Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Plaza West Healthcare And Rehab during CMS and state inspections, most recent first.
The facility did not consistently provide enough nursing staff to meet resident needs, as evidenced by multiple unfilled nurse, CNA, and CMA shifts and lack of documentation that these gaps were covered. Staff interviews confirmed frequent short-staffing, and the facility was unable to provide a staffing policy when requested.
Persistent strong urine odors and stained furniture were observed throughout Hall 400 and its commons area, with administrative staff confirming these unsanitary conditions. The facility was also unable to provide a clean environment policy when requested, resulting in residents being exposed to an unclean and unhomelike environment.
Several newly admitted residents did not have baseline care plans in the EMR that included required interventions for ADLs, dialysis, wound care, or colostomy care. Staff provided basic care but lacked documented guidance, and one resident dependent on dialysis did not have dialysis care reflected in her care plan or physician orders. Nursing staff interviews confirmed that baseline care plans were not consistently completed as required by facility policy.
Several residents with cognitive and physical impairments did not receive regular bathing or alternative hygiene care as required, with staff failing to consistently offer or document alternative options when showers were refused. Observations showed residents in the same clothing for days and with poor personal hygiene, and staff interviews confirmed inconsistent follow-up and documentation.
Several residents experienced lapses in care, including missing nursing assessments before hospital transfers, lack of documentation for skin injuries, and absence of care plan instructions for medical devices such as a back brace. These deficiencies resulted in residents not receiving care according to physician orders, facility policy, or their individual needs.
The facility did not serve meals at regular times aligned with resident needs and preferences, resulting in prolonged waiting periods for food in both the main dining room and Memory Care Unit. Staff struggled with meal ordering systems, served meals inconsistently, and could not provide a meal service policy when requested. Residents expressed frustration and hunger due to these delays, and staff acknowledged that late meal service was common.
Surveyors identified that the facility's QAA program failed to recognize and address multiple care issues, including incomplete assessments, care planning lapses, medication errors, inadequate staffing, and infection control breaches. These deficiencies affected all residents and were observed through interviews, record reviews, and direct observation, indicating widespread lapses in quality oversight.
A resident was not given the required CMS 10055 Advanced Beneficiary Notice (ABN) with an estimated cost when skilled services ended. Staff interviews and record review confirmed the ABN was not provided, and the facility's policy for timely Medicare coverage notification was not followed.
A resident with a history of stroke, cognitive-communication deficits, and significant care needs exhibited ongoing sexually inappropriate behaviors toward female staff and another resident. Despite care plan interventions such as paired care and one-to-one supervision, documentation and communication lapses occurred, including inconsistent physician notification and unclear staff understanding of monitoring reasons. The facility did not ensure these behaviors were consistently addressed, placing others at risk.
Three residents did not have their comprehensive admission MDS assessments completed on time or at all, as required by CMS RAI guidelines. Staffing shortages led to delays and incomplete assessments, with nursing staff reporting they were unable to keep up with MDS duties while covering floor shifts. This resulted in the affected residents lacking timely, accurate assessments and individualized care plans.
Two residents experienced changes in skin condition—one developed a skin tear and another a Stage 3 pressure ulcer—yet their care plans were not updated with appropriate interventions or wound care instructions. Staff interviews and record reviews confirmed that care plans were not revised in a timely manner, resulting in a lack of direction for staff and placing the residents at risk for further injury.
A resident with significant medical conditions and high risk for pressure ulcers developed an avoidable Stage 3 pressure ulcer due to the facility's failure to update the care plan with specific wound care interventions and to document detailed skin assessments. Nursing staff did not consistently implement or record necessary interventions, and care plan updates were delayed, resulting in inadequate prevention and management of the resident's pressure injury.
A resident with multiple serious health conditions was provided supplemental oxygen therapy without a physician's order, and staff did not monitor or document the effectiveness of the therapy as required. The care plan did not address oxygen therapy, and the nasal cannula was not properly stored when not in use, as confirmed by staff interviews and record review.
A resident dependent on dialysis did not have their dialysis needs documented in the care plan, lacked physician orders and progress notes for dialysis, and did not receive required assessments or communication sheets before and after treatments. Staff confirmed that standard procedures for monitoring and communicating dialysis care were not followed, resulting in a failure to meet professional standards.
Staff failed to consistently sign controlled medication count logs at the beginning and end of shifts, as required by facility policy. Observations showed missing signatures on multiple dates, and interviews confirmed that staff were expected to complete this process to ensure accurate reconciliation of controlled substances.
