Deficiencies (last 4 years)
Deficiencies (over 4 years)
28.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
375% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Annual Inspection
Census: 130
Deficiencies: 20
Date: Mar 19, 2025
Visit Reason
Annual inspection of Plaza West Healthcare and Rehab to assess compliance with regulatory requirements across multiple domains including resident care, environment, medication management, and staffing.
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. Several residents were at risk due to these deficiencies.
Deficiencies (20)
F582: The facility failed to provide Resident 2 with the CMS 10055 Advanced Beneficiary Notice regarding Medicaid/Medicare coverage and potential liability for services not covered.
F584: The facility failed to maintain a clean, odor-free, homelike environment on Hall 400, with persistent urine odor and stained furniture.
F600: The facility failed to address Resident 121's sexually aggressive behaviors, placing residents at risk of sexual abuse.
F636: The facility failed to complete admission comprehensive Minimum Data Set assessments timely for Residents 98, 112, and 13.
F655: The facility failed to develop and implement baseline care plans including ADL care and dialysis care for Residents 78, 98, 13, and 295.
F657: The facility failed to revise care plans for Residents 78 and 117 to include interventions for pressure ulcers and skin tears.
F677: The facility failed to provide consistent bathing for Residents 48, 71, 92, 99, 117, 121, and 125, placing them at risk for poor hygiene.
F684: The facility failed to complete nursing assessments prior to hospital discharge for Residents 35 and 142, failed to complete admission nursing assessment for Resident 128, and failed to implement interventions for skin tear and back brace use for Residents 117 and 13.
F686: The facility failed to implement preventative interventions for Resident 78 who developed a Stage 3 pressure ulcer.
F695: The facility failed to obtain a physician's order for supplemental oxygen therapy for Resident 346 and failed to monitor oxygen saturation and properly store oxygen cannula.
F698: The facility failed to obtain physician orders and provide consistent dialysis care for Resident 295, including assessments and communication with dialysis center.
F725: The facility failed to ensure adequate nursing staff daily to meet resident needs.
F755: The facility failed to maintain accurate controlled substance counts with signatures on medication carts.
F756: The facility's Consultant Pharmacist failed to identify and report out-of-parameter accu-checks for Resident 29.
F757: The facility failed to notify the physician for out-of-parameter accu-checks and failed to document medication administration for Resident 295.
F760: The facility failed to prevent medication administration errors for Resident 29 who received wrong dosage of Zinc supplement for six administrations.
F761: The facility failed to label and store biologicals properly, failing to place an open date on Resident 31's Humalog insulin pen.
F809: The facility failed to provide meals at regular times comparable to normal mealtimes for residents in the Memory Care Unit and for room meal trays, causing residents to wait extended periods.
F849: The facility failed to ensure collaboration of care between hospice provider and facility for Resident 112, lacking a hospice plan of care.
F880: The facility failed to provide a sanitary and comfortable environment and failed to implement enhanced barrier precautions for Residents 8 and 88, placing them at risk for infection.
Report Facts
Residents: 130
Deficiencies cited: 21
Medication administration errors: 6
Out-of-parameter accu-checks: 48
Pressure ulcer measurements: 5.01
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements regarding deficiencies, expectations, and corrective actions |
| Licensed Nurse J | Licensed Nurse | Provided statements regarding care plans, wound care, and oxygen therapy |
| Certified Nurse Aide M | Certified Nurse Aide | Reported on bathing refusals and shower sheets |
| Certified Medication Aide R | Certified Medication Aide | Reported medication administration and dosage discrepancy for Resident 29 |
| Licensed Nurse G | Licensed Nurse | Verified medication discrepancies and nursing assessments |
Inspection Report
Census: 130
Deficiencies: 20
Date: Mar 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, safety, medication management, infection control, staffing, and hospice services.
Findings
The facility had multiple deficiencies including failure to provide required Medicare notices, maintain a clean environment, address resident behavioral issues, complete timely assessments and care plans, provide consistent bathing, ensure proper medication administration and documentation, maintain adequate staffing, and implement infection control precautions. Several residents were at risk due to these deficiencies.
Deficiencies (20)
F582: The facility failed to provide Resident 2 with the CMS 10055 Advanced Beneficiary Notice including estimated costs for skilled services, placing the resident at risk for uninformed decisions.
F584: The facility failed to maintain a clean, odor-free environment on Hall 400, with strong urine odor and stained furniture, placing residents at risk for unsanitary conditions.
