20 Reports
Inspection Report — Jul 28, 2025
Complaint Investigation
Date: Jul 28, 2025
Visit Reason
On-site complaint investigation of intake numbers 00137011 and 2567181 at a Nursing Care Institution, conducted 28 July 2025.
Complaint Details
A complaint investigation was conducted on July 28, 2025 of intake # 00137011 and intake # 2567181. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 9, 2025
Complaint Investigation
Date: Jul 9, 2025
Visit Reason
On-site complaint investigation of intakes 00134938, AZ00165621, AZ00163161, AZ00225032, AZ00165620, and AZ00163158 at a Nursing Care Institution, conducted 9 July 2025.
Complaint Details
Investigation of intakes # 00134938, AZ00165621, AZ00163161, AZ00225032, AZ00165620, and AZ00163158 was conducted on July 9, 2025. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 6
Inspection Report — May 29, 2025
Complaint Investigation
Date: May 29, 2025
Visit Reason
On-site complaint investigation of intakes 00130899, 00131256, AZ00187124, AZ00186889, AZ00177639, AZ00224549, AZ00224585, AZ00187121, AZ00186889, and AZ00177638 at a Nursing Care Institution, conducted 29 May 2025.
Complaint Details
The complaint survey was conducted on May 29, 2025, investigating multiple intake numbers including 00130899, 00131256, AZ00187124, AZ00186889, AZ00177639, AZ00224549, AZ00224585, AZ00187121, AZ00186889, and AZ00177638. No deficiencies were cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 10
Inspection Report — Apr 16, 2025
Complaint Investigation
Date: Apr 16, 2025
Visit Reason
On-site complaint investigation of complaints 00125120, 00124120, 00121996, AZ00221375, AZ00224013, AZ00223956, AZ00223750, and AZ00221374 at a Nursing Care Institution, conducted 16 April 2025.
Complaint Details
A complaint survey was conducted on April 16, 2025 through April 16, 2025 of intakes # 00125120, 00124120, 00121996, AZ00221375, AZ00224013, AZ00223956, AZ00223750, AZ00221374. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 8
Inspection Report — Jan 30, 2025
Date: Jan 30, 2025
Visit Reason
On-site other inspection of a Nursing Care Institution at Plaza Healthcare, conducted 30 January 2025.
Findings
The inspection found one deficiency related to the failure to maintain corridor doors properly, which could allow smoke to pass between rooms and pose a risk to patients and staff.
Deficiencies (1)
NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5 — The facility failed to maintain several corridor doors, resulting in gaps and door play that would not prevent smoke from traveling between rooms, confirmed by management during the tour and exit conference.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 24, 2025
Routine
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 — Jan 24, 2025
Annual Inspection
Date: Jan 24, 2025
Visit Reason
On-site combined complaint investigation and annual recertification survey conducted January 21 through January 24, 2025, at Plaza Healthcare, covering multiple complaint intake numbers including AZ00222090, AZ00222091, AZ00221304, and others.
Complaint Details
The recertification survey was conducted January 21, 2025 through January 24, 2025 in conjunction with the investigation of intake numbers 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, and AZ00222426.
Findings
Eight deficiencies were cited during this inspection. No evidence details were provided for any of the deficiencies.
Deficiencies (8)
R9-10-411 — No evidence was provided regarding the establishment and maintenance of medical records for each resident as required.
R9-10-411 — No evidence was provided regarding the establishment and maintenance of medical records for each resident as required.
R9-10-422 — No evidence was provided regarding the establishment of an infection control program to prevent infections and communicable diseases.
R9-10-422 — No evidence was provided regarding the establishment of an infection control program to prevent infections and communicable diseases.
R9-10-423 — No evidence was provided regarding the facility's ability to store, refrigerate, and reheat food to meet residents' dietary needs when contracting with a food establishment.
R9-10-423 — No evidence was provided regarding the facility's ability to store, refrigerate, and reheat food to meet residents' dietary needs when contracting with a food establishment.
R9-10-425 — No evidence was provided regarding the premises and equipment being free from conditions that may cause physical injury to residents or individuals.
R9-10-425 — No evidence was provided regarding the premises and equipment being free from conditions that may cause physical injury to residents or individuals.
Report Facts
Deficiencies cited: 8
Complaints investigated: 33
Inspection Report — Jan 7, 2025
Complaint Investigation
Date: Jan 7, 2025
Visit Reason
On-site complaint investigation of intakes AZ00221636 and AZ00221559 at a Nursing Care Institution, conducted 7 January 2025.
Complaint Details
An onsite complaint survey was conducted on January 7, 2025 for the investigation of intake # AZ00221636, AZ00221559. There were no deficiencies cited. Federal comments also note an onsite complaint survey for intake # AZ00221635, AZ00221559 with no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Dec 30, 2024
Complaint Investigation
Date: Dec 30, 2024
Visit Reason
On-site complaint investigation of complaints AZ00220427, AZ00221043, AZ00220999 at a Nursing Care Institution, conducted 30 December 2024.
Complaint Details
The investigation of complaints AZ00220427, AZ00221043, AZ00220999 was conducted on 12/30/2024. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Nov 14, 2024
Complaint Investigation
Date: Nov 14, 2024
Visit Reason
On-site complaint investigation of complaint AZ00218287 at a Nursing Care Institution, conducted 14 November 2024.
Complaint Details
The Complaint survey was conducted on November 14, 2024 for the investigation of the complaint #AZ00218287. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 1
Inspection Report — Oct 31, 2024
Complaint Investigation
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 — Sep 24, 2024
Complaint Investigation
Date: Sep 24, 2024
Visit Reason
On-site complaint investigation of complaints AZ00215759 and AZ00215755 at a Nursing Care Institution, conducted 24 September 2024.
