The Healthcare Resort of Topeka

Inspectors wroteThe facility reported a census of 67 residents. Based on observation, interview, and record review, the facility failed to prepare food under sanitary conditions, related to the use of unsanitary pots and pans used to prepare food in the main kitchen, where all residents meals are prepared prior to distribution to two satellite kitchens, which include the east kitchenette that served the residents of the long-term care and skilled residents of the facility.

Inspectors wroteThe facility reported a census of 67 residents; there were 18 residents sampled, which included two residents selected for closed record review. Based on observation, interview, and record review, the facility failed to ensure nursing documentation in Resident (R) 27's health record met the professional standards of care when staff repeatedly documented application of a brace or splint even when they did not apply the device, inaccurately representing the provision of treatments.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to measure and record food temperatures for pureed food items at mealtimes, placing the two residents who received a pureed diet at risk for foodborne illness.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents with five residents reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interview, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination, or a physician-documented contraindication for pneumococcal PCV20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease.

Inspectors wrote- On 02/07/24 at 12:05 PM, observation of the [NAME] dining room revealed residents sat at the dining room tables and ate lunch. Continued observation revealed Dietary Staff BB asked the surveyor to relocate to a different table in the dining room because the staff needed the feeders to sit at that table so staff could assist them with their meals. Dietary Staff BB again stated the other table where the feeders normally sat was filled up, so staff needed to use the table. On 02/13/24 at 09:30 AM, Administrative Nurse D verified staff were to not call residents feeders, the term was unacceptable. Administrative Nurse D said she would speak with the staff regarding the issue. [...]

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents, with two reviewed for choices. Based on observation, record review, and interview, the facility failed to offer Resident (R) 163 a choice of showers instead of sponge baths. This placed R163 at risk for decreased self-determination and impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents. Based on record review and interview, the facility failed to provide Resident (R)16 and R12 or their representative, the completed Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055. This placed the resident at risk of uninformed decisions and costs about their skilled services.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents. Based on record review and interview, the facility staff failed to identify an unwitnessed fall that resulted in serious injury as a potential allegation of neglect or abuse and report immediately to the State Survey Agency (SA), when Resident (R) 172, a cognitively impaired resident, had an unwitnessed fall with injuries. This placed the resident at risk for further injury and unidentified abuse or neglect.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents. Based on record review, and interview, the facility failed to identify an unwitnessed fall that resulted in serious injury as a potential allegation of neglect or abuse and conduct a thorough investigation, when Resident (R) 172, a cognitively impaired resident, had an unwitnessed fall with serious injuries. This placed the resident at risk for further injury and unidentified abuse or neglect.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents, with one reviewed for catheters (a tube inserted into the bladder to drain urine into a collection bag). Based on observation, record review, and interview, the facility failed to notify the physician when Resident (R) 10's urine output was less than 360 milliliters (ml) in 12 hours as ordered. This placed the resident at risk for physical decline.

Inspectors wroteThe facility had a census of 70 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to date Resident(R)20's insulin (a hormone which allows cells throughout the body to uptake glucose) flex pen when opened and failed to discard R11 and R12 insulin flex pen when outdated. This deficient practice placed the affected resident at risk for ineffective medications.

Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents with one resident reviewed for self-administration of medications. Based on observations, interviews, and record reviews, the facility failed to assess Resident (R)116 for the ability to safely self-administrator medications. This deficient practice placed R116 at risk for medication errors and unnecessary side effects. Findings Included: - A review of R116's Electronic Medical record (EMR) revealed that she was admitted to the facility on [DATE]. [...]

Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents with one resident reviewed for physician notification. Based on observations, interviews, and record reviews, the facility failed to notify Resident (R)18's physician of R18's face/head injuries obtained during an accident while being transferred with a Hoyer lift (total body mechanical lift used to transfer residents). This deficient practice placed R18 at risk for complications related to accidents and injuries. Findings Included: [...]

Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents with 18 residents reviewed for development of comprehensive care plans. Based on observation, record review, and interviews, the facility failed to develop a person-centered comprehensive care plans for Resident (R) 43, related to an individualized toileting program and/or bladder retraining. This deficient practice placed the resident at risk of not achieving and/or maintaining her highest practicable physical, mental, and psychosocial well-being due to unmet or uncommunicated care needs.

Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents with two residents sampled for respiratory care. Based on observation, record review and interview, the facility failed to ensure that a comprehensive person-centered care plan was implemented for R58's oxygen (O2) therapy/use. This deficient practice placed R58 at risk uncommunicated care needs related to O2 therapy.

Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents with three residents reviewed for accidents. Based on observations, interviews, and record reviews, the facility failed to ensure a safe environment free from preventable accidents when staff hit Resident (R)18 in the face with the Hoyer lift (total body mechanical lift used to transfer residents) swivel bar during a transfer. This deficient practice placed R18 at risk for complications related to accidents and injuries. Findings Included: [...]

Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide an individualized toileting program for Resident (R) 43 to promote continence. This placed her at risk for increased incontinence and impaired dignity and well-being.

Inspectors wroteThe facility identified a census of 63 residents. The sample included 18 residents with 18 residents reviewed for competent nurse staffing. Based on observations, interviews, and record reviews, the facility failed to ensure that staff possessed the knowledge and skills necessary to ensure Resident (R)18 was assessed after an accident with a Hoyer lift (total body mechanical lift used to transfer residents) transfer. The facility additionally failed to complete follow-up assessments for R18's injury. This deficient practice placed R18 at risk for complications from accident related injuries. Findings Included: [...]