F600: The facility failed to address Resident 121's sexually aggressive behaviors adequately, placing residents at risk of sexual abuse.
F636: The facility failed to complete admission comprehensive Minimum Data Set assessments timely for Residents 98, 112, and 13, risking inaccurate care planning.
F655: The facility failed to develop baseline care plans including ADL and dialysis care for Residents 13, 78, 98, and 295, risking delayed care and decline.
F657: The facility failed to revise care plans for Residents 78 and 117 to include interventions for pressure ulcers and skin tears, risking further injury.
F677: The facility failed to provide consistent bathing for Residents 48, 71, 92, 99, 117, 121, and 125, placing residents at risk for poor hygiene.
F684: The facility failed to complete nursing assessments prior to hospital discharge for Residents 35 and 142, failed to complete admission nursing assessment for Resident 128, and failed to implement interventions for Resident 117's skin tear and Resident 13's back brace care.
F686: The facility failed to implement preventative interventions for Resident 78's pressure ulcer, placing the resident at risk for complications.
F695: The facility failed to obtain physician orders for oxygen therapy, failed to monitor oxygen saturation, and failed to properly store oxygen cannula for Resident 346, risking respiratory complications.
F698: The facility failed to obtain physician orders and provide consistent dialysis care and communication for Resident 295, risking complications related to dialysis treatment.
F725: The facility failed to ensure adequate daily nursing staff to meet resident needs, placing 130 residents at risk of delayed care.
F755: The facility failed to maintain accurate controlled medication counts with missing signatures, risking medication misappropriation.
F756: The facility's consultant pharmacist failed to identify and report out-of-parameter blood glucose readings for Resident 29, risking ineffective medication management.
F757: The facility failed to notify the physician of out-of-parameter blood glucose readings and failed to document medication administration for Resident 295, risking adverse medication effects.
F760: The facility failed to prevent medication administration errors for Resident 29, who received incorrect doses of a supplement for six administrations.
F761: The facility failed to label and store biologicals properly, including failure to place an open date on Resident 31's Humalog insulin pen.
F809: The facility failed to provide meals at regular times comparable to normal mealtimes for residents in the Memory Care Unit and for room meal trays, causing residents to wait extended periods for meals.
F849: The facility failed to ensure collaboration and provision of hospice care for Resident 112, lacking a hospice plan of care and coordination with hospice provider.
F880: The facility failed to provide a sanitary and comfortable environment and failed to implement enhanced barrier precautions for Residents 8 and 88, placing them at risk for infection.
Report Facts
Residents present: 130
Deficiencies cited: 20
Accu-checks outside parameters: 48
Medication administration missing documentation: 14
Pressure ulcer wound size: 5.01
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements regarding deficiencies and expectations |
| Licensed Nurse J | Licensed Nurse | Verified medication storage and care plan issues |
| Certified Nurse Aide M | Certified Nurse Aide | Reported on bathing refusals and shower sheet procedures |
| Certified Medication Aide R | Certified Medication Aide | Administered medications and reported medication discrepancies |
| Licensed Nurse G | Licensed Nurse | Reported on medication discrepancies and skin tear assessment |
| Certified Nurse Aide Q | Certified Nurse Aide | Observed not following enhanced barrier precautions |
Inspection Report
Annual Inspection
Census: 134
Deficiencies: 1
Date: Jan 28, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations and to evaluate the facility's provision of respiratory care services.
Findings
The facility failed to provide necessary respiratory care and services for one resident, resulting in missed nebulizer treatments and improper storage of nebulizer equipment, which placed the resident at risk for infection and physical complications.
Deficiencies (1)
F 0695: The facility failed to provide safe and appropriate respiratory care for a resident when needed, including missed nebulizer treatments and improper storage of nebulizer tubing and mask.
Report Facts
Scheduled nebulizer treatments missed: 26
Scheduled nebulizer treatments missed: 17
Scheduled nebulizer treatments missed: 9
Census: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse (LN) G | Provided statements regarding administration and documentation of breathing treatments | |
| Administrative Nurse D | Provided statements regarding expectations for administration and documentation of breathing treatments |
Inspection Report
Annual Inspection
Census: 133
Deficiencies: 4
Date: Sep 30, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident dignity, infection prevention, staff training, and resident rights.
Findings
The facility failed to ensure staff treated a resident with dignity, prevented cross-contamination during incontinence care and equipment use, and provided required training on effective communication and resident rights to a Certified Nurse Aide. These deficiencies placed residents at risk for decreased dignity, infection, impaired communication, and loss of rights.
