Plaza West

Inspectors wroteBased on record review and interview, the facility failed to complete the Nursing Home Transfer and Discharge Notice, notify the receiving facility, and document a discharge summary for two residents (#98 and #8) out of two residents sampled.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide quality care and services related to wound care for three residents (#56, #58, #11) out of three sampled residents. Findings Included: 1. During an observation on 07/28/2025 at 12:23 p.m., Resident #56 was observed sitting in a wheelchair with undated white bandages around both of her lower legs. Review of Resident #56's admission record revealed an initial admission date of 04/17/2025. Resident #56 was admitted with diagnosis to include partial intestinal obstruction, unspecified as to cause, acute embolism and thrombosis of unspecified deep veins of left lower extremity, and peripheral vascular disease, unspecified. Review of Resident #56's Medicare 5-day Minimum Data Set (MDS) revealed Section M. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to accurately assess and implement appropriate interventions for two residents (#2 and #8) of six residents sampled for accidents.

Inspectors wroteBased on observations and interviews the facility did not ensure food service standards were followed related to hand hygiene and sanitary practices in the main kitchen and in one of three satellite kitchens.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to the storage of urinary catheters for one resident (#104) of one resident sampled, failed to perform appropriate hand hygiene during the administration of medications for one resident (#33) of six residents observed during medication administration observation, failed to ensure one Staff (C) out of 25 staff fingernails were kept in a manner that allowed for hand hygiene to be completed in a sanitary manner, and failed to implement Enhanced Barrier Precautions (EBP) for three residents (#56, #58 and #11) of seven residents sampled for infection control practices. 1. Review of Resident #56's admission Record revealed an initial admission date of 04/17/2025. [...]

Inspectors wroteBased on observations, medical record review and staff interviews, the facility failed to ensure care plan interventions were implemented for one resident (#6) of three sampled residents related to positioning during enteral nutrition administration.

Inspectors wroteBased on observations, interviews and record review the facility failed to assist with the placement of hearing aids for one resident (#17) out of one resident sampled. Findings Included: During an interview on 07/28/2025 at 10:21 a.m. Resident #17 stated You will have to come closer and speak louder, I don't have my hearing aids in, so I can't hear you. I don't know where my hearing aids are you will have to check with my son. Resident #17 was observed to not have hearing aids in during the interview. During a phone interview on 07/29/2025 at 1:08 p.m., Resident #17's Family Member (FM) stated he has spoken with the facility a few times about helping his mom with her hearing aids. He stated they always forget to charge them so she can't use them. We have family who want to call and talk with her, but if she does not have her hearing aids in, she cannot use the phone. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to accurately assess and notify the physician related to resident's pain and ineffectiveness of the prescribed pain medication for one resident (#38) of two sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure timely administration of medications, as prescribed by the medical provider, and did not ensure medications were administered by a medical professional for one Resident (#106) out of one resident reviewed. The facility also failed to administer scheduled psychotropic medication per physician orders for one resident (#110) out of five medication administration observations.

Inspectors wroteBased on record review and interview the facility failed to ensure an anti-anxiety medication had an appropriate indication for it's use for one resident (#10) out of five residents sampled.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed and five errors were identified for three (Residents #73, #50, and #86) of four residents observed. These errors constituted a 16.13% medication error rate.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure medications stored at the bedside were assessed for safe administration for one (Resident #336) of twenty-five sampled residents. Findings Included: On 05/08/2023 at 09:41 a.m., Resident #336 was observed lying in his bed and was receptive to an interview. When he spoke, his speech was soft toned and garbled at times. His son was present and assisted with the interview. Resident #336 appeared comfortable and denied any discomfort when asked. On his over the bedside table an inhaler was present. Resident #336 stated, it's for my Parkinson's and confirmed he took it on his own as needed. On 05/09/2023 at 2:45 p.m., Resident #336 was lying in his bed with his eyes closed and appeared comfortable. His son was present at the time and confirmed his inhaler remained in his bedroom. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that appropriated care and services related to the use of oxygen was provided to 1 of 25 (#187) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure recommendations reported by the consultant pharmacist regarding irregularities in the resident's drug regimen were acted upon for one (Resident #12) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain the kitchen in a safe and sanitary manner related to failing to ensure that the range hood was free from dust and grease.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that the resident care plan for one (Resident #138) of twenty eight sampled residents was revised to reflect the appropriate use of a Cervical Collar.

Inspectors wroteBased on record review, and interviews, it was determined that the facility failed to ensure physician orders were followed as written according to professional quality of care standards for nursing for one (Resident #138) of twenty eight sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and two errors were identified for two (Residents #21 and #10) of nine residents observed. These errors constituted a 6.67% medication error rate.

Inspectors wroteBased on observations, policy review, and interviews the facility failed to ensure that a supplement with a shortened shelf life was dated when opened in one (Med Cart 1) out of three Medication Carts sampled, expired medications were disposed of, and inhalation medications were stored appropriately in one (1 South Med Room) of one Medication Preparation room.