Deficiencies (last 4 years)
Deficiencies (over 4 years)
35.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
497% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
130 residents
Based on a March 2025 inspection.
Census over time
Inspection Report
Routine
Census: 130
Deficiencies: 23
Mar 19, 2025
Visit Reason
The inspection was a routine survey of Plaza West Healthcare and Rehab to assess compliance with regulatory requirements including resident care, environment, medication management, and quality assurance.
Findings
The facility had multiple deficiencies including failure to provide required Medicare notices, maintain a clean environment, address resident behaviors, complete timely assessments and care plans, provide consistent bathing, ensure proper medication management, maintain adequate staffing, and implement infection control precautions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 23
Deficiencies (23)
| Description | Severity |
|---|---|
| Failed to provide form CMS 10055 Advanced Beneficiary Notice to Resident 2 regarding skilled services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a clean, odor-free environment on Hall 400. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to address sexually aggressive behaviors of Resident 121, placing residents at risk of sexual abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete admission comprehensive Minimum Data Set (MDS) assessments timely for Residents 98, 112, and 13. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop baseline care plans including dialysis care for Residents 13, 78, 98, and 295. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plans for Residents 78 and 117 to include interventions for skin tears and pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing for Residents 48, 71, 92, 99, 117, 121, and 125. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete nursing assessments prior to hospital discharge for Residents 35 and 142 and after admission for Resident 128. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement interventions to prevent skin tear for Resident 117 and failed to provide care instructions for Resident 13's back brace. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement preventative interventions for Resident 78 who developed a Stage 3 pressure ulcer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain physician order for oxygen therapy and failed to properly store oxygen cannula for Resident 346. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain orders for dialysis care and failed to provide ongoing assessments and communication for Resident 295 receiving dialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate daily nursing staff were always available to meet resident needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff possessed necessary competencies to provide nursing and related services for Residents 128 and 142. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician involvement for Resident 121 with behaviors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document signatures in the narcotic count log. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify physician of out-of-parameter accu-checks for Resident 29. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document medication administration for Resident 295. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent medication administration errors for Resident 29 receiving wrong dosage of supplement. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to place an open date on Humalog insulin pen for Resident 31. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide meals at regular times comparable to normal mealtimes for residents in Memory Care Unit and other dining areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a hospice plan of care and ensure collaboration with hospice provider for Resident 112. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a sanitary and comfortable environment and failed to provide enhanced barrier precautions for Residents 8 and 88. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 27
Census: 130
Pressure ulcer measurements: 5.01
Pressure ulcer measurements: 4.33
Pressure ulcer measurements: 1.51
Pressure ulcer measurements: 0.1
Braden Scale score: 9
Zinc supplement wrong dose administrations: 6
Accu-checks outside parameters: 25
Accu-checks outside parameters: 17
Accu-checks outside parameters: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements regarding deficiencies, expectations, and corrective actions |
| Licensed Nurse G | Licensed Nurse | Verified medication discrepancies and nursing care issues |
| Certified Medication Aide S | Certified Medication Aide | Reported medication administration and count issues |
| Certified Nurse Aide M | Certified Nurse Aide | Reported resident bathing refusals and care practices |
| Licensed Nurse J | Licensed Nurse | Provided information on care plans and resident care |
| Licensed Nurse I | Licensed Nurse | Discussed MDS assessments and medication orders |
| Certified Nurse Aide O | Certified Nurse Aide | Described bathing care and skin assessments |
| Licensed Nurse Q | Licensed Nurse | Observed infection control breaches with catheter care |
| Certified Nurse Aide Q | Certified Nurse Aide | Failed to don gown during care for resident on enhanced barrier precautions |
Inspection Report
Routine
Census: 130
Deficiencies: 23
Mar 19, 2025
Visit Reason
The inspection was a routine regulatory survey of Plaza West Healthcare and Rehab to assess compliance with Medicare and Medicaid requirements, including resident care, safety, and facility operations.