A consultant pharmacist did not identify or report that staff failed to notify a physician when a resident's blood glucose readings were outside of ordered parameters. The resident, who had diabetes and other chronic conditions, received daily insulin and had specific orders for blood glucose monitoring and physician notification. Despite multiple out-of-range results over several months, the pharmacist's monthly medication reviews did not document or communicate these issues to facility administration.
Staff failed to notify a physician when a resident's blood glucose readings were outside ordered parameters and did not document the administration of prescribed medications for two residents. These actions were not in accordance with facility policy and placed the residents at risk for adverse effects related to their medication regimens.
A resident with multiple chronic conditions received the wrong dosage of a prescribed Zinc supplement for six consecutive administrations. The error occurred when a CMA administered 50 mg instead of the ordered 30 mg, without verifying the physician's order, resulting in a significant medication error.
A medication cart was found to contain an opened Humalog insulin Kwik pen for a resident without an open date, as confirmed by a nurse. Staff acknowledged that the pen should have been dated upon opening, and administrative staff confirmed this expectation. The facility did not provide a policy on dating insulin pens, resulting in a deficiency related to proper storage and labeling of biologicals.
A resident with multiple serious health conditions was admitted to hospice care, but the facility failed to maintain the required hospice plan of care and documentation of medications and equipment provided by hospice. Staff interviews confirmed that this information was missing from the resident's records, contrary to facility policy, resulting in a lack of documented collaboration between the facility and the hospice provider.
Staff did not follow Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices, including a feeding tube and a urinary catheter. During high-contact care activities, such as transferring, dressing, and catheter care, staff wore gloves but failed to don gowns as required by facility policy. Staff involved were unaware of EBP requirements and had not received adequate training, despite care plans and signage indicating the need for EBP. This resulted in a failure to maintain a sanitary environment and prevent infection transmission.
A resident with COPD and other health issues did not receive necessary respiratory care, missing numerous scheduled nebulizer treatments over several months. Observations showed improper storage of nebulizer equipment, and the resident reported not receiving treatments as scheduled. Staff interviews revealed inconsistencies in treatment administration and documentation, with facility policies lacking guidance on nebulizer tubing storage.
A CNA failed to receive effective communication training, leading to improper interactions with a resident. Video footage showed the CNA using a raised voice and not addressing the resident's discomfort. The facility lacked documentation and a policy on communication training, contributing to the deficiency.
A CNA at the facility failed to receive required training on resident rights, leading to interactions with a resident that compromised dignity and care standards. Video footage showed the CNA using a raised voice, handling the resident roughly, and using unsanitary wipes. The facility could not provide documentation of the CNA's training, and administrative staff confirmed the oversight.
A resident with cognitive impairment and end-stage renal disease was treated without dignity by a CNA, as captured on video. The CNA spoke in a raised voice, dismissed the resident's discomfort, and used unsanitary wipes during incontinence care. Facility policies emphasize respectful treatment, but the CNA's actions did not align with these standards.
A facility failed to prevent cross-contamination during incontinence care and did not disinfect a Hoyer lift between uses. CNAs did not change gloves or perform hand hygiene between dirty and clean tasks, and the lift was not disinfected before being used for another resident. Staff interviews confirmed that facility policies were not followed, posing a risk of infection.
Failure to Maintain Adequate Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure adequate daily nursing staff were always available to meet the needs of all residents. The Facility Assessment, revised on 12/19/24, indicated that staffing needs and assignments should vary based on census and resident acuity, with additional staffing provided according to resident preferences when possible. However, a review of daily nursing staffing schedules from 12/01/24 to 03/18/25 revealed numerous unfilled slots for nurses, certified nurse aides (CNA), and certified medication aides (CMA) across different halls and shifts. There was no documentation that these open slots were filled by other staff members. Interviews with staff confirmed ongoing staffing issues. One CMA responsible for daily staffing stated that if she was not on duty and staff called in or did not show up, the charge nurse or Administrative Nurse would attempt to find replacements, but sometimes failed to update the schedule to reflect these changes. Another CMA reported that she was often required to assist CNAs due to being short-staffed about half the time. Additionally, the facility was unable to provide a staffing policy when requested. These findings demonstrate that the facility did not consistently maintain adequate nursing staff to meet resident needs.