Deficiencies (4)
F 0550: The facility failed to ensure staff treated Resident 1 with dignity, including respectful communication and care during incontinence assistance, placing the resident at risk for decreased self-esteem and dignity.
F 0880: The facility failed to prevent cross-contamination during incontinence care for Resident 2 and failed to disinfect the Hoyer lift between resident uses, placing residents at risk for infection.
F 0941: The facility failed to ensure Certified Nurse Aide M received required effective communication training, placing residents at risk for impaired communication.
F 0942: The facility failed to ensure Certified Nurse Aide M received required resident rights training, placing residents at risk for impaired rights and loss of dignity.
Report Facts
Resident census: 133
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in findings related to failure to treat resident with dignity, failure to receive effective communication and resident rights training |
| CNA N | Certified Nurse Aide | Provided statements on dignity and infection control practices |
| Licensed Nurse G | Licensed Nurse | Provided statements on dignity and infection control practices |
| Administrative Nurse D | Administrative Nurse | Provided statements on staff expectations for dignity, infection control, and training |
| Administrative Staff A | Administrative Staff | Verified lack of communication and resident rights training for CNA M |
| CNA O | Certified Nurse Aide | Observed during incontinence care and Hoyer lift use |
| CNA P | Certified Nurse Aide | Observed during incontinence care and Hoyer lift use |
Inspection Report
Routine
Census: 122
Deficiencies: 3
Date: Dec 28, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding resident notification of transfers and discharges, bed hold policies, and activities of daily living care in a nursing home.
Findings
The facility failed to provide timely written notification to residents or their representatives regarding hospital transfers and bed hold policies for two residents, placing them at risk for uninformed care choices and potential loss of residence. Additionally, the facility failed to provide appropriate assistance with activities of daily living for one resident, leaving her unattended on the toilet, which placed her at risk of impaired ADL and decreased quality of life.
Deficiencies (3)
F 0623: The facility failed to provide timely written notification to residents R3 and R4 or their representatives regarding facility-initiated transfers to the hospital. This placed the residents at risk for uninformed care choices.
F 0625: The facility failed to provide residents R3 and R4 or their representatives with written information about the facility's bed hold policy upon hospital transfer. This placed the residents at risk for not being permitted to return and resume residence in the nursing facility.
F 0676: The facility failed to provide appropriate ADL care for Resident R1 when staff left her unattended on the toilet in the shower room. This placed R1 at risk of impaired ADL and decreased quality of life.
Report Facts
Residents in sample: 8
Residents reviewed for hospitalization: 3
Residents reviewed for ADLs: 3
Bed hold duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Stated social service staff responsibility for providing written transfer and bed hold information |
| Social Service Designee X | Social Service Designee | Responsible for notifying residents or representatives of hospital transfers and bed hold policy |
| Certified Medication Aide M | Certified Medication Aide | Documented leaving Resident R1 unattended on the toilet in the shower room |
| Certified Nurse Aide N | Certified Nurse Aide | Reported assisting Resident R1 to the toilet and sometimes leaving her unattended |
Inspection Report
Routine
Census: 117
Deficiencies: 19
Date: Oct 9, 2023
Visit Reason
Routine inspection of Plaza West Healthcare and Rehab to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility failed to provide adequate personal hygiene and bathing assistance to multiple residents, failed to ensure safe transfers and accident prevention, failed to implement a water management program for Legionella, failed to provide trauma informed care, failed to ensure proper medication administration and storage, failed to provide consistent activities for dementia residents, and failed to obtain vaccination consents.
Deficiencies (19)
F 0550: The facility failed to promote care for residents R115, R33, and R84 in a manner to maintain dignity and respect, including failure to provide privacy and appropriate care assistance.
F 0553: The facility failed to include resident R48 in the development and planning of the resident's care plan, placing the resident at risk for impaired care and autonomy.
F 0554: The facility failed to assess resident R101 for the ability to safely self-administer nasal spray medication, placing the resident at risk for improper medication use.
F 0561: The facility failed to support resident R48's bathing preferences, resulting in inconsistent bathing frequency and risk of impaired autonomy.
F 0565: The facility failed to act promptly upon resident council concerns regarding care and life issues, placing residents at risk for decreased quality of care.
F 0656: The facility failed to develop a comprehensive care plan addressing R8's PTSD diagnosis and trauma-informed care, placing the resident at risk for unmet care needs.
F 0677: The facility failed to provide consistent bathing and hygiene assistance to residents R78, R3, R25, R2, R32, R47, and R90, placing residents at risk for poor hygiene and related complications.