Findings
The facility had multiple deficiencies including failure to provide required Medicare notices, maintain a clean environment, address resident behaviors, complete timely assessments and care plans, provide consistent bathing, ensure proper nursing assessments for hospital transfers, implement pressure ulcer prevention, provide adequate staffing, ensure medication safety and accuracy, and maintain infection control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 23
Deficiencies (23)
| Description | Severity |
|---|---|
| Failed to provide form CMS 10055 Advanced Beneficiary Notice to Resident 2 regarding skilled services coverage and cost. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a clean, odor-free environment on Hall 400, including strong urine odor and stained furniture. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to address sexually aggressive behaviors of Resident 121, placing residents at risk of sexual abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete admission comprehensive Minimum Data Set (MDS) assessments timely for Residents 98, 112, and 13. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop baseline care plans including dialysis care for Residents 13, 78, 98, and 295. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plans for Residents 78 and 117 to include interventions for skin tears and pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing for Residents 48, 71, 92, 99, 117, 121, and 125, placing residents at risk for poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete nursing assessments prior to hospital discharge for Residents 35 and 142, and failed to complete admission nursing assessment for Resident 128. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement interventions to prevent skin tear for Resident 117 and failed to provide care plan instructions for Resident 13's back brace. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement preventative interventions for Resident 78 who developed a Stage 3 pressure ulcer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain physician order for oxygen therapy and failed to store oxygen tubing properly for Resident 346. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain orders for dialysis care and failed to provide ongoing assessments and communication for Resident 295 receiving dialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate daily nursing staff were always available to meet resident needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff possessed competencies and skills necessary to provide nursing and related services for Residents 128 and 142. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician involvement for Resident 121 with behaviors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document signatures in the narcotic count log. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Consultant Pharmacist identified and reported Resident 29's out-of-parameter accu-checks. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify physician for out-of-parameter accu-checks and failed to document medication administration for Resident 295. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent medication administration errors for Resident 29 receiving wrong dosage of supplement. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to place open date on Humalog insulin pen for Resident 31. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide meals at regular times comparable to normal mealtimes for residents in Memory Care Unit and other dining areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide hospice plan of care and collaboration between hospice provider and facility for Resident 112. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a sanitary and comfortable environment and failed to provide enhanced barrier precautions for Residents 8 and 88. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 27
Census: 130
Pressure ulcer wound measurement length: 4.33
Pressure ulcer wound measurement width: 1.51
Pressure ulcer wound measurement depth: 0.1
Pressure ulcer wound total area: 5.01
Zinc supplement wrong dose administrations: 6
Accu-checks outside physician parameters: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Provided multiple statements regarding deficiencies, expectations, and facility policies | |
| Licensed Nurse G | Verified medication discrepancies and nursing care issues | |
| Certified Medication Aide S | Reported medication administration and count issues | |
| Certified Nurse Aide M | Reported resident bathing refusals and care practices | |
| Licensed Nurse J | Provided statements on care plan and wound care | |
| Certified Nurse Aide O | Described bathing and skin care practices | |
| Licensed Nurse H | Discussed resident refusals and care practices | |
| Licensed Nurse I | Discussed MDS assessments and order entry | |
| Certified Nurse Aide Q | Observed not following enhanced barrier precautions | |
| Licensed Nurse Q | Observed not following enhanced barrier precautions |
Inspection Report
Annual Inspection
Census: 134
Deficiencies: 2
Jan 28, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with respiratory care standards, specifically reviewing respiratory services provided to residents, including medication administration and equipment handling.
Findings
The facility failed to provide necessary respiratory care and services for Resident 1, including missed nebulizer treatments and improper storage of nebulizer equipment, placing the resident at risk for infection and physical complications.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide scheduled ipratropium-albuterol nebulizer treatments to Resident 1, with numerous missed treatments documented over three months. | Level of Harm - Minimal harm or potential for actual harm |
| Improper storage of nebulizer mask and tubing, with tubing found disconnected and laid on the floor. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missed nebulizer treatments: 26
Missed nebulizer treatments: 17
Missed nebulizer treatments: 9
Census: 134
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statements regarding administration and documentation of breathing treatments |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding expectations for administration and documentation of breathing treatments |
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 4
Sep 30, 2024
Visit Reason
The inspection was conducted due to complaints regarding staff treatment of residents with dignity, infection prevention practices, and staff training deficiencies.