Failure to Maintain Clean, Odor-Free Environment on Hall 400
Penalty
Summary
The facility failed to maintain a clean, odor-free, and homelike environment on Hall 400, as evidenced by persistent strong urine odors detected throughout the hall and commons area on multiple days. Observations also revealed two blue-colored couches in the Hall 400 commons area with visible brown stains. Administrative staff confirmed the presence of the odor and the stained furniture. Additionally, the facility was unable to provide a clean environment policy upon request. These conditions resulted in residents on Hall 400 being exposed to unclean and unhomelike surroundings.
Failure to Develop and Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for several residents, as required by its own policy. Specifically, the baseline care plans for multiple newly admitted residents did not include care areas or interventions for activities of daily living (ADLs), dialysis care, wound care, or colostomy care. Staff interviews revealed that while basic care was provided, the necessary documentation and direction for staff regarding these care needs were missing from the electronic medical record (EMR) care plans. For example, one resident with a history of end-stage renal disease and dependence on dialysis did not have dialysis care or treatment documented in the baseline care plan. There were also no physician orders or progress notes reflecting the need for or participation in dialysis, despite the resident and staff confirming that the resident attended dialysis sessions regularly. Additionally, the resident reported that staff had not assessed her arteriovenous (AV) shunt after dialysis and that no communication sheet was sent with her to dialysis appointments. Interviews with certified nurse aides, licensed nurses, and administrative nursing staff confirmed that the responsibility for completing baseline care plans was not consistently fulfilled. The facility's policy required that baseline care plans include instructions for effective and person-centered care, including ADL assistance and any special needs such as dialysis or wound care. The lack of these care plan elements placed residents at risk of delayed care, possible decline, and injury, as directly stated in the report.
Failure to Provide Consistent Bathing and Hygiene Assistance
Penalty
Summary
The facility failed to provide consistent bathing and hygiene assistance to several residents who were unable to perform activities of daily living independently. Multiple residents with severe cognitive impairments, such as dementia and vascular dementia, as well as other medical conditions including depression, chronic kidney disease, and incontinence, did not receive regular baths or showers as scheduled. Documentation revealed that when residents refused showers, staff did not consistently offer alternative bathing options, such as sponge baths, or attempt bathing at different times, despite care plans and facility policy directing them to do so. In several cases, there was a lack of follow-up documentation regarding the attempts made to provide bathing or alternative hygiene measures. Observations during the survey found that residents often wore the same clothing for multiple days, had greasy or uncombed hair, and appeared disheveled, indicating a lack of adequate personal hygiene. Staff interviews confirmed that while refusals were sometimes documented, alternative bathing methods were not always offered, and documentation of these efforts was inconsistent or missing. In some instances, staff stated they would try again later if a resident refused, but there was no evidence that these follow-up attempts or alternative hygiene measures were consistently implemented or recorded. The facility's own policies required staff to assist residents with bathing to maintain hygiene and prevent skin issues, and to provide clean washcloths for perineal care. However, the records and staff statements indicated that these policies were not consistently followed. The lack of regular bathing and inadequate documentation of refusals and alternative hygiene measures placed residents at risk for poor hygiene, as directly observed and noted in the report.
Failure to Document Assessments and Implement Care Plans
Penalty
Summary
Multiple deficiencies were identified in the facility's provision of care and documentation for several residents. In one case, a resident with a history of stroke, atrial fibrillation, and a gastrostomy tube was transferred to the hospital, but the electronic medical record (EMR) lacked any nursing assessment or documentation regarding the reason or timing of the transfer. This was contrary to the facility's policy, which required staff to document assessment findings and relevant information for emergency transfers. The absence of this documentation placed the resident at risk for lack of quality care. Another resident with vascular dementia, depression, and epilepsy was found to have a red, bloody area on her forearm, but there was no documentation in the EMR regarding an assessment of the area or the cause of the injury. Staff were unaware of how the injury occurred, and the care plan did not include interventions to prevent skin tears or bruises. The facility's policy required thorough skin assessments and documentation of any skin conditions, but this was not followed, placing the resident at risk of further injury. Additional deficiencies included the lack of a nursing admission assessment and baseline care plan for a resident admitted with hospice services, as well as the absence of nursing assessments prior to the hospital transfer of a resident with epilepsy and dementia. In another case, a resident admitted with a lumbar vertebrae fracture did not have a physician's order for a back brace or care plan instructions for its use, despite recommendations from the hospital. These failures to assess, document, and implement appropriate care and interventions placed the residents at risk for inappropriate care, unmet goals, and delays in recovery.
