Plaza Community Living Center

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure the residents' right to reside in a clean, comfortable, and homelike environment, as evidenced by dark-colored staining and residue on hallway vents and wall surfaces, damaged wall surfaces with paint scraped away exposing the underlying wall material, and recurring roof leaks for three (3) of six (6) halls. (Northeast, North Central, and South Central)

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to provide written notification of a resident transfer to a resident or a resident's representative (RR) and failed to provide notification to the ombudsman for one (1) of three (3) closed records reviewed. Resident #93Findings include:A review of the facility's policy, Transfer or Discharge Notice, reviewed 04/10/2023, revealed, .Residents and/or representatives are notified in writing, and in a language and format they understand. Policy Interpretation and Implementation.4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge.d. An immediate transfer or discharge is required by the resident's urgent medical needs.5. The resident and representation are notified in writing of the following information: a. [...]

Inspectors wroteBased on record review, staff interview, and the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected services received by a resident by coding dialysis as not received when the resident received dialysis during the assessment reference period, affecting one (1) of eighteen (18) sampled residents for MDS accuracy. (Resident #2).

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to implement care plan interventions related to shaving for two (2) of 18 sampled residents. Residents #32 and #26.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene and grooming in accordance with a resident's needs and preferences by failing to remove facial hair for two (2) of eighteen (18) sampled residents. (Resident #32 and #26).

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure Schedule II controlled substances were maintained in permanently affixed compartments when two (2) of four (4) medication carts contained removable narcotic storage boxes.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to provide the residents with a homelike environment during an annual recertification survey on 01/09/2025 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of seven (7) deficiencies cited. F584. Findings Include:Review of the facility's policy, QAPI Plan, revealed, Purpose: The purpose of QAPI.is to take a proactive approach to continually improve the way we care for.our residents. Scope. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to develop the comprehensive person-centered care plan for pressure injuries for one (1) of three (3) sampled residents. (Resident #1).

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure residents' rights for a clean, sanitary, and home-like environment as evidenced by resident rooms with holes in the walls and leaks in the ceilings in the dining room and hallways for one (1) of four (4) days of survey.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to protect residents' right to be free from physical abuse when Resident #62 received scratches to his neck and face in an altercation with Resident #48 and Resident #41 received a hematoma to her head during an altercation with Resident #78 for four (4) of 20 sampled residents.

Inspectors wroteBased on observation, interviews, record review, and the facility policy review the facility failed to provide adequate supervision to prevent resident-on-resident altercations between Resident #62 and Resident #48 and between Resident #41 and Resident #78 for four (4) of 22 sampled residents.

Inspectors wroteBased on interviews, record review, and facility policy review the facility failed to implement their policy related to abuse, as evidenced by not reporting an allegation of abuse by Resident #54 in a timely manner and allowing an accused staff member to work during the investigation process and not completing a thorough investigation regarding an altercation between Resident#48 and Resident #62 for three (3) of 20 sampled residents.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to discard expired food items from the refrigerator, remove opened, exposed, and unlabeled food items from freezer, and ensure dietary staff wore a hair restraint while plating food for two (2) of three (3) observations.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to prevent the possible spread of infection when a Certified Nurse Aide (CNA) placed soiled linens on the floor of a resident's room and against her clothes for one (1) of four (4) days.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to accurately code Minimum Data Set (MDS) assessments when bedrails that were used as an enabler were coded as physical restraints on the MDS for three (3) of 20 sampled residents. (Residents #14, #73, and #43).

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, the facility failed to ensure there were sufficient staff to meet the needs of residents for one (1) of two (2) Units in the facility, the South Wing. This deficient practice had the potential to affect 55 residents who reside on the South Wing.

Inspectors wroteBased on interviews, record review and facility policy review the facility failed to develop and/or implement an individualized person-centered care plan for two (2) of 22 care plans reviewed.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident who was dependent on staff for incontinence care received those services for one (1) of five (5) residents reviewed for incontinence care. Resident #25. Findings Include: A review of the facility's policy Routine Resident Checks, dated 6/1/2000, revealed, .It is the policy of this facility to make routine resident checks to assure that the resident's safety and wellbeing are maintained. Procedure 1. To ensure the safety and well-being of our residents, a resident check will be made every two (2) hours by nursing service personnel . On 05/21/23 at 12:07 PM, in an interview and observation with Resident #25, she reported that at 10:00 AM this morning, she informed a Certified Nurse Aide (CNA) that she needed to be changed because she had a bowel movement. [...]

Inspectors wroteBased on observation, interviews, record reviews and facility's policy review the facility failed to administer intravenous (IV) antibiotics per Physician's Orders for one (1) of two (2) Residents reviewed for hospitalization. Resident #35. Findings Include: A record review of the facility's policy admission Criteria with a review date of 4/25/23 revealed .Our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation 1. The objectives of our admission criteria policy are to: . b. admit residents who can be cared for adequately by the facility . 7. Some examples of nursing/medical needs that can be met adequately include a. medication management . [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to maintain the dignity of a resident during mealtime for one (1) of 22 sampled residents.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure the residents had a safe, clean, homelike environment in the main dining room for one (1) of four (4) communal areas observed.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to complete a Level I Pre-admission Screening and Resident Review (PASARR) evaluation for one (1) of three (3) residents reviewed for Pre-admission Screens (PAS). A Level II screening was not performed for this resident because the Level I PAS was not completed.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to accurately complete the Pre-admission Screening (PAS) to indicate residents who had a diagnosis of a major mental illness for two (2) of three (3) residents reviewed. Level II screenings were not completed for these residents because of the inaccurate PAS.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, to prevent the possibility of a urinary tract infection for one (1) of five (5) residents reviewed for incontinent care.

Inspectors wroteBased on observations, staff interviews, record review and facility policy review, the facility failed to remove expired insulin from medication cart for one (1) of two (2) medication carts reviewed.

Inspectors wroteBased on observation and staff interview, the facility failed to post the direct care daily staffing numbers in a location accessible to residents and visitors for four (4) of five (5) days of survey. This affected all residents in the facility. Findings Include: Observations of the facility from 05/21/23 through 05/24/23, revealed there was no posting of the direct care daily staffing numbers. On 05/24/22 at 3:32 PM, in an interview with Staff Development Registered Nurse (RN) # 1, she confirmed the facility had not posted the direct care daily staffing numbers in an area where the residents and visitors could access the information. RN #1 said she had worked the floor as a staff nurse and had not posted the information. [...]