The Plaza at Lubbock

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff, and the public, for 2 of 4 shower rooms (Hall 200 and Hall 400) and 1 of 1 public toilet, reviewed for physical environment. The facility failed to ensure:The shower room on hall 200 had loose and missing tiles in numerous areas of the showerThe shower room on hall 400 had loose and missing tiles in numerous areas of the shower. The door to the shower room on hall 200 was broken. The vanity in shower room [ROOM NUMBER] contained water damage. The hand sink in shower room [ROOM NUMBER] contained corrosion and calcium build up under the sink faucet. The toilet seat in the public bathroom near the nurse's station was loose. This failure could lead to residents falls, injuries, and experiencing a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that was palatable, attractive and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 (Lunch) meal reviewed for palatability. 1) The facility failed to provide food that was palatable for the lunch meal on 01/07/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to store bowls and plates upside down, ensure the deep fryer was cleaned, ensure no expired food items were in the kitchen, ensure all food items in the refrigerator were properly labeled or stored in airtight containers, ensure all food items in the dry storage area were properly sealed, and ensure the oven door was clean. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 9 residents observed for infection control (Resident #33, #98, #94, and #8) .LVN A failed to utilize enhanced barrier precautions (EBP) during medication administration for Resident #98. The facility failed to ensure Resident #94 had an EBP sign on her door and a personal protective equipment (PPE) box available. CNA B failed to remove the dirty pad from the bed during incontinence care for Resident #33. CNA C failed to change his gloves during incontinence care for Resident #8. CNA D failed to utilize hand hygiene between glove changes during incontinence care for Resident #8. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I assessments accurately reflected the resident's status for 2 of 24 residents (Residents #16 and #5) reviewed for PASRR screening, in that:The facility failed to ensure:Residents #5 and #16's PASRR Level 1 assessment did not indicate a diagnosis of mental illness. These failures could place residents who had a mental illness at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 1 of 1 noon meals observed for puree texture. The facility failed to ensure puree meat, and spinach bake were prepared to a smooth uniform texture on 01/07/26. This failure could place residents at risk of decreased food intake, choking and aspiration.

Inspectors wroteBased on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) for 1 of 7 residents reviewed for advanced directives. (Resident #1, #2, #3, #4, #5, #6, and #7). The RN A did not initiate CPR for Resident #1 when Resident #1 was found with no pulse or respirations. Resident #1 was listed as Full Code (all resuscitation procedures are provided to keep a person alive during a medical emergency). This failure could place all residents in the facility who requested a full code status at risk of death. An Immediate Jeopardy situation was identified on [DATE] at 3:20 PM. [...]

Inspectors wroteBased on interviews and record review, the facility failed to notify the residents physician and representative regarding a change in the resident's condition, for 1 of 2 residents (Resident #1) reviewed for changes in condition. 1. RN C failed to notify Resident #1's family and physician when RN C administered Resident #2's lorazepam to Resident #1 on 11/21/2024. This failure could place residents at risk of not having their family and physicians notified of changes resulting in a delay in decision making for medical interventions.

Inspectors wroteBased on interviews and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 3 residents (Resident #1), reviewed for pharmacy services. 1. The facility failed to ensure Resident #1 was free of significant medication errors when a dose of lorazepam 1 mg was administered on 11/21/2024 by RN C. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure residents the right to be free from abuse and/or neglect for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for abuse and/or neglect. 1. The facility failed to keep RN A made inappropriate sexual comments to Resident #1 resulting in Resident #1 feeling ashamed and embarrassed. 2. The facility failed to ensure that CNA B did not refuse to change Resident #2 when Resident #2's brief was saturated. 3. The facility failed to ensure that CNA B did not make verbally abusive comments to Resident #2 when Resident #2 was talking to CNA B 4. The facility failed to ensure that CNA B was not excessively rough when transferring Resident #3 from wheelchair to the commode. [...]