Failure to Provide Timely Meal Service According to Resident Needs and Preferences
Penalty
Summary
The facility failed to provide meals and snacks at regular times in accordance with residents’ needs, preferences, and requests, as evidenced by multiple observations in both the main dining room and the Memory Care Unit. On several occasions, residents were seated in the dining areas well before the posted mealtimes but experienced significant delays before being served their meals. For example, in the large dining room, residents began arriving before noon, but the first meals were not served until after 1:00 PM, with some residents waiting even longer. Staff were observed struggling with a malfunctioning computer system for meal orders, resorting to paper and pencil, and serving meals in a random order, resulting in some residents being served much later than others at the same table. In the Memory Care Unit, similar delays were observed, with residents seated and provided drinks but not receiving their meals for extended periods. On one occasion, residents waited over an hour and a half before being served lunch, and on another, breakfast was delayed, leading to visible frustration and repeated requests for food from residents. Staff confirmed that late meal service was more common than timely service. Residents were observed expressing hunger and distress due to the delays, and staff were unable to provide clear answers about when meals would be served. Additionally, the facility was unable to provide a policy for serving meals or for mealtimes when requested by surveyors. The lack of a consistent and timely meal service, combined with the absence of a documented policy, resulted in residents having to wait extended periods before receiving meals, contrary to their needs, preferences, and plans of care.
Systemic Failures in Quality Assessment and Assurance Program
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) program failed to identify and address multiple care issues affecting all 130 residents. Surveyors found that the QAA program did not make good faith efforts to recognize deficiencies, resulting in a range of unaddressed problems. Specific deficiencies included failure to provide required CMS forms, maintain a safe and comfortable environment, address a resident's history of sexually aggressive behavior, and complete timely comprehensive assessments and baseline care plans for several residents. Additional issues involved not revising care plans, inconsistent bathing, incomplete nursing assessments before hospital discharges and after admissions, and failure to implement necessary interventions for skin integrity and medical devices. Further findings showed failures in obtaining and documenting physician orders for treatments such as oxygen therapy and dialysis, inadequate daily nursing staff, lack of staff competencies, insufficient physician involvement for behavioral issues, and medication management errors. The facility also did not ensure proper storage and labeling of medications, timely meal service, care planning for hospice residents, and maintenance of a safe, sanitary environment to prevent infections. These deficiencies were observed through record reviews, interviews, and direct observation, indicating systemic lapses in the facility's QAA processes.
Failure to Provide Required Medicare Advanced Beneficiary Notice
Penalty
Summary
The facility failed to provide the required CMS 10055 Advanced Beneficiary Notice (ABN) to a resident or their representative when skilled services ended. Specifically, the ABN form, which should have included an estimated cost for continued services, was not given to the resident when their skilled services were discontinued. Documentation was lacking to show that the resident or their representative received the ABN form at the appropriate time. Interviews with staff confirmed that the form was not provided, and the responsible social service staff member was no longer employed at the facility, resulting in a gap in the process. The facility's policy required timely notification regarding Medicare eligibility and coverage, including the provision of the SNFABN, Form CMS-10055. However, this policy was not followed in the case of the resident whose skilled services ended, as the necessary notice and cost estimate were not provided. This omission was confirmed by both social services and nursing administration during interviews.
Failure to Address Sexually Aggressive Behaviors
Penalty
Summary
The facility failed to adequately address a resident's sexually aggressive behaviors, resulting in a deficiency related to the protection of residents from abuse. The resident in question had a history of cerebral infarction, spastic hemiplegia, cognitive-communication deficits, and required significant assistance with activities of daily living. Despite having intact cognition, the resident exhibited sexually inappropriate behaviors towards female staff, including groping, making inappropriate comments, and attempting to pull staff into bed during care. The care plan identified these behaviors and directed staff to provide care in pairs and encourage the resident not to engage in such actions. Multiple progress notes documented ongoing sexually inappropriate behaviors, including groping staff, making sexual remarks, and inappropriately touching another resident. The care plan was updated to include one-to-one supervision, and staff were assigned to monitor the resident. However, there was a lack of clear communication and understanding among staff regarding the reason for the monitoring, and the electronic medical record did not consistently document physician notification of the sexual behaviors involving staff. The facility's policy required the identification, assessment, and care planning for residents with behaviors that could lead to abuse or neglect. Despite this, the facility did not ensure that the resident's sexually aggressive behaviors were consistently addressed, documented, or communicated to all relevant parties. This failure placed other residents at risk of sexual abuse.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments for three residents in accordance with Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines. Specifically, one resident's admission MDS was not completed until several days after the assessment reference date, another resident's admission MDS was not completed at all, and a third resident's admission MDS was incomplete following readmission. These lapses were identified through observation, record review, and staff interviews. Licensed nursing staff reported being behind on MDS assessments due to staffing shortages and having to cover floor duties, which contributed to the delays and omissions. The facility's policy required the MDS/RAI coordinator to track and complete all MDS assessments within specified timeframes, but this was not adhered to for the affected residents. As a result, the residents were at risk for having inaccurate assessments of their status and not having individualized, comprehensive, person-centered care plans developed in a timely manner.
