Plaza West Healthcare and Rehab

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to ensure adequate daily nursing staff were always available to meet the needs of the residents who resided in the facility.

Inspectors wroteThe facility had a census of 130 residents. Based on observation and interview, the facility failed to maintain a clean homelike environment free of odor-free environment for one of the nine halls. This deficient practice placed the resident at risk for unhomelike, unsanitary conditions.

Inspectors wroteThe facility identified a census of 130 residents. The sample included 27 residents reviewed for baseline care plans. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 78, R98, and R13 baseline care plans were developed and implemented to provide effective and person-centered care that included interventions with staff direction for the resident's needed cares of their activities of daily living (ADL). The facility failed to develop a baseline care plan that included care areas and interventions for R295's ADLs and her dialysis (a procedure where impurities or wastes are removed from the blood) care. The facility failed to develop a baseline care plan that included dialysis care and treatment. This deficient practice placed these residents at risk of delayed care, possible decline, and injuries.

Inspectors wrote- R71's Electronic Medical Record (EMR) documented she had diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), urge incontinence (involuntary passage of urine occurring soon after a strong sense of urgency to void), and intellectual disabilities (involuntary passage of urine occurring soon after a strong sense of urgency to void). R71's Annual Minimum Data Set(MDS), dated [DATE], documented that R71 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS also documented that the resident required partial, moderate staff assistance with bathing, and it was very important to choose the type of bathing. [...]

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents, with five residents sampled for assessments, interventions placed timely, and follow-up for Resident (R) 35, R117, R128, R142, and R13. This placed the residents at risk for lack of quality of care.

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to provide at regular times comparable to normal mealtimes for two dining room and room meal trays. This placed the residents at risk of meals by resident needs, preferences, requests, and plans of care for having to wait extended periods before receiving meals.

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents. Based on observation., record review, and interview, 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.

Inspectors wroteThe facility had a census of 130 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide form CMS 10055 Advanced Beneficiary Notice (ABN), which included the estimated cost to continue services for skilled services to the resident or their representative for one of three residents, Resident (R) 2. This deficient practice placed R2 at risk for uninformed decisions and unanticipated costs related to skilled services.

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 121's sexually aggressive behaviors were addressed. This placed the residents of the facility at risk of sexual abuse.

Inspectors wroteThe facility identified a census of 130 residents. The sample included 27 residents who were reviewed for comprehensive assessments and timing. Based on observation, record review, and interview, the facility failed to ensure the admission comprehensive Minimum Data Set (MDS) was completed for Resident (R) 98, R112, and R13 using the Centers for Medicaid and Medicare (CMS) - specified Resident Assessment Instrument (RAI) guidelines. This deficient practice placed these residents at risk for inaccurate reflections of the resident's status and needed to develop an individualized comprehensive person-centered plan of care.

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for Resident (R) 117 with interventions to prevent skin tears and failed to [NAME] R78's care plan with interventions to prevent pressure ulcers. This placed the residents at risk of further injury and uncommunicative care needs.

Inspectors wroteThe facility identified a census of 130 residents. The sample included 27 residents, with four sampled residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as the result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure interventions were in place and implemented for Resident (R) 78 to prevent skin breakdown which resulted in an avoidable pressure ulcer development. This deficient practice placed R78 at risk for complications and possible infection-associated pressure wounds.

Inspectors wroteThe facility identified a census of 130 residents. The sample included 27 residents with two sampled residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 346 had a physician's order for supplement oxygen (O2) therapy. The facility failed to ensure staff monitored and documented the effectiveness of R346's supplemental O2. The facility failed to ensure R346's nasal cannula (NC - a thin hollow tube that assists in providing supplemental eO2) was appropriately stored when not used. This deficient practice placed R346 at risk of respiratory complications and possible infection.

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 295 who received care and services for dialysis (a procedure where impurities or wastes were removed from the blood), was consistent with professional standards of practice, which included ongoing assessments of residents' condition, communication, and collaboration with the dialysis facility. This placed R295 at risk of complications and unmet care needs related to dialysis treatment.