F 0684: The facility failed to prevent pressure ulcers for residents R84 and R32 and failed to promote healing of pressure injuries, placing residents at risk for further injury.
F 0689: The facility failed to ensure safe environment and supervision to prevent accidents, including failure to follow care plans for mechanical lifts and wheelchair safety for residents R115, R84, R106, and R328.
F 0690: The facility failed to provide continence care and sanitary catheter management for residents R25 and R84, placing residents at risk for urinary tract infections and complications.
F 0695: The facility failed to provide proper respiratory care for resident R30 by storing nebulizer equipment uncovered, increasing risk for infection.
F 0699: The facility failed to provide trauma informed care for resident R8 to mitigate triggers and prevent re-traumatization, placing the resident at risk for unmet behavioral health needs.
F 0726: The facility failed to ensure certified staff possessed competencies to safely administer medications when a Certified Medication Aide failed to administer nasal spray as ordered for resident R101.
F 0732: The facility failed to post current daily nursing staff hours for residents and families.
F 0744: The facility failed to provide appropriate dementia care and services for resident R327, lacking individualized interventions and behavior management.
F 0758: The facility failed to ensure appropriate use and monitoring of psychotropic medication clonazepam for resident R78, lacking stop date or specified duration.
F 0761: The facility failed to label insulin flex pens with date opened and discard date and failed to discard expired medications, placing residents R33, R115, and R119 at risk for ineffective medication.
F 0880: The facility failed to implement a water management program for Legionella disease, placing residents at risk for infectious disease.
F 0883: The facility failed to obtain signed consent or declination for influenza and pneumococcal vaccinations for residents R95, R115, and R120, placing residents at risk for infectious disease complications.
Report Facts
Resident census: 117
Sample size: 28
Days no bath/shower: 21
Days no bath/shower: 11
Days no bath/shower: 23
Days no bath/shower: 18
Days no bath/shower: 21
Days no bath/shower: 3
Days no bath/shower: 17
Days no bath/shower: 13
Days no bath/shower: 23
Days no bath/shower: 12
Days no bath/shower: 12
Days no bath/shower: 9
Days no bath/shower: 26
Days no bath/shower: 14
Days no bath/shower: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA R | Certified Medication Aide | Failed to administer nasal spray medication as ordered to resident R101 |
| Administrative Nurse D | Verified multiple findings including safe transfers, medication administration, and catheter care | |
| Certified Nurse Aide O | Certified Nurse Aide | Unaware of bruise on R47 and assisted with transfers |
| Licensed Nurse G | Licensed Nurse | Verified medication administration and care plan compliance issues |
| Activity Staff Z | Reported resident council concerns and activity provision | |
| Nurse Consultant HH | Verified fall incident and vaccination consent issues | |
| Consultant GG | Reported staffing shortages contributing to wounds and infections |
Inspection Report
Routine
Census: 117
Deficiencies: 18
Date: Oct 9, 2023
Visit Reason
Routine inspection of Plaza West Healthcare and Rehab to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility failed to provide adequate personal hygiene and bathing assistance to multiple residents, failed to ensure safe transfers and accident prevention, lacked proper medication administration and storage practices, failed to provide trauma-informed care, and did not implement an effective water management program for Legionella. Additional deficiencies included failure to provide consistent activities for dementia residents, incomplete care planning, and failure to obtain vaccination consents.
Deficiencies (18)
F550: The facility failed to maintain resident dignity and respect, including failure to assist residents with toileting and appropriate clothing, and failure to provide private care areas for medication administration.
F553: The facility failed to include resident R48 in the development and planning of her care plan, placing her at risk for impaired care and autonomy.
F554: The facility failed to assess Resident R101 for the ability to safely self-administer nasal spray medication, placing the resident at risk for improper medication use.
F561: The facility failed to support Resident R48's bathing preferences, placing the resident at risk for impaired autonomy.
F565: The facility failed to act upon resident council concerns regarding care and life issues, placing residents at risk for decreased quality of care.
F656: The facility failed to develop a comprehensive care plan addressing Resident R8's PTSD diagnosis, placing the resident at risk for unmet care needs.
F677: The facility failed to ensure residents R78, R3, R25, R2, R32, R47, and R90 received consistent bathing and hygiene assistance as care planned, placing residents at risk for poor hygiene and related complications.
F679: The facility failed to provide consistent activities for 13 residents on the locked dementia unit, risking decline in physical, mental, and psychosocial well-being.