Failure to Revise Care Plans After Changes in Skin Condition
Penalty
Summary
The facility failed to revise and update care plans for two residents following significant changes in their skin condition, as required by policy. For one resident with vascular dementia, depression, and epilepsy, the care plan did not include interventions to prevent skin tears and bruises, despite the resident being dependent on staff for all activities of daily living and having severely impaired cognition. An observation revealed a red, bloody area on the resident's left forearm, but there was no documentation in the electronic medical record regarding an assessment of the area or the cause. Staff interviews confirmed a lack of awareness and documentation regarding the skin tear, and the care plan was not updated to address prevention of further skin injuries. Another resident with diagnoses including atrial fibrillation, congestive heart failure, embolism, and thrombosis, and who was at high risk for pressure ulcers, developed a Stage 3 pressure ulcer on the right buttock. The care plan for this resident was not updated to include interventions for wound care or specify the level of assistance required, even after the wound was identified and dressing changes were ordered. Weekly skin assessments were documented, but lacked detailed descriptions or measurements of the wound when it first appeared. Staff interviews revealed that care plans had not been updated due to staff being behind on documentation, and the necessary interventions for the pressure ulcer were not included in the care plan at the time of the survey. The facility's policy required that care plans be reviewed and revised upon a change in resident status, with new or modified interventions communicated to all staff involved in care. In both cases, the failure to update care plans following changes in the residents' skin condition resulted in a lack of direction for staff and placed the residents at risk for further injury and unmet care needs. The deficiencies were identified through observation, record review, and staff interviews, which confirmed that care plans were not promptly or adequately revised as required.
Failure to Implement and Update Pressure Ulcer Interventions
Penalty
Summary
A resident with multiple medical conditions, including atrial fibrillation, congestive heart failure, embolism, and thrombosis of the lower extremities, was identified as being at high risk for pressure ulcer development upon admission. The resident was dependent on staff for all functional abilities, always incontinent of bowel and bladder, and required a wheelchair for mobility. The care plan and medical orders indicated the need for weekly skin assessments, use of pressure-reducing devices, and interventions to maintain skin integrity. Despite these documented risks and interventions, the care plan was not updated to include specific wound care instructions or the level of assistance required after the development of a pressure ulcer. The resident's electronic medical record showed that weekly skin checks were performed, but documentation was incomplete, lacking detailed descriptions or measurements of the affected skin area when a new pressure-related wound was identified. The first measurement and staging of the wound as a Stage 3 pressure ulcer occurred several weeks after the initial skin issue was noted. Interviews with nursing staff revealed that care plans had not been updated in a timely manner to reflect the new wound and necessary interventions, and staff responsible for updating care plans had fallen behind due to other duties. Facility policy required prompt assessment, documentation, and care plan updates for pressure injuries, but these steps were not followed. The failure to implement and document appropriate interventions and to update the care plan resulted in the avoidable development of a Stage 3 pressure ulcer for the resident, placing them at risk for further complications.
Failure to Obtain Physician Order and Monitor Supplemental Oxygen Therapy
Penalty
Summary
A resident with diagnoses of end-stage renal disease, congestive heart failure, and respiratory failure was admitted to the facility and required supplemental oxygen therapy. Upon review, it was found that the resident did not have a physician's order for supplemental oxygen documented in the electronic medical record, and the care plan lacked a section addressing oxygen therapy. Additionally, the treatment administration record did not include instructions for staff to monitor and document the resident's oxygen saturation levels each shift. Observations showed the resident using a nasal cannula connected to an oxygen concentrator, with an additional oxygen canister and nasal cannula present in the room. The nasal cannula attached to the canister was not stored in a bag when not in use, contrary to facility expectations. Interviews with staff confirmed that an order for oxygen therapy should have been present, and that oxygen saturation should be monitored and documented each shift. Staff acknowledged that the omission of the oxygen order and monitoring instructions was an oversight following the resident's return from the hospital.