Complaint Details
The complaint survey was conducted on September 24, 2024 of the following complaint # AZ00215759. The complaint survey was conducted on September 24, 2024 of the following complaint #AZ00215755. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Sep 4, 2024
Complaint Investigation
Date: Sep 4, 2024
Visit Reason
On-site complaint investigation of intake AZ00215227 and AZ00215226 at a Nursing Care Institution, conducted 4 September 2024.
Complaint Details
An onsite complaint survey was conducted on September 4, 2024 for the investigation of intake # AZ00215227. An onsite complaint survey was conducted on September 4, 2024 for the investigation of intake # AZ00215226.
Findings
This inspection found no deficiencies.
Inspection Report — Aug 27, 2024
Complaint Investigation
Date: Aug 27, 2024
Visit Reason
On-site complaint investigation of intake numbers AZ00214979 and AZ00214978 at a Nursing Care Institution, conducted 27 August 2024.
Complaint Details
An onsite complaint survey was conducted on August 27, 2024 for the investigation of intake # AZ00214979 and intake # AZ00214978. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Aug 10, 2023
Date: Aug 10, 2023
Visit Reason
On-site other inspection of a Nursing Care Institution at Plaza Healthcare, conducted 10 August 2023.
Findings
No deficiencies were found during this inspection. The facility met all applicable federal, state, and local standards.
Inspection Report — Aug 10, 2023
Annual Inspection
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 — Jul 7, 2023
Complaint Investigation
Date: Jul 7, 2023
Visit Reason
On-site complaint investigation of intake #AZ00197410 and intake #AZ00197409 at a Nursing Care Institution, conducted 6-7 July 2023.
Complaint Details
An onsite survey was conducted on July 6, 2023 through July 7, 2023 for the investigation of intake #AZ00197410. A complaint survey was conducted on July 6, 2023 through July 7, 2023 for the investigation of intake #AZ00197409. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jun 5, 2023
Complaint Investigation
Date: Jun 5, 2023
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On-site complaint investigation of intake AZ00195521 at a Nursing Care Institution, conducted 5 June 2023.
Complaint Details
An onsite survey was conducted on June 5, 2023 for the investigation of intake #AZ00195521. No deficiencies were cited. A complaint survey was conducted on June 5, 2023 for the investigation of intake #AZ00195521. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jun 16, 2022
Complaint Investigation
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 |
Inspection Report — Jun 16, 2022
Routine
Date: Jun 16, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication consent, room transfers, food safety, and infection control at Plaza Healthcare.
Findings
The facility was found deficient in ensuring informed consent for psychotropic medications, providing written notice for room changes, implementing care plans respecting resident preferences, maintaining food safety standards including proper hair restraints and clean kitchenware, and enforcing infection control practices such as proper PPE use.
Deficiencies (5)
Failed to ensure one resident and/or their representative were informed of the risks and benefits of psychotropic medication prior to administration.
Failed to ensure one resident's responsible party was provided written notice prior to a room change or after the room change occurred.
Failed to implement a complete care plan for one resident regarding safety plan interventions, specifically same gender caregiver preferences.
Failed to ensure staff wore hair restraints appropriately, maintain clean kitchenware, and keep fans clean in the kitchen.
Failed to ensure staff followed infection control standards related to wearing PPE, including proper use of N95 masks.
Report Facts
Sample size: 5
Sample size: 2
Sample size: 24
Dates of room change forms completed: 7/6/2021, 10/5/2021, 12/30/2021, 1/11/2022, 1/18/2022
Dates of medication orders: Diazepam order dated 2022-02-17, Escitalopram order dated 2022-02-24
Dates of medication administration: Diazepam first administered 2022-02-17, Escitalopram first administered 2022-02-25
Dates male staff provided care contrary to care plan: May 9, 13, 28 and June 8, 12, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services staff #4 | Interviewed regarding psychotropic medication consent process | |
| Health Information Director staff #229 | Interviewed regarding consent audits and uploading | |
| Director of Nursing (DON) staff #192 | Interviewed regarding psychotropic medication consent and room transfer policies | |
| Registered Nurse (RN) staff #214 | Interviewed regarding room transfer notification process | |
| Registered Nurse (RN) staff #213 | Interviewed regarding room transfer notification | |
| Director of Social Services staff #2 | Interviewed regarding room transfer process and documentation | |
| Director of Medical Records staff #229 | Interviewed regarding room transfer form completion | |
| Administrator staff #102 | Interviewed regarding room transfer issue and quality assurance | |
| Certified Nursing Assistant (CNA) staff #145 | Interviewed regarding same gender caregiver requests | |
| Licensed Practical Nurse (LPN) staff #42 | Interviewed regarding honoring same gender caregiver requests | |
| Certified Nursing Assistant (CNA) staff #154 | Interviewed regarding providing care to opposite gender residents | |
| Director of Nursing Level I (DON) staff #204 | Interviewed regarding care plan compliance and staffing constraints | |
| Director of Nutritional Services staff #179 | Interviewed regarding hair restraint, kitchen cleanliness, and PPE use | |
| Infection Preventionist (IP) staff #21 | Interviewed regarding infection control and PPE requirements |
4 CMS Surveys
CMS Survey — Oct 31, 2024
Oct 31, 2024
CMS Survey — Jun 16, 2022
Jun 16, 2022
CMS Survey — Aug 10, 2023
Aug 10, 2023
CMS Survey — Jan 24, 2025
Jan 24, 2025
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