F684: The facility failed to implement interventions to prevent skin tears and bruises for Resident R47 and failed to monitor daily weights, placing the resident at risk for injury and declining health.
F686: The facility failed to prevent pressure ulcers for Residents R84 and R32 and failed to promote healing of R32's pressure injury, placing residents at risk for further unhealed pressure injuries.
F687: The facility failed to provide foot care to Resident R32 who had overgrown toenails, placing the resident at risk for foot complications.
F689: The facility failed to ensure safe environment free from accident hazards when staff failed to use foot pedals on Resident R328's wheelchair, placing the resident at risk for accidents and injuries.
F690: The facility failed to ensure Residents R25 and R84 received appropriate continence care and catheter management, placing residents at risk for urinary tract infections and related complications.
F695: The facility failed to provide necessary respiratory care for Resident R30 by improperly storing nebulizer equipment, placing the resident at risk for respiratory infections.
F699: The facility failed to ensure Resident R8 received trauma informed care to eliminate or mitigate triggers that may cause re-traumatization, placing the resident at risk for unmet psychosocial needs.
F726: The facility failed to ensure certified staff possessed competencies to safely administer medications when a Certified Medication Aide failed to administer ordered nasal spray to Resident R101, placing the resident at risk for decreased quality of care.
F732: The facility failed to post current daily nursing staff hours for residents and families.
F883: The facility failed to obtain signed consent or declination for pneumococcal and influenza vaccinations for Residents R95, R115, and R120, placing residents at risk for infectious disease complications.
Report Facts
Resident census: 117
Sample size: 28
Days no bath/shower: 21
Days no bath/shower: 11
Days no bath/shower: 23
Days no bath/shower: 12
Days no bath/shower: 12
Days no bath/shower: 9
Days no bath/shower: 13
Days no bath/shower: 26
Days no bath/shower: 17
Days no bath/shower: 13
Days no bath/shower: 14
Days no bath/shower: 13
Days no bath/shower: 21
Days no bath/shower: 23
Days no bath/shower: 18
Days no bath/shower: 3
Expired medication: 3
Expired medication: 2
Medication stop date missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA R | Certified Medication Aide | Failed to administer nasal spray medication properly to Resident R101 and administered medication with hair and lint on pill. |
| Administrative Nurse D | Administrative Nurse | Verified multiple care deficiencies including failure to label insulin pens, failure to document bathing, and failure to ensure safe transfers. |
| CMA S | Certified Medication Aide | Performed Hoyer lift transfer alone for Resident R106 and pushed Resident R328's wheelchair without foot pedals. |
| LN G | Licensed Nurse | Verified nursing responsibilities and care plan deficiencies for multiple residents including R32, R328, and R78. |
| Nurse Consultant HH | Nurse Consultant | Verified fall incident for Resident R115 and vaccination consent deficiencies. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 1, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Plaza West Healthcare and Rehab.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 120
Deficiencies: 4
Date: Jun 20, 2023
Visit Reason
Routine inspection based on observations, record review, and interviews to assess compliance with physician orders, infection control, vaccination policies, and other regulatory requirements.
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.
Deficiencies (4)
F684: The facility failed to implement care consistent with physician orders by not accurately transcribing Resident 13's methotrexate titration order after admission, risking missed medications and complications.
F880: The facility failed to ensure staff performed appropriate hand hygiene and use of PPE when caring for Resident 1 in isolation, risking spread of infection to residents.
F883: The facility 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, placing residents at risk of pneumococcal disease.
F887: The facility failed to provide COVID-19 vaccination after consent was obtained for Resident 10, placing the resident at risk of COVID-19 complications.
Report Facts
Resident census: 120
Sample size: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide R | Certified Medication Aide | Named in medication transcription deficiency for Resident 13 |
| Licensed Nurse H | Licensed Nurse | Named in medication transcription deficiency for Resident 13 and hand hygiene/PPE observations |
| Administrative Nurse D | Administrative Nurse | Named in medication transcription deficiency for Resident 13 and vaccination consent process |
| Certified Nurse Aide M | Certified Nurse Aide | Named in infection control deficiency related to hand hygiene and PPE use for Resident 1 |
| Licensed Nurse G | Licensed Nurse | Named in infection control deficiency related to hand hygiene and PPE use |
Inspection Report
Routine
Census: 120
Deficiencies: 4
Date: Jun 20, 2023
Visit Reason
Routine inspection based on observations, record review, and interviews to assess compliance with physician orders, infection control, vaccination policies, and other regulatory requirements.