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to provide an accurate reconciliation of controlled drugs during the daily work shift. This placed residents at risk for misappropriation of medication by staff.

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report to facility administration the staff had not notified the physician of out-of-parameter accu-checks (blood glucose monitoring test) for one resident, Resident (R) 29. This placed the resident at risk for physical decline and an ineffective medication regimen.

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician for an Accu-check (blood glucose monitoring test) outside of physician-ordered parameters, for one resident, Resident (R) 29. The facility failed to document in the Medication Administration Record (MAR) after administering medication for R295. This placed the residents at risk for adverse effects related to medications.

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to prevent medication administration errors for Resident (R) 29, who received the wrong dosage of a medication supplement for six out of six administrations. This placed the resident at risk for physical decline and other related complications.

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, 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 (rapid-acting) Insulin (a hormone that lowers the level of glucose in the blood) Kwik pen (a prefilled, disposable insulin pen).

Inspectors wroteThe facility identified a census of 130 residents. The sample included 27 residents, with two residents sampled for hospice care. Based on observation, record review, and interview, the facility failed to ensure there was a collaboration of care between Resident (R) 112's hospice provider and the facility. This placed R112 at risk of inadequate end-of-life care.

Inspectors wroteThe facility had a census of 130 residents. The sample included 27 residents. Based on observation, record 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 R88. This deficient practice placed the residents at risk for possible exposure to infection for R8 and R88.

Inspectors wroteThe facility identified a census of 134 residents. The sample included one resident reviewed for respiratory services. Based on observations, record review, and interviews, the facility failed to provide necessary respiratory care and services for Resident (R) 1. This deficient practice placed R1 at risk for infection and unwarranted physical complications.

Inspectors wroteThe facility identified a census of 133 residents. Based on record review and interviews, the facility failed to ensure Certified Nurse Aide (CNA) M received the required effective communication training. This deficient practice placed residents at risk for impaired communication.

Inspectors wroteThe facility identified a census of 133 residents. Based on record review and interviews, the facility failed to ensure Certified Nurse Aide (CNA) M received the required resident rights training. This deficient practice placed residents at risk for impaired resident rights and loss of dignity.

Inspectors wroteThe facility identified a census of 133 residents. The sample included three residents. Based on record review and interviews, the facility failed to ensure staff treated Resident (R) 1 with dignity. This deficient practice placed R1 at risk for decreased self-esteem and dignity.

Inspectors wroteThe facility identified a census of 133 residents. Based on observations, record review, and interviews, the facility failed to ensure staff prevented cross-contamination during incontinence care (lack of voluntary control over urination or defecation) for Resident (R) 2 and failed to disinfect the Hoyer lift (total body mechanical lift) between resident usage. This deficient practice placed the affected residents at risk for infection and related complications.

Inspectors wroteThe facility had census of 122 residents. The sample included seven residents with three reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide a written notice as soon as practicable for a facility-initiated transfer to Resident (R) 3 and R4, or their representatives, when they were transferred to the hospital. This placed the residents at risk for uninformed care choices.

Inspectors wroteThe facility had a census of 122 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to provide two of three residents reviewed for hospitalization, Resident (R)3 and R4 or their representative, with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the residents at risk for not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 122 residents. The sample included eight residents with three reviewed for activities of daily living (ADLs). Based on record review and interview, the facility staff failed to provide appropriate ADL care and assistance for Resident (R) 1 when staff left her on the toilet in the shower room unsupervised. This placed R1 at risk or impaired ADL and decreased quality of life.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to prevent pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 84 who developed two stage 3 pressure ulcers (full thickness pressure injury extending through the skin into the tissue below) and one stage 4 pressure ulcers (a deep wound that reaches the muscles, ligaments, or even bone) and R32 who developed a stage 4 pressure ulcer. The facility also failed to promote healing of the pressure injury for R32. These deficient practices placed the resident at risk of further unhealed pressure injuries.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease or heavy tobacco use are most at risk of developing a pneumonia caused by legionella). This placed the residents in the facility at risk for infectious disease. Findings Included: - On 10/06/23 at 12:55 PM, Administrative Staff A stated the last maintenance supervisor was fired a few months ago and the facility was unable to locate or retrieve the information regarding the water testing if or when it had been completed and the testing results. [...]