Failure to Provide Safe and Appropriate Dialysis Care and Communication
Penalty
Summary
A resident with diagnoses including a left tibia fracture, arteriovenous fistula, dependence on renal dialysis, end-stage renal disease, bipolar disorder, and anxiety disorder was admitted to the facility. The resident's baseline care plan did not include documentation or instructions regarding the dialysis process, and there were no physician orders or progress notes reflecting the need for or participation in dialysis. The Minimum Data Set (MDS) had not been completed due to the recent admission. Staff interviews confirmed that the resident attended dialysis twice weekly, but there was no evidence of required assessments before or after dialysis, nor was there a communication sheet sent with the resident to the dialysis center. Further interviews with facility staff revealed that the standard practice of sending a communication sheet with vital signs, changes in condition, or medications for dialysis residents was not followed for this resident. The administrative nurse verified that assessments before and after dialysis and proper documentation were not completed, and the care plan did not reflect the resident's dialysis needs. The facility's own hemodialysis policy required ongoing assessment, monitoring, and communication with the dialysis provider, but these procedures were not followed, resulting in a failure to provide care and services consistent with professional standards of practice.
Failure to Accurately Reconcile Controlled Medications at Shift Changes
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled medications during daily work shifts. Observations of the treatment and medication carts on the 400-hall revealed missing signatures for both coming on and going off shifts on multiple dates. Specifically, the controlled medication count logs lacked required staff signatures for several consecutive days, indicating that the mandated verification process was not consistently followed. Interviews with a licensed nurse and a certified medication aide confirmed that staff were expected to sign the controlled medication logs at the beginning and end of each shift to ensure accuracy. The facility's own Controlled Substance Administration and Accountability policy required two licensed nurses to account for all controlled substances and access keys at the end of each shift, in the absence of automated dispensing systems. Despite this policy, administrative staff acknowledged the expectation for staff to sign the logs, but the observed records showed this was not being done. This failure to accurately reconcile controlled medications at shift changes placed residents at risk for misappropriation of medications by staff.
Consultant Pharmacist Failed to Report Missed Physician Notifications for Out-of-Range Blood Glucose Results
Penalty
Summary
The facility's Consultant Pharmacist (CP) failed to identify and report that staff had not notified the physician when a resident's blood glucose (accu-check) results were outside of the physician-ordered parameters. The resident in question had multiple diagnoses, including diabetes mellitus, depressive disorder, vascular dementia, hypertension, and epilepsy, and required daily insulin administration. The resident's care plan and physician's orders specifically directed staff to monitor fasting blood sugars and notify the physician if results exceeded a certain threshold. However, electronic medical records showed that, over several months, there were numerous instances where blood glucose readings were outside the ordered parameters and the physician was not notified as required. The monthly medication regimen reviews conducted by the CP for January and February did not document any identification or notification to facility administration regarding these missed notifications. Interviews with facility staff confirmed a lack of awareness or adherence to the physician's orders regarding blood glucose notifications. The facility's pharmacy services policy required the CP to provide consultation on all aspects of pharmacy services, but the CP did not report the failure to notify the physician about out-of-parameter blood glucose results, as required by facility policy.
Failure to Notify Physician and Document Medication Administration
Penalty
Summary
The facility failed to ensure proper management and documentation of medication administration for two residents, resulting in deficiencies related to unnecessary drugs. For one resident with diagnoses including diabetes mellitus, depressive disorder, vascular dementia, hypertension, and epilepsy, staff did not notify the physician when blood glucose (Accu-check) results were outside the physician-ordered parameters. The physician's order required notification if fasting blood sugar exceeded a specific threshold, but review of the electronic medical record showed multiple instances over three months where this did not occur. Staff interviews confirmed a lack of awareness or adherence to the order, and facility policy required such notifications to promote resident well-being. For another resident with a history of left tibia fracture, arteriovenous fistula, end-stage renal disease, bipolar disorder, and anxiety, the facility failed to document the administration of prescribed medications, including bupropion and levothyroxine, on several dates. The medication administration record (MAR) lacked signatures or reasons for missed doses, and there was no documentation of physician notification regarding the missed or unsigned administrations. Staff interviews indicated uncertainty about medication availability and responsibility for administration, while facility policy required medications to be given as ordered and documented in the MAR. These failures in following physician orders and documenting medication administration placed the residents at risk for adverse effects related to their medication regimens. The facility's own policies required staff to manage and monitor drug regimens to avoid unnecessary drugs and ensure resident safety, but these were not followed in the cases identified.