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.
Deficiencies (4)
F0684: The facility failed to implement care consistent with physician orders by not accurately transcribing Resident 13's methotrexate titration order after admission, risking missed medications and complications.
F0880: The facility failed to ensure staff performed appropriate hand hygiene and use of PPE when caring for Resident 1 in isolation, risking spread of infection to residents.
F0883: The facility 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, placing residents at risk of pneumococcal disease.
F0887: The facility failed to provide COVID-19 vaccination after consent was obtained for Resident 10, placing the resident at risk of COVID-19 complications.
Report Facts
Resident census: 120
Sample size: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide R | Certified Medication Aide | Stated methotrexate order for Resident 13 stopped and was not remembered in medication cart |
| Licensed Nurse H | Licensed Nurse | Described order entry process and verification for Resident 13 and hand hygiene practices |
| Administrative Nurse D | Administrative Nurse | Described order entry process, audits, and vaccination consent procedures |
| Certified Nurse Aide M | Certified Nurse Aide | Observed failing to don PPE and perform hand hygiene when caring for Resident 1 in isolation |
| Licensed Nurse G | Licensed Nurse | Observed performing blood sugar check with improper hand hygiene |
Inspection Report
Annual Inspection
Census: 125
Deficiencies: 2
Date: May 30, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with food safety and nutrition standards in the nursing home.
Findings
The facility failed to ensure safe and palatable food temperatures and failed to prepare and serve meals in a safe and sanitary manner. These deficiencies placed residents at risk for impaired nutrition and foodborne illness.
Deficiencies (2)
F 0804: The facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures. Food temperature logs were incomplete and some meals were served at unsafe temperatures.
F 0812: The facility failed to procure food from approved sources and to store, prepare, distribute, and serve food according to professional standards. This placed residents at risk for foodborne illness.
Report Facts
Residents census: 125
Food temperatures recorded: 113.5
Food temperatures recorded: 133.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary BB | Stated responsibility of cook for food temperature assessments and acknowledged failure to verify temperature logs | |
| CMA R | Confirmed food temperature readings for residents' meals |
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 5
Date: Feb 23, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident care, medication errors, neglect, accident hazards, and medication administration errors at Plaza West Healthcare and Rehab.
Complaint Details
The investigation was complaint-driven, focusing on allegations of neglect, medication errors, inadequate supervision, and failure to follow physician orders. The facility was found to have placed residents at risk through multiple deficiencies, including Immediate Jeopardy related to Resident 1's care and medication management.
Findings
The facility failed to ensure residents had access to call lights, failed to prevent neglect including medication errors and failure to follow physician orders, failed to monitor and manage bowel movements leading to fecal impaction, failed to prevent accidents resulting in a resident fracture, and failed to prevent significant medication errors including wrongful administration of potassium leading to resident death.
Deficiencies (5)
F 0558: The facility failed to ensure Residents 3, 4, and 5 had their call lights within reach, placing them at risk for inadequate care and feelings of helplessness.
F 0600: The facility failed to ensure Resident 1 remained free from neglect when staff failed to follow physician orders, prevent medication errors, collect labs, report abnormal results, and provide ongoing assessment, placing Resident 1 in Immediate Jeopardy.
F 0684: The facility failed to provide care consistent with standards when staff failed to follow physician orders, prevent medication errors, report abnormal vital signs, and monitor bowel function, resulting in Resident 1's death and Resident 3's fecal impaction requiring hospital treatment.
F 0689: The facility failed to ensure Resident 2 was free from accidents and injury when staff failed to transfer Resident 2 with two staff members using a sit to stand lift, resulting in bruises and a fractured left femur requiring surgery.
F 0760: The facility failed to prevent significant medication errors when staff wrongly administered potassium to Resident 1 despite elevated potassium levels and failed to administer cardiac medication, contributing to Resident 1's death.
Report Facts
Resident census: 126
Potassium level: 5.5
Potassium level: 5.9
Medication administration errors: 4
Medication doses missed: 3
Bowel movement monitoring opportunities missed: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA R | Certified Medication Aide | Admitted to administering potassium to Resident 1 that was not ordered |
| CNA M | Certified Nurse Aide | Operated sit to stand lift alone resulting in Resident 2's fall and fracture |
| LN G | Licensed Nurse | Verified call light placement issues and noted medication errors for Resident 1 |
| LN J | Licensed Nurse | Assessed Resident 3 prior to hospital transfer for fecal impaction |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding lab