Findings
The facility failed to ensure staff treated Resident 1 with dignity, failed to prevent cross-contamination during incontinence care and failed to disinfect equipment between residents, and failed to provide required training on effective communication and resident rights to Certified Nurse Aide M. These deficiencies placed residents at risk for decreased dignity, infection, and impaired communication.
Complaint Details
The complaint investigation was triggered by concerns about staff treating Resident 1 without dignity, improper infection control practices during incontinence care, and inadequate staff training on communication and resident rights. The complaint was substantiated based on video evidence and staff interviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure staff treated Resident 1 with dignity, including inappropriate tone and handling during care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent cross-contamination during incontinence care for Resident 2 and failed to disinfect the Hoyer lift between resident usage. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Certified Nurse Aide M received required effective communication training. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Certified Nurse Aide M received required resident rights training. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 3
Residents Affected: 133
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide M | Certified Nurse Aide | Named in findings related to failure to treat Resident 1 with dignity and lack of required training |
| Certified Nurse Aide O | Certified Nurse Aide | Involved in infection control deficiency related to incontinence care and Hoyer lift use |
| Certified Nurse Aide P | Certified Nurse Aide | Involved in infection control deficiency related to incontinence care and Hoyer lift use |
| Certified Nurse Aide N | Certified Nurse Aide | Provided statements on proper dignity and infection control practices |
| Licensed Nurse G | Licensed Nurse | Provided statements on proper dignity and infection control practices |
| Administrative Nurse D | Administrative Nurse | Provided statements on expectations for dignity, infection control, and staff training |
| Administrative Staff A | Administrative Staff | Provided statements on staff training audits and verification of CNA M's lack of training |
Inspection Report
Routine
Census: 122
Deficiencies: 3
Dec 28, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to resident notification of hospital transfers, bed hold policies, and activities of daily living care.
Findings
The facility failed to provide timely written notification to residents R3 and R4 or their representatives regarding hospital transfers and bed hold policies, placing residents at risk for uninformed care choices and potential loss of residence. Additionally, the facility failed to provide appropriate ADL care for Resident R1 by leaving her unattended on the toilet, risking impaired ADL and decreased quality of life.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide timely written notification to residents or representatives before transfer or discharge, including appeal rights. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify residents or representatives in writing about the facility bed hold policy when transferred to hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary ADL care and assistance for Resident R1 when staff left her unattended on the toilet in the shower room. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in sample: 7
Residents in sample: 8
Bed hold duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Designee X | Social Service Designee | Responsible for notifying residents or representatives of hospital transfers and bed hold policy; verified lack of written notification |
| Administrative Nurse D | Administrative Nurse | Stated social service staff responsible for providing written transfer information and bed hold policy |
| Certified Medication Aide M | Certified Medication Aide | Assisted Resident R1 to shower room toilet and left her unattended |
| Certified Nurse Aide N | Certified Nurse Aide | Reported assisting Resident R1 with toileting and sometimes leaving her unattended |
Inspection Report
Routine
Census: 117
Deficiencies: 41
Oct 9, 2023
Visit Reason
The inspection was a routine survey of Plaza West Healthcare and Rehab to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and care, participation in care planning, medication administration, bathing and hygiene assistance, pressure ulcer prevention and treatment, accident prevention, activity provision, trauma-informed care, respiratory care, infection control, and vaccination consent. Several residents were identified at risk due to these deficiencies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 44
Deficiencies (41)
| Description | Severity |
|---|---|
| Failed to honor resident dignity including appropriate toileting assistance and privacy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to include resident in care plan development placing resident at risk for impaired care and autonomy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess resident for ability to self-administer nasal spray medication placing resident at risk for improper medication use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to support resident bathing preferences placing resident at risk for impaired rights and autonomy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to act upon resident council concerns regarding care and facility life placing residents at risk for decreased quality of care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop comprehensive care plan addressing PTSD diagnosis placing resident at risk for uncommunicated care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing assistance for multiple residents placing them at risk for skin breakdown and impaired psychosocial wellbeing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent grooming and hygiene assistance placing residents at risk for poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement interventions to prevent skin tears and bruises and failed to monitor daily weights as ordered placing residents at risk for injury and declining health. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing and grooming assistance placing residents at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement care planned interventions to prevent skin tears and bruises and failed to monitor daily weights as ordered placing residents at risk for injury and declining health. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide foot care to resident with diabetes mellitus placing resident at risk for foot complications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safe transfer with mechanical lifts placing residents at risk for falls and injuries. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safe environment free from accident hazards when staff failed to use foot pedals on wheelchair placing resident at risk for accident and injury. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide trauma informed care to resident with PTSD placing resident at risk for unmet behavioral health care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary respiratory care and services when staff stored uncovered nebulizer masks placing resident at risk for respiratory infections and complications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label and date insulin flex pens and failed to discard expired medications placing residents at risk for ineffective medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain pneumococcal and influenza vaccination consent or declination placing residents at risk for infectious disease. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 117
Sample size: 28
Bathing missed days: 21
Bathing missed days: 11
Bathing missed days: 23
Bathing missed days: 12
Bathing missed days: 12
Bathing missed days: 9
Bathing missed days: 11
Bathing missed days: 23
Bathing missed days: 26
Bathing missed days: 17
Bathing missed days: 13
Bathing missed days: 23
Medication expiration: 3
Medication expiration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CMA R | Certified Medication Aide | Did not administer nasal spray medication as ordered to Resident 101 and administered medication with hair and lint on pill |
| Administrative Nurse D | Administrative Nurse | Verified multiple care deficiencies and provided clarifications on care plans and procedures |
| Nurse Consultant HH | Nurse Consultant | Verified fall incident and vaccination consent deficiencies |
| Certified Nurse Aide O | Certified Nurse Aide | Reported on bathing refusals and resident care observations |
| Licensed Nurse G | Licensed Nurse | Provided statements on bathing, foot care, and activity provision |
| Certified Medication Aide S | Certified Medication Aide | Observed pushing resident in wheelchair without foot pedals and reported staffing issues on dementia unit |
| Administrative Staff A | Administrative Staff | Reported on water management program and resident council concerns |
| Social Service Staff X | Social Service Staff | Reported on trauma informed care assessment and care plan |
| Activity Staff Z | Activity Staff | Reported on resident council meetings and activity documentation |
Inspection Report
Routine
Census: 117
Deficiencies: 19
Oct 9, 2023
Visit Reason
The inspection was a routine survey of Plaza West Healthcare and Rehab to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate care planning and participation, improper medication administration, inconsistent bathing and hygiene assistance, unsafe transfers, failure to prevent pressure ulcers, inadequate infection control, and failure to provide trauma-informed care. Several residents were at risk for harm due to these deficiencies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 18
Level of Harm - Actual harm: 2
Deficiencies (19)
| Description | Severity |
|---|---|
| Failure to honor resident dignity and provide care in a manner that maintains respect and privacy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to include resident in care plan development and implementation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to assess resident for ability to self-administer medication safely. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to support resident bathing preferences and provide consistent bathing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide assistance with activities of daily living for residents unable to perform them independently. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a comprehensive care plan addressing post-traumatic stress disorder. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to prevent accidents and ensure safe transfers and use of assistive devices. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide consistent bathing and grooming assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing. | Level of Harm - Actual harm |
| Failure to provide adequate supervision and prevent accidents related to mechanical lifts and wheelchair safety. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate catheter care and maintain catheter drainage bag in sanitary manner. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate respiratory care including proper storage of nebulizer equipment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure certified staff possessed competencies and skills necessary to provide safe nursing and related services. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to label insulin flex pens with date opened and discard expired medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide consistent activities for residents on the locked dementia unit. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide dementia care and services to address behaviors and maintain mental and psychosocial well-being. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide trauma informed care to eliminate or mitigate triggers for residents with PTSD. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement gradual dose reductions and limit PRN psychotropic medication use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain consent or declination for influenza and pneumococcal vaccinations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 117
