monthly and discussed concerns related to the residents. They had been making a lot of changes for the good of the residents and hope to continue improving the quality of life for all of the residents.

The facility's Quality Assurance and Performance Improvement (QAPI) policy, dated 03/19/25, documented

the facility, develop, implement, and maintain an effective, comprehensive, data-driven QAPI program. The program focused on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.

The facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concern for the 130 residents who resided in the facility. This placed all residents at risk for unidentified and ongoing care issues.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 53 175255 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32358 potential for actual harm

The facility had a census of 130 residents. The sample included 27 residents. Based on observation, record Residents Affected - Few review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the 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 Resident R88. This deficient practice placed the residents at risk for possible exposure to infection for Resident R8 and Resident R88.

Findings included:

- Resident R8's Electronic Medical Record (EMR) documented that Resident R8 had a diagnosis of dysphagia (swallowing difficulty).

Resident R8's Quarterly Minimum Data Set (MDS), dated [DATE REDACTED], documented that Resident R8 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS documented Resident R8 had a feeding tube.

Resident R8's Care Plan, revised 03/03/25, documented Resident 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 Resident 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 Resident R8's clothes. CNA Q assisted Resident R8 in transferring from the wheelchair to the toilet, took off her pajama top, and placed a new blouse on Resident R8.

On 03/18/25 at 09:00 AM, CNA Q when asked if Resident 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 Resident 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 Resident 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 53 175255 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 c. transferring

Level of Harm - Minimal harm or d. providing hygiene potential for actual harm e. changing linens Residents Affected - Few f. changing briefs or assisting with toileting

g. device care or use of central lines, urinary catheters, feeding tubes, tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted), ventilator, wound care, and skin opening requiring a dressing.

The facility staff failed to ensure staff provided EBP when providing care for Resident R8, who had a feeding tube.

This placed the resident at risk for infection.

- Resident R88's Electronic Medical Record (EMR) documented Resident R88 had a diagnosis of urine retention (lack of ability to urinate and empty the bladder).

Resident R88's Admission Minimum Data Set (MDS), dated [DATE REDACTED], documented Resident R88 had a Brief Interview of Mental Status (BIMs) of 14, which indicated intact cognition. The MDS documented Resident R88 as independent with most activities of daily living (ADL). The MDS documented Resident R88 had a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag).

The Urinary Incontinence Care Area Assessment (CAA), dated 12/03/25, documented urinary incontinence would be addressed in the resident's care plan. Staff to monitor for signs and symptoms of consequences of incontinence, such as infection, to help prevent prolongation of infection. Staff to encourage fluids to help prevent infection. Staff to provide incontinence care as needed to help minimize risks of incontinence.

Resident R88's Care Plan, revised 02/24/25, documented Resident R88 required Enhanced Barrier Precautions (EBP) due to having an indwelling medical device. The plan instructed staff to don personal protective equipment (PPE) while providing care to the effected area.

On 03/18/25 at 11:50 AM, Licensed Nurse (LN) Q entered Resident R88's room, applied gloves and asked Resident R88 if it was ok to empty her urinary catheter bag, LN Q failed to don a gown. LN Q stated Resident R88's urinary catheter bag had two ports. LN Q retrieved a graduated cylinder from the bathroom, placed it on the floor, took the port from the holder, unclipped it drained the urine into the cylinder, refastened the port, and placed it in the holder. LN Q unscrewed the cap from the other drainage port, drained the urine into the cylinder with the other urine, and placed the cap back on the drainage port without disinfecting either port. LN Q placed the uncovered urinary catheter bag back on the bed, towards the head of the bed, with the uncovered urinary catheter bag touching the floor. LN Q verified the urinary catheter bag was uncovered and touched the floor. When asked if she would normally wipe off the drainage ports with a disinfectant wipe or alcohol pad, LN Q stated she had not been trained to do that, but she could.

On 03/18/25 at 01:15 PM, when asked if anyone in the 600 hall was on EBP LN Q stated she was unaware of anyone being on EBP. LN Q verified she had not donned a gown when providing catheter care for Resident R88.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 53 175255 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 03/19/25 at 11:19 AM, Administrative Nurse D stated he expected staff to follow the EBP precautions for Resident R8. Administrative Nurse D stated the door had an EBP sign on the side of the entrance room door and Level of Harm - Minimal harm or supplies were on the back of the Resident R8's entrance door. potential for actual harm

The facility's EBP policy, implemented 06/14/23, documented EBP referred to the use of gloves and gown for Residents Affected - Few 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

c. transferring

d. providing hygiene

e. changing linens

f. changing briefs or assisting with toileting

g. device care or use of central lines, urinary catheters, feeding tubes, tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted), ventilator, wound care, and skin opening requiring a dressing.

The facility staff failed to ensure staff provided EBP when providing care for Resident R8, who had a feeding tube.

This placed the resident at risk for infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 53 175255