Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Jul 28, 2025
Visit Reason
A complaint investigation was conducted with no deficiencies cited.
Complaint Details
Intake # 00137011
Findings
A complaint investigation was conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
Investigation of multiple intakes was conducted with no deficiencies cited.
Complaint Details
Intakes # 00134938, AZ00165621, AZ00163161
Findings
Investigation of multiple intakes was conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: May 29, 2025
Visit Reason
Complaint survey conducted with no deficiencies cited.
Complaint Details
Intakes # 00130899, 00131256, AZ00187124, AZ00186889, AZ00177639
Findings
Complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Apr 16, 2025
Visit Reason
Complaint survey conducted with no deficiencies cited.
Complaint Details
Intakes # 00125120, 00124120, 00121996, AZ00221375
Findings
Complaint survey conducted with no deficiencies cited.
Inspection Report
Routine
Deficiencies: 3
Date: Jan 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, food safety, infection prevention, and medication administration in the nursing home.
Findings
The facility was found deficient in ensuring resident safety regarding medication self-administration, proper food labeling and storage, and infection prevention related to catheter care. Specific issues included unauthorized medications at a resident's bedside, expired and unlabeled food items, and catheter bags improperly placed on the floor increasing infection risk.
Deficiencies (3)
Failed to ensure that one sampled resident was safe to self-administer medication, with unauthorized medications found at bedside without physician orders or assessments.
Failed to ensure food was properly labeled, with expired pork breast found in the kitchen without proper open or expiration dates.
Failed to maintain infection prevention and control standards regarding catheter bags for two residents, with catheter bags observed lying on the floor.
Report Facts
Days past expiration: 22
Days past expiration: 15
Catheter size: 16
Catheter balloon size: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN/staff #83) | Entered resident #36's room and noted medications at bedside | |
| Licensed Practical Nurse (LPN/staff #257) | Stated residents cannot bring medications and described medication handling policy | |
| Chief Clinical Officer (CCO/staff #218) | Oversaw clinical staff and described medication self-administration policy and infection control | |
| Dietary Director (staff #277) | Observed expired food and described food labeling policies | |
| Dietitian (staff #112) | Participated in kitchen tour and food safety observations | |
| Kitchen staff (staff #65) | Described food labeling and discarding procedures | |
| Certified Nursing Assistant (CNA/staff #25) | Described catheter bag infection control practices | |
| Licensed Practical Nurse (LPN/staff #269) | Described catheter care procedures | |
| Certified Nursing Assistant (CNA/staff #138) | Described catheter care frequency and catheter bag emptying | |
| Licensed Practical Nurse (LPN/staff #300) | Described catheter bag placement and infection risks |
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 4
Date: Jan 21, 2025
Visit Reason
Recertification survey with complaint investigation citing 8 deficiencies related to medical records, infection control, food contracts, and premises maintenance.
Complaint Details
Intakes # AZ00222090, AZ00222091, AZ00221304, AZ00221306, AZ00221110, AZ00221113, AZ00218939, AZ00217235, AZ00217236, AZ00210501, AZ00210502, AZ00204760, AZ00203971, AZ00203972, AZ00199599, AZ00199600, AZ00199516, AZ00199517, AZ00199275, AZ00198520, AZ00198320, AZ00198321, AZ00198255, AZ00204749, AZ00204792, AZ00204794, AZ00204788, AZ00204789, AZ00222299, AZ00222301, AZ00222424, AZ00222426
Findings
Recertification survey with complaint investigation citing 8 deficiencies related to medical records, infection control, food contracts, and premises maintenance.
Deficiencies (4)
R9-10-411.A — Medical record maintenance
R9-10-422 — Infection control program
R9-10-423.A — Food establishment contracts
R9-10-425.A — Premises and equipment maintenance
Inspection Report
Capacity: 179
Deficiencies: 1
Date: Jan 21, 2025
Visit Reason
Recertification survey for Medicare under Life Safety Code 2012 with no deficiencies noted based on acceptance of a plan of correction.
Findings
Recertification survey for Medicare under Life Safety Code 2012 with no deficiencies noted based on acceptance of a plan of correction.
Deficiencies (1)
Corridor - Doors — Doors protecting corridor openings not maintained
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
Onsite complaint survey conducted with no deficiencies cited.
Complaint Details
Intake # AZ00221636, AZ00221559
Findings
Onsite complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Dec 30, 2024
Visit Reason
Investigation of complaints conducted with no deficiencies cited.
Complaint Details
Complaints AZ00220427, AZ00221043, AZ00220999
Findings
Investigation of complaints conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
Complaint survey conducted with no deficiencies cited.
Complaint Details
Complaint #AZ00218287
Findings
Complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 31, 2024
Visit Reason
The inspection was conducted following a complaint alleging resident-to-resident verbal abuse during a bingo game involving residents #30 and #54.
Complaint Details
The complaint investigation substantiated that resident #54 verbally abused resident #30 during a bingo game on October 19, 2024, using racial slurs and derogatory language. Staff #48 witnessed the incident but did not intervene or report it immediately. Other staff members were informed later and took corrective actions including excluding the residents from bingo the following day. The facility policy requires immediate reporting and intervention, which was not followed.
Findings
The facility failed to prevent and appropriately respond to verbal abuse between residents #30 and #54, where resident #54 used derogatory language towards resident #30 during a bingo game. Staff failed to intervene or report the incident immediately, violating facility policies on abuse prevention and reporting.