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of (Resident #4) 10 residents reviewed for misappropriation of property. The facility did not prevent CNA F from taking a bag of chips from Resident #4. This failure could place residents at risk of continued misappropriation of property.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 7 of 18 confidential residents. The facility failed to ensure 7 of 18 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, were provided access to the Grievance form, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group, individual activities, and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of 7 of 18 residents (confidential residents) reviewed for quality of life. The facility: 1. Failed to engage in activities at scheduled times. 2. Failed to offer engaging activity replacement for scheduled activities that were cancelled or not completed. This failure could affect Residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1of 2 treatment carts observed for pharmacy services. The facility failed to ensure 1 tube of Medih [NAME] Gel and 1 tube of zinc oxide ointment were dated when opened. The facility failed to ensure that all medical supplies in the treatment cart were not past their expiration date. The facility failed to ensure single use open collagen packets were not stored in the treatment cart after being opened. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure food was accurately dated and labeled. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 4 Residents and 5 of 5 staff members (LVN A, CNA A, CNA C, CNA E and CNA F) observed for infection control practices (Resident #7, #15, #87, and #257). in that: 1. CNA A failed to use proper hand hygiene before or after assisting with incontinent care for Resident #7. 2. CNA C failed to use proper hand hygiene before or after assisting with wound care for Resident #15. 3. LVN A failed to use proper wound care techniques and CNA D did not use proper hand hygiene before or after assisting with wound care for Resident #87 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal privacy was provided for 1 of 1 residents reviewed for dignity. (Resident #257) 1. CNA D and LVN A failed to pull the privacy curtain while providing wound care for Resident #257. These failures could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing for 2 of 2 residents (Residents #87 and Resident #257) reviewed for pressure ulcer care. 1. LVN A failed to use the correct wound techniques during wound care for Resident #87 and #257. These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new pressure ulcers, worsening of existing pressure ulcers, and infection.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 7 (Resident #1) residents in that: The facility failed to ensure Resident #1 was treated with respect, dignity, and care when they failed to obtain clear informed consent on 8/11/2024 at approximately 3:30 AM, to perform a straight catheter procedure to collect a urine sample. An Immediate Jeopardy (IJ) situation was determined to have existed on 8/11/24. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse for 2 of 7 residents (Resident #1 and Resident #2) reviewed for abuse in that: 1. The facility staff failed to protect Resident #1 from abuse when staff woke up the resident at approximately 3:30 AM on 8/11/24 and performed an invasive straight catheter procedure which caused Resident #1 physical pain and mental anguish, and Resident #1 reported she felt violated, traumatized, abused, and raped. 2. The facility failed to protect Resident #2 from verbal abuse from CNA C, when CNA C continued call Resident #2 names and belittle him and made a threat to do it again (call him names), at the nurse's station after being told to stop. An Immediate Jeopardy (IJ) situation was determined to have existed on 8/11/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 7 residents (Resident #1) reviewed for physician notification of changes. 1. The facility failed to follow their policy on change of condition by not immediately notifying the physician, and DON of Resident #1's UTI symptoms on 8/9/2024. 2. The facility failed to consult with Resident #1's physician and provide all necessary details, when Resident #1 complained of feeling burning and discomfort when urinating on 8/9/2024. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident, who was continent of bowel and bladder, received appropriate treatment for a urinary tract infection, for 1 of 7 residents (Resident #1) reviewed for urinary straight catheters. 1. The facility failed to ensure Resident #1 had a physician order prior to performing a straight catheter procedure. 2. The facility failed to follow their policy on urine specimen collection by not determining the appropriate measurement method for urine collection. 3. The facility failed to follow their policy on physician orders by not receiving and transcribing physician orders for a UA recollection for Resident #1. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 7 residents (Resident #1) reviewed for laboratory services in that: 1. The facility failed to follow physician standing orders for lab blood analysis, on facility admission of Resident #1. These failures could place residents at risk of not having laboratory services completed and cause delay in their care.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 7 residents (Residents #1) reviewed for accuracy of medical records in that 1. The facility failed to document communication between RN D and Resident #1 when Resident #1 reported feeling as if she had a UTI on 8/9/2024. 2. The facility failed to document Resident #1's change in condition when she reported to staff, she felt she had a UTI on 8/9/2024. 3. The facility failed to document communication between RN D and FNP when Resident #1 reported feeling as if she had a UTI and obtaining an order for the UA on 8/9/2024. 4. The facility failed to document communication between staff and FNP when a contaminated UA sample was reported to the facility on 8/10/24 at 8:30pm for Resident #1. 5. [...]

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 39 of 46 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10,#11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, # 27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40 and #41) The facility failed to ensure MA F administered medications to (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10,#11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, # 27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40 and #41) accurately within the 2 hour window per physician orders. [...]