Sample size: 28
Bathing missed days: 21
Bathing missed days: 23
Bathing missed days: 12
Bathing missed days: 11
Bathing missed days: 23
Bathing missed days: 18
Bathing missed days: 21
Bathing missed days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CMA R | Certified Medication Aide | Did not administer nasal spray medication as ordered to R101 and dropped a pill with hair and lint on it but allowed resident to take it |
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including improper transfers, missed baths, improper medication administration, and failure to document weights |
| Nurse Consultant HH | Nurse Consultant | Verified fall incident for R115 and lack of vaccination consents |
| Certified Nurse Aide O | Certified Nurse Aide | Reported on bathing refusals and resident care needs |
| Licensed Nurse G | Licensed Nurse | Verified medication administration and resident care issues |
| Activity Staff Z | Activity Staff | Verified resident council concerns and activity documentation |
| Certified Medication Aide S | Certified Medication Aide | Pushed resident in wheelchair without foot pedals, reported no activity staff on weekends |
| Social Service Staff X | Social Service Staff | Reported lack of trauma informed care assessment for R8 |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 1, 2023
Visit Reason
The inspection was conducted as an annual survey of Plaza West Healthcare and Rehab to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Routine
Census: 120
Deficiencies: 4
Jun 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, infection prevention and control, vaccination policies, and other care standards at Plaza West Healthcare and Rehab.
Findings
The facility failed to accurately transcribe medication orders for Resident 13, resulting in missed medication doses. Staff failed to perform appropriate hand hygiene and use necessary PPE when caring for an isolated resident, risking infection spread. The facility also failed to provide pneumococcal and COVID-19 vaccinations after obtaining consent for some residents and failed to obtain signed consent or declination for pneumococcal vaccination for one resident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement care consistent with physician orders due to inaccurate transcription of Resident 13's medication orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff performed appropriate hand hygiene and use of necessary PPE for Resident 1 in isolation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pneumococcal vaccinations after consent was obtained for Residents 10 and 12 and failed to obtain signed consent or declination for Resident 11. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide COVID-19 vaccination after consent was obtained for Resident 10. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in sample: 13
Methotrexate dosage tablets: 6
Census: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide R | Certified Medication Aide | Mentioned in relation to failure to administer methotrexate dose after 06/09/23 |
| Licensed Nurse H | Licensed Nurse | Described medication order transcription process and hand hygiene practices |
| Administrative Nurse D | Administrative Nurse | Discussed order entry and audit process and vaccination consent procedures |
| Certified Nurse Aide M | Certified Nurse Aide | Observed failing to don PPE and perform hand hygiene when caring for isolated resident |
| Licensed Nurse G | Licensed Nurse | Observed performing blood sugar check and insulin administration with some hand hygiene lapses |
Inspection Report
Routine
Census: 120
Deficiencies: 4
Jun 20, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication administration, infection prevention and control, vaccination policies, and other care standards at Plaza West Healthcare and Rehab.
Findings
The facility failed to accurately transcribe medication orders for Resident 13, failed to ensure proper hand hygiene and PPE use for Resident 1 in isolation, failed to provide pneumococcal vaccinations after consent for some residents, and failed to provide COVID-19 vaccination after consent for Resident 10. These deficiencies posed risks of medication errors, infection spread, and vaccine-preventable diseases.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement care consistent with physician orders due to inaccurate transcription of Resident 13's methotrexate orders on admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff performed appropriate hand hygiene and usage of necessary PPE to care for Resident 1 in isolation for a respiratory infection. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pneumococcal vaccinations after consent was obtained for Residents 10 and 12 and failed to obtain signed consent or declination for Resident 11. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide COVID-19 vaccination after consent was obtained for Resident 10. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 120
Sample size: 13
Methotrexate dosage: 2.5
Methotrexate tablets: 6
Consent dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) R | Reported methotrexate order did not continue after 06/09/23 for Resident 13 | |
| Licensed Nurse (LN) H | Described order entry and audit process for Resident 13's medication orders | |
| Administrative Nurse D | Explained order entry process and audits for medication orders and vaccination consent process | |
| Certified Nurse Aide (CNA) M | Observed failing to don PPE and perform hand hygiene when caring for Resident 1 in isolation | |
| Licensed Nurse (LN) G | Observed performing blood sugar check and insulin administration with some hand hygiene lapses |
Inspection Report
Annual Inspection
Census: 125
Deficiencies: 2
May 30, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and nutrition standards, specifically ensuring food and drink are palatable, attractive, and served at safe temperatures, as well as verifying that food is procured, stored, prepared, and served according to professional standards.