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to act upon the concerns for the resident council group concerning issues of care and life in the facility. This placed the residents at risk of decreased quality of care and services.

Inspectors wrote- R78's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The admission Minimum Data Set (MDS) dated documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R78 required set up assistance of one staff member for activities of daily living (ADLs). The MDS documented R78 required supervision of oversight with her bathing activity during the look back period. The Quarterly MDS dated 07/15/23 documented a BIMS score of 14 which indicated intact cognition. [...]

Inspectors wroteThe facility had a census of 117 residents. The sample included 27 residents, with 14 reviewed for accidents. Based on observation, record review, and interview, the facility failed to to prevent accidents for two residents, Resident (R) 84 and R115, who both fell out from mechanical lifts. The facility failed to utilize two staff during a full body mechanical lift transfer for R106, and failed to put foot pedals on R328's wheelchair while transporting a resident. These deficient practices placed the residents at risk for increased risk for falls and related injury.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)33, R115 and R119s' insulin (hormone which allows cells throughout the body to uptake glucose) flex pens with the date opened and discard date on one medication cart and failed to discard expired stock medication in one medication room. These deficient practices placed the affected resident at risk for ineffective medications.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to maintain an environment that promoted dignity for Resident (R) 84, R115, and R31. This deficient practice placed the residents at risk for undignified experience and embarrassment.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to include Resident (R) 48 in the development and planning of the resident's care plan, which placed R48 at risk of impaired care and autonomy.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review and interview, the facility failed to ensure Resident (R) 101 was assessed for the ability to safely self-administer nasal spray medication. This placed R101 at risk of improper use of medication and related side effects.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to support Resident (R) 48's bathing preferences which placed the residents at risk for impaired rights to exercise their autonomy regarding those things that are important in their life.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 8's post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) diagnosis which placed the R8 at risk for uncommunicated care needs.

Inspectors wroteThe facility identified a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interviews, the facility failed to consistently provide activities for the 13 residents who lived on Willow, the locked dementia unit. This deficient practice had the risk for a decline in physical, mental, and psychosocial well-being and independence for these residents.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to implement interventions to prevent skin tears and failed to follow the care plan for Resident (R) 47. The facility further failed to monitor daily weights for R7. This placed the residents at risk for further injury and declining health.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to provide footcare to one sampled resident, Resident (32), who had a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) type 2 and required foot care from a licensed nurse. This placed the resident at risk for complications, poor hygiene and injuries.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 25 received services and assistance to maintain continence, and/or improve incontinence and failed to manage R84's catheter (tube inserted into the bladder to drain urine) in a sanitary manner. This placed the residents at risk for increased incontinence and urinary tract infections related complications.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents, with one reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide necessary respiratory care and services for Resident (R) 30, when staff stored the uncovered nebulizer (turns liquid medication into a mist so that you can inhale it into your lungs) masks on top of the nebulizer machine. This placed the resident at increased risk for respiratory infections and complications.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 8 received trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident's which placed the resident at risk for unmet behavioral health care needs.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to ensure certified staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promoted each resident's rights, physical, mental and psychosocial well-being when a Certified Medication Aide (CMA) did not administer medications as ordered or within acceptable standards of practice This placed the affected resident at risk for decreased quality of care.

Inspectors wroteThe facility identified a census of 117 residents. The sample included 28 residents with two residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion). Based on observation, record review, and interviews, the facility failed to provide dementia care and services for Resident (R) 327, who had behaviors. This deficient practice placed R327 at risk for increased behaviors, confusion, and decline in ability to maintain the highest practicable mental and psychosocial well-being.

Inspectors wroteThe facility identified a census of 117 residents. The sample included 28 residents with five reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure R78's as needed psychotropic (affects mood or thought) clonazepam (psychotropic medication used to teat stress or anxiety) had a stop date or a physician ordered specified duration for administration. This deficient practice placed R78 at risk for potential harm and adverse side effects related to unnecessary medications.