Inspectors wroteBased on record review and interview the facility failed to maintian residnet medical records in accordance with accepted professional standards and practicies. The facility must maintain medical records on each resident that are accurately documented. The facility failed to ensure staff documented medications given to residents in the Medication Administration Record for 41 of 46 ((Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10,#11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, # 27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40 and #41) ) reviewed for acurrate documentation. This failure could place residents at risk of receiving incorrect amounts of medication as prescribed by their physician

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a change in residents health status for 2 of 46 residents (Residents #6 & # 25) reviewed for notification of changes. This failure could affect all Residents by causing their physicians, and representatives to be unaware of changes in a Resident's condition.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, psychosocial status and when there was a need to alter treatment significantly for 1 of 5 resident (Resident #1) reviewed for notification of changes. The facility failed to immediately consult with the resident's responsible party when Resident #1 expired. This failure could place residents at the risk of not being aware/informed of residents' condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 CNA of 7 employees observed during infection control observation. The facility failed to ensure CNA A properly removed his N-95 mask after exiting a COVID positive resident room. The facility failed to ensure CNA A disinfected his hands after removing his N-95 mask. These failures could place residents at risk of transmission of a communicable disease or infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical soft and pureed) at 1 of 1 meal observed (8/23/23 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services and 10 of 24 resident rooms (rooms 102, 109, 202, 205, 206, 211, 212, 213, 214 and 215), in that: 1)The facility failed to ensure foods were processed under sanitary conditions, 2) The facility failed to ensure Dietary staff dated and labeled foods as required, 3) The facility failed to ensure Dietary staff maintained quaternary sanitizer levels within acceptable ranges in wiping cloth solutions. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 7 of 29 residents ( Resident #9, #11, #14, #33, #92, #250 and #303) reviewed for resident rights . 1. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #9, #14, #92, #250 and #303 prior to administering melatonin (sleep aide). 2. [...]

Inspectors wroteBased on observation, interview and record, review the facility, failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 4 of 4 common baths (100, 200, 300 and 400), resident transport van and 19 of 29 resident rooms (101, 102, 109, 110, 112, 113, 203, 204, 205, 206, 207, 209, 210, 211, 212, 213, 214, 215 and 216) reviewed for environment, The facility failed to ensure resident that use common areas and rooms were clean, safe and did not need repair. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receiving psychotropic medications had an approved diagnosis and PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, for 4 of 29 residents (Resident #11, Resident #38, Resident #92 and Resident #250): Resident #11 continued to have a PRN order for Lorazepam 0.25mL after 14 days without an evaluation by the physician for continued treatment. Resident #38 was receiving Klonopin 0.5mg and Olanzapine 2.5mg without an adequate diagnosis. Resident #92 continued to have a PRN order for Hydroxyzine 25mg after 14 days without an evaluation by the physician for continued treatment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure menus were followed for 1 of 3 food forms (puree) for 5 residents (Residents #1, 2, 32, 33 and 38) reviewed during mealtime. The facility failed to ensure Residents #1, 2, 32, 33 and 38 received their meals according to the menu. This failure could place residents at risk for unwanted, weight loss and hunger.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 nonsmoking facility observed for safety and cleanliness in that: The facility failed to ensure that the facility was non-smoking and that staff adhered to the facility policy. The facility failed to dispose of cigarette butts safely. These failures place residents, staff, and visitors at risk of being in an unsafe environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 29 (Resident #2) residents in that: Hospice CNA A provided Resident #2 personal care (bathing and brief change) with the privacy curtain not pulled, door open, and window blinds open. This could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder, received appropriate treatment and services to prevent urinary tract infections for 2 of 2 resident with a urinary catheter (Resident #55 and #304); in that: 1. The facility failed to ensure catheter drainage bag was covered for privacy. 2. The facility failed to position the catheter tubing in a manner to prevent infections. These failures could place residents at risk for urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly in 1 of 1 refuse disposal areas which included 1 dumpster and 1 grease disposal container, in that: The facility failed to maintain the dumpster and the grease disposal container in a manner that effectively prevented the harborage and attraction of pest. These failures could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 kitchen, in that: The facility failed to ensure the kitchen steamtable was maintained in safe operating condition. This failure could place residents at risk for receiving cold meals and at risk for fire emergencies.