Findings
The facility failed to ensure safe and palatable food temperatures during meal services and failed to prepare and serve meals in a safe and sanitary manner, placing residents at risk for impaired nutrition and foodborne illness. Temperature logs were incomplete, and some meals were served at unsafe temperatures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure safe and palatable food temperatures for residents, with incomplete temperature logs and meals served at unsafe temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to procure, store, prepare, distribute, and serve food in accordance with professional standards, risking foodborne illness. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 125
Food temperature: 113.5
Food temperature: 133.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CMA R | Confirmed food temperature readings for residents' meals | |
| Dietary BB | Dietary Staff | Commented on food temperatures and responsibility for temperature logs |
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 5
Feb 23, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident care, medication errors, neglect, accident hazards, and medication administration issues at Plaza West Healthcare and Rehab.
Findings
The facility failed to ensure residents had access to call lights, failed to prevent neglect and medication errors leading to resident harm and death, failed to monitor and manage bowel movements resulting in fecal impaction, and failed to provide adequate supervision during transfers causing injury. These failures placed residents at risk for inadequate care, unmet needs, feelings of helplessness, and actual harm.
Complaint Details
The complaint investigation revealed substantiated neglect and medication errors that placed residents at risk of harm and resulted in actual harm and death. The facility failed to follow physician orders, provide adequate supervision, and ensure proper medication administration.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 3
Level of Harm - Actual harm: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure residents R3, R4, and R5 had call lights within reach, placing them at risk for inadequate care and feelings of helplessness. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident R1 remained free from neglect when staff failed to follow physician orders, prevent medication errors, ensure labs were collected and reported, and failed to provide ongoing assessment after acute changes, resulting in resident death. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to provide appropriate treatment and care consistent with physician orders for Resident R1 and failed to monitor and manage bowel function for Resident R3, resulting in fecal impaction and emergency room visit. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to ensure Resident R2 was free from accidents and injury when staff failed to provide necessary assistance during transfer using sit to stand lift, resulting in bruises and a fractured left femur requiring surgery. | Level of Harm - Actual harm |
| Failed to prevent significant medication errors by administering potassium to Resident R1 despite elevated potassium levels and failing to administer cardiac medication as ordered, contributing to resident death. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Census: 126
Medication error duration: 4
Bowel monitoring missed opportunities: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide T | Certified Medication Aide | Verified call lights should be within reach of residents |
| Certified Medication Aide R | Certified Medication Aide | Administered potassium to Resident R1 not ordered; verified call light placement for Resident R3 |
| Licensed Nurse G | Licensed Nurse | Verified call light placement issues; noted medication errors and bruising on Resident R2 |
| Administrative Nurse D | Administrative Nurse | Discussed call light concerns and medication errors; involved in investigation and corrective actions |
| Certified Nurse Aide M | Certified Nurse Aide | Operated sit to stand lift alone causing Resident R2 to fall and sustain injury |
| Licensed Nurse J | Licensed Nurse | Assessed Resident R3 prior to hospital transfer; noted bowel sounds and impaction |
| Certified Medication Aide S | Certified Medication Aide | Described mechanical lift transfer procedures and supervision requirements |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 1
Feb 6, 2023
Visit Reason
The inspection was conducted due to concerns about infection prevention and control related to COVID-19 exposure and isolation practices within the facility.
Findings
The facility failed to protect seven residents from prolonged exposure to COVID-19 by rooming COVID-19 negative residents with COVID-19 positive residents, contrary to CDC guidance. Several residents who tested negative were isolated in the same rooms with positive residents, increasing their risk of infection.
Complaint Details
The investigation found that COVID-19 positive and negative residents were cohorted together in rooms despite CDC guidance against this practice. Administrative staff confirmed lack of awareness of proper cohorting procedures and facility plans for COVID-19 outbreaks.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide and implement an infection prevention and control program to prevent COVID-19 transmission among residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents tested positive for COVID-19: 9
Residents affected by deficiency: 7
Census: 124
Isolation duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Confirmed COVID-19 positive and negative residents were isolated together and was unaware of facility plan for COVID-19 outbreak |
| Administrative Staff A | Administrative Staff | Stated cohorting a positive and negative but exposed COVID-19 resident seemed the right thing to do |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 1
Feb 6, 2023
Visit Reason
The inspection was conducted due to concerns about infection prevention and control related to Covid-19 exposure among residents.
Findings
The facility failed to protect seven residents from prolonged exposure to Covid-19 by rooming Covid-19 negative residents with Covid-19 positive residents, contrary to CDC guidance, placing those residents at increased risk of infection.
Complaint Details
The complaint investigation found that seven residents were exposed to Covid-19 due to cohorting Covid-19 positive residents with negative residents, despite CDC guidance against such practice. Administrative staff confirmed lack of awareness and improper cohorting practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide and implement an infection prevention and control program to prevent Covid-19 transmission among residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 124
Residents reviewed for infection control: 17
Residents tested positive for Covid-19: 9
Residents affected by deficiency: 7
Isolation duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Confirmed that Covid-19 positive and negative residents were isolated together and was unaware of facility plan for Covid-19 outbreak |
| Administrative Staff A | Administrative Staff | Stated that cohorting a positive and negative but exposed Covid-19 resident seemed the right thing to do |
Inspection Report
Routine
Census: 122
Deficiencies: 11
Apr 21, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey of Plaza West Healthcare and Rehab to assess compliance with healthcare facility regulations, including resident care, safety, medication management, and food service.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate care planning and implementation for falls and toileting, improper catheter care, inconsistent bathing services, failure to provide appropriate respiratory care, failure to hold medications per physician orders, and unsafe food handling and storage practices. These deficiencies placed residents at risk for harm including undignified care, falls, infections, respiratory complications, medication errors, and foodborne illness.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to treat residents with dignity by not covering urinary catheter bags, exposing residents to embarrassment and undignified environment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to honor resident's choice for female staff assistance with bathing, placing resident at risk for undignified and unpleasant bathing experience. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plan with interventions to prevent further falls after resident fell while attempting to toilet herself, placing resident at risk for inadequate care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide consistent bathing services for residents, placing them at risk for complications related to poor hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide interventions to prevent development of new pressure ulcer on resident's left foot, placing resident at risk for wound complications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide interventions to prevent falls for residents, including failure to place feet on wheelchair footrests during van loading, placing residents at risk for falls and injury. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate catheter care including anchoring catheter and preventing tubing or drainage bag from touching floor or passing above bladder, placing resident at risk for urinary tract infections and injury. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store nebulizer masks by leaving them uncovered on top of nebulizer machines, placing residents at risk for infection and respiratory complications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to hold blood pressure medication when systolic blood pressure was below physician ordered parameters, placing resident at risk for physical decline and complications related to low blood pressure. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to hold food at safe temperatures above 135 degrees Fahrenheit, placing residents at risk for foodborne illness. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, prepare, and serve food under sanitary conditions including storing food on floor and personal items near food prep areas, placing residents at risk for foodborne illness. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 122
Sample size: 25
Blood pressure readings below ordered parameter: 26
Food temperature: 112
Food temperature: 120
Food temperature: 130
Food temperature: 140
Food temperature: 135
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified catheter care expectations, bathing preferences, toileting care plan adherence, nebulizer mask storage, and medication holding procedures |
| Licensed Nurse G | Licensed Nurse | Verified medication administration errors and catheter care deficiencies |
| Certified Nurse Aide P | Certified Nurse Aide | Mentioned unawareness of resident bathing preferences and catheter bag coverage |
| Consultant Pharmacist JJ | Consultant Pharmacist | Unable to confirm reporting of blood pressure irregularities for Resident 15 |
| Dietary Staff BB | Dietary Staff | Verified food temperature standards and food storage practices |
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