Inspectors wroteThe facility identified a census of 117 residents. The sample included 28 residents with three residents reviewed for pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations and Influenza (highly contagious viral disease). Based on record review and interviews, the facility failed to obtain pneumococcal and/or influenza vaccination consent and administer vaccines, or obtain informed declinations for Resident (R) 95, R 115 and R120 after the residents were admitted to the facility. This deficient practice placed the residents at risk to acquire, spread, and experience complications from the pneumococcal and influenza disease.

Inspectors wroteThe facility had a census of 117 residents. The sample included 28 residents. Based on observation and interview, the facility failed to display current daily hours for nursing staff.

Inspectors wroteThe facility had a census of 122 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to hold food at safe temperature to prevent foodborne illness of the 122 residents who received meals from one of one kitchen. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 122 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for 122 residents who resided in the facility and received meals from the facility kitchen, placing the residents at risk for food borne illness.

Inspectors wrote-Resident (R) 11 Physician Order Sheet (POS), documented diagnoses of chronic kidney disease, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 had intact cognition, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), verbal and physical behavioral symptoms directed at others and rejection of care which occurred four to six days of the look back period. [...]

Inspectors wroteThe facility had a census of 122 residents. The sample included 25 residents of which four were reviewed for dignity. Based on observation, record review and interview the facility failed to treat two of the four residents, Resident (R) 96 and R 13, with respect and dignity when the facility failed to ensure the urine collection bag was covered and not visible to other residents and guests. This placed the residents at risk for impaired dignity.

Inspectors wroteThe facility had a census of 122 residents. The sample included 25 residents, with eight reviewed for bathing. Based on observation, record review, and interview, the facility failed to honor Resident (R) 15's choice to have a female staff member assist her with bathing as care planned. This placed the resident at risk for an undignified and unpleasant bathing experience.

Inspectors wroteThe facility had a census of 122 residents. The sample included 25 residents. Based on observation, interview, and record review the facility failed to revise the care plan with interventions to prevent further falls when Resident (R)60 fell while attempting to toilet herself. This deficient practice placed R60 at risk for inadequate care.

Inspectors wroteThe facility had a census of 122 residents. The sample included 25 residents, with eight reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for two sampled residents, Resident (R) 14 and R15. This placed the residents at risk for complications related to poor hygiene.

Inspectors wroteThe facility had a census of 122 residents. The sample included 25 residents with seven residents reviewed for pressure ulcers (PU- injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Based on observation, interview, and record review the facility failed to provide interventions for Resident (R) 57's left foot to prevent the development of a new PU. This deficient practice placed R57 at increased risk for wound related complications including infection and pain.

Inspectors wroteThe facility had a census of 122 residents. The sample included 25 residents with 10 reviewed for falls. Based on observation, interview, and record review the facility failed to provide interventions to prevent falls for two of ten sampled residents. Resident (R)60 fell while attempting to toilet herself and R95 fell when staff failed to place his feet on wheelchair footrests while loading into the facility van. This deficient practice placed R60 and R95 at risk for falls and injury.

Inspectors wrote- R60 was admitted to the facility after a fall causing a femur (large bone of the upper leg) fracture and surgery. The medical record included diagnoses of anxiety (nervous disorder characterized by a state of excessive uneasiness and apprehension) hemiparesis (partial paralysis affecting only one side of the body) following a stroke, and epilepsy (central nervous system (neurological) disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired decision-making skill. The MDS documented the resident did not walk, required extensive staff assistance for bed mobility, transfers, dressing, toileting, and hygiene. [...]

Inspectors wroteThe facility had a census of 122 residents. The sample included 25 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report multiple episodes of systolic blood pressures outside of physician ordered parameters for Resident (R)15. This place R15 at risk for physical decline and complications related to low blood pressures.

Inspectors wroteThe facility had a census of 122 residents. The sample included 25 residents, with five reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to hold amlodipine (a medication for high blood pressure) when systolic blood pressures were out of parameter for one of five sampled residents, Resident (R) 15. This placed R15 at risk for physical decline and complications related to low blood pressure.