Failure to Prevent Significant Medication Error in Supplement Administration
Penalty
Summary
A resident with diagnoses including diabetes mellitus, depressive disorder, vascular dementia, hypertension, and epilepsy was prescribed Zinc 30 mg by mouth in the morning for a specified period. The resident's care plan directed staff to administer medications as ordered and monitor for side effects. However, the Medication Administration Record (MAR) showed that the resident received six doses of Zinc at the wrong dosage, specifically 50 mg instead of the prescribed 30 mg, for six consecutive administrations. The error was identified when a Certified Medication Aide (CMA) noticed the discrepancy between the Zinc supplement bottle and the physician's order during a medication pass. The CMA had been administering the higher dose since the order was written, without verifying the correct dosage. The facility's policy required medications to be administered per physician's orders and for staff to evaluate medication errors once identified. The failure to administer the correct dosage constituted a significant medication error.
Failure to Label Opened Insulin Pen with Date
Penalty
Summary
Surveyors observed that one of seven medication carts contained a Humalog insulin Kwik pen for a resident that lacked an open date, despite the pen having been previously opened. A licensed nurse confirmed that the pen had been opened and acknowledged that staff should have documented the open date at that time. An administrative nurse also stated that staff are expected to place an open date on insulin pens when they are opened. The facility was unable to provide a policy regarding the dating of Humalog pens. This failure to label the insulin pen with an open date constituted a deficiency in the storage and labeling of biologicals as required.
Failure to Collaborate with Hospice Provider for Resident Care
Penalty
Summary
The facility failed to ensure proper collaboration of care between a resident's hospice provider and the facility. The resident in question had multiple significant diagnoses, including lung cancer, stroke, chronic kidney disease, and peripheral vascular disease, and was admitted to hospice care. Documentation in the resident's care plan indicated that hospice services had started, and staff were directed to assess and manage symptoms, provide emotional support, and coordinate with hospice for significant changes or complications. However, the care plan did not specify which medications or supplies were provided by hospice, and a review of the hospice provider's notebook revealed the absence of a hospice plan of care. Interviews with facility staff confirmed that the hospice plan of care, as well as a list of medications and equipment provided by hospice, should have been present in the resident's hospice book but were not. Staff could not provide a reason for this omission. The facility's policy required coordination and documentation of hospice services, including a coordinated plan of care, but this was not followed for the resident, resulting in a lack of documented collaboration and potentially inadequate end-of-life care.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) as required for two residents with indwelling medical devices. One resident with a feeding tube, who had moderate cognitive impairment and required supervision with eating, was observed being assisted by a Certified Nurse Aide (CNA) who donned gloves but did not wear a gown during high-contact care activities such as transferring, dressing, and toileting. The CNA was unaware of the resident's EBP status and reported not having received training on EBP. Another resident with a urinary catheter, who was cognitively intact and independent with most activities of daily living, was assisted by a Licensed Nurse (LN) who also failed to don a gown while emptying the urinary catheter bag. The LN did not disinfect the drainage ports and placed the uncovered catheter bag on the bed, allowing it to touch the floor. The LN stated she had not been trained to disinfect the ports and was unaware of any residents on EBP in the unit. Both residents had care plans and medical records indicating the need for EBP due to their indwelling devices. Facility policy required the use of gloves and gowns during high-contact care for residents at increased risk of multi-drug resistant organism (MDRO) acquisition. Despite signage and supplies being available, staff did not follow EBP protocols, resulting in a failure to maintain a sanitary environment and prevent the potential transmission of infections.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident diagnosed with chronic obstructive pulmonary disease (COPD), tobacco use, dementia with behavioral disturbance, and a personal history of pulmonary embolism. The resident's care plan indicated altered respiratory status and difficulty breathing related to COPD and emphysema, requiring administration of medications and monitoring for effectiveness. However, the Treatment Administration Record (TAR) revealed that the resident missed a significant number of scheduled ipratropium-albuterol nebulizer treatments over several months, with 26 out of 90 treatments missed in November, 17 out of 93 in December, and nine out of 81 in January. Observations on January 28 revealed that the resident's nebulizer mask was improperly stored, with the tubing disconnected and laid on the floor. The resident reported not receiving breathing treatments as scheduled, although she could request them. Interviews with nursing staff indicated that treatments were supposed to be administered and documented in the TAR, including any refusals. However, the resident had previously reported that staff refused to provide or offer the treatments. The facility's policies on medication administration and oxygen safety did not adequately address the storage of nebulizer tubing, contributing to the deficient practice that placed the resident at risk for infection and unwarranted physical complications.