Deficiencies (2)
Failed to protect resident #30 from verbal abuse by resident #54.
Failed to respond appropriately to alleged verbal abuse and failed to intervene and report the incident immediately.
Report Facts
Residents affected: 2
Date of survey completed: Oct 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #48 | Receptionist | Witnessed the verbal abuse incident but failed to intervene or report immediately |
| Staff #77 | Activities Assistant | Reported the incident to supervisor after bingo and was instructed to stop the game if incident recurred |
| Staff #62 | Social Services Director | Supervised receptionists and provided education to Staff #48 about failure to report the incident |
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 2
Date: Oct 30, 2024
Visit Reason
Onsite complaint survey citing 2 deficiencies related to abuse reporting and resident abuse prevention.
Complaint Details
Intakes #AZ00217941, AZ00217815
Findings
Onsite complaint survey citing 2 deficiencies related to abuse reporting and resident abuse prevention.
Deficiencies (2)
R9-10-403.F — Abuse reporting and intervention
R9-10-410.B — Resident abuse prevention
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Sep 24, 2024
Visit Reason
Complaint survey conducted with no deficiencies cited.
Complaint Details
Complaint # AZ00215759
Findings
Complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Sep 4, 2024
Visit Reason
Onsite complaint survey conducted with no deficiencies cited.
Complaint Details
Intake # AZ00215227
Findings
Onsite complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Aug 27, 2024
Visit Reason
Onsite complaint survey conducted with no deficiencies cited.
Complaint Details
Intake # AZ00214979
Findings
Onsite complaint survey conducted with no deficiencies cited.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
The inspection was conducted as an annual survey of Plaza Healthcare to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Capacity: 179
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
Recertification survey conducted with no deficiencies cited.
Findings
Recertification survey conducted with no deficiencies cited.
Inspection Report
Capacity: 179
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
Recertification survey for Life Safety Code compliance with no deficiencies cited.
Findings
Recertification survey for Life Safety Code compliance with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
Onsite complaint survey conducted with no deficiencies cited.
Complaint Details
Intake #AZ00197410
Findings
Onsite complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
Onsite complaint survey conducted with no deficiencies cited.
Complaint Details
Intake #AZ00195521
Findings
Onsite complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Capacity: 179
Deficiencies: 0
Date: Apr 7, 2023
Visit Reason
Onsite complaint survey conducted with no deficiencies cited.
Complaint Details
Intakes # AZ00192933, AZ00193145
Findings
Onsite complaint survey conducted with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 16, 2022
Visit Reason
The inspection was conducted to investigate complaints related to informed consent for psychotropic medications, resident notification of room changes, implementation of care plans regarding safety interventions, food safety and hygiene practices, and infection control compliance.
Complaint Details
The investigation was complaint-driven, focusing on issues including informed consent for psychotropic medications, resident notification of room changes, care plan adherence, food safety, and infection control practices. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure timely informed consent for psychotropic medications, proper written notification to resident representatives prior to room changes, adherence to care plans for same gender caregiver requests, proper food handling and hygiene practices including hair restraints and clean kitchenware, and consistent use of PPE by staff, potentially risking resident safety and infection transmission.
Deficiencies (5)
Failure to ensure residents or their representatives were informed of risks and benefits of psychotropic medications prior to administration.
Failure to provide written notice to resident's responsible party prior to or after a room change.
Failure to implement a care plan ensuring safety plan interventions such as female-only staff for certain care activities.
Failure to ensure staff wore hair restraints properly, maintain clean kitchenware, and clean fans in the kitchen.
Failure to ensure staff followed infection control standards related to wearing PPE properly.
Report Facts
Sample size: 5
Sample size: 2
Sample size: 24
Residents affected: 1
Residents affected: 1
Residents affected: 1
Dates of room change forms completed: 5
Dates of medication orders: 2
Dates of medication administration: 2
Dates of Psychoactive Medication Consent forms: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Social Services | Interviewed regarding psychotropic medication consent process |
| Staff #229 | Health Information Director | Interviewed regarding audits of psychotropic medication consents |
| Staff #192 | Director of Nursing | Interviewed regarding psychotropic medication consent and room transfer policies |
| Staff #214 | Registered Nurse | Interviewed regarding room transfer notification procedures |
| Staff #2 | Director of Social Services | Interviewed regarding room transfer process and documentation |
| Staff #213 | Registered Nurse | Interviewed regarding room transfer notification |
| Staff #102 | Administrator | Interviewed regarding room transfer issue and quality assurance |
| Staff #145 | Certified Nursing Assistant | Interviewed regarding same gender caregiver requests |
| Staff #42 | Licensed Practical Nurse | Interviewed regarding same gender caregiver requests |
| Staff #154 | Certified Nursing Assistant | Interviewed regarding care provision and documentation for same gender caregiver requests |
| Staff #204 | Director of Nursing Level I | Interviewed regarding care plan adherence and staffing constraints |
| Staff #179 | Director of Nutritional Services | Interviewed regarding food safety, hair restraints, and PPE compliance |
| Staff #178 | Dishwasher | Observed with improper PPE use |
| Staff #203 | Cook | Observed with improper PPE use |
| Staff #21 | Infection Preventionist | Interviewed regarding infection control policies and outbreak status |
Viewing
Loading inspection reports...