Deficiency in Effective Communication Training for CNA
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) M received the required effective communication training, which placed residents at risk for impaired communication. The deficiency was identified through a review of video footage and interviews. The footage revealed multiple interactions between CNA M and a resident, R1, where CNA M used a raised voice and did not effectively communicate with R1. During these interactions, R1 expressed discomfort and pain, which CNA M did not adequately address. CNA M also used wipes that had fallen on the floor on R1, further indicating a lack of proper communication and care. The facility was unable to provide documentation that CNA M had completed the necessary education on effective communication. Interviews with administrative staff confirmed that while onboarding education included topics such as resident rights and infection control, it did not include effective communication training. The facility also did not have a policy on effective communication training, which contributed to the deficiency. This lack of training and policy oversight led to the observed interactions that compromised the quality of care provided to R1.
Failure to Provide Resident Rights Training to CNA
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) M received the required training on resident rights, which is a critical component of staff education. This deficiency was identified through a review of video footage and interviews, revealing that CNA M engaged in interactions with a resident, R1, that compromised the resident's dignity and rights. During these interactions, CNA M displayed a lack of sensitivity and respect towards R1, including using a raised voice, handling the resident roughly, and failing to maintain proper hygiene standards by using wipes that had fallen on the floor. Additionally, CNA M did not provide appropriate assistance to R1, who expressed discomfort and pain multiple times during the care process. The facility was unable to provide documentation that CNA M had completed the necessary training on resident rights, as required. Interviews with administrative staff confirmed that while onboarding education was supposed to include resident rights, infection control, hand washing, and abuse, CNA M did not receive this training. The absence of a policy on resident rights training further highlighted the facility's failure to ensure compliance with training requirements, placing residents at risk for impaired rights and loss of dignity.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure that staff treated a resident, identified as R1, with dignity, as evidenced by interactions captured on video footage. R1, who had diagnoses including end-stage renal disease, cognitive communication deficit, and required assistance with personal care, was subjected to undignified treatment by a Certified Nurse Aide (CNA) identified as M. The resident's medical records indicated moderate cognitive impairment and a need for substantial assistance with toileting hygiene. The care plan emphasized the need for staff to approach R1 in a gentle and friendly manner. On two separate occasions, video footage revealed CNA M interacting with R1 in a manner that lacked respect and dignity. During the first incident, CNA M entered R1's room, spoke in a raised voice, and handled R1's incontinence care without regard for her comfort, using wipes that had fallen on the floor. R1 expressed discomfort multiple times, but CNA M dismissed her concerns. In the second incident, CNA M again entered R1's room, turned off her call light, and attempted to transfer R1 to a wheelchair without proper communication or consideration for R1's expressed discomfort. Interviews with other staff members, including a CNA, a Licensed Nurse, and an Administrative Nurse, highlighted the facility's expectations for treating residents with dignity, such as maintaining a respectful tone, ensuring privacy, and addressing residents by their preferred names. Despite these expectations, the actions of CNA M did not align with the facility's policies on resident rights and dignity, as outlined in their undated policies. This deficiency placed R1 at risk for decreased self-esteem and dignity.
Infection Control Deficiency in Incontinence Care and Equipment Disinfection
Penalty
Summary
The facility failed to ensure proper infection prevention and control during incontinence care for a resident and did not disinfect a Hoyer lift between resident uses. During an observation, two CNAs were seen performing incontinence care for a resident without changing gloves between the dirty and clean portions of the care. The CNAs did not perform hand hygiene after removing soiled gloves and before donning new ones, which is a critical step in preventing cross-contamination. Additionally, the CNAs did not disinfect the Hoyer lift after using it for one resident before moving it to another resident's room. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, revealed that the facility's expectations and policies were not followed. The staff acknowledged the importance of changing gloves and performing hand hygiene during incontinence care and disinfecting equipment between uses. The facility's policies on perineal care and cleaning and disinfection of resident-care equipment were not adhered to, leading to a risk of infection and related complications for the residents involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Topeka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Excel Healthcare And Rehab Topeka | 1.2 mi | — | 0 | 0 |
| The Healthcare Resort Of Topeka | 1.4 mi | ★★★★★ | 8 | 0 |
| Rolling Hills Health Center | 1.5 mi | ★★★★★ | 9 | 1 |
| Topeka Presbyterian Manor | 1.7 mi | ★★★★★ | 2 | 0 |
| Tanglewood Nursing & Rehabilitation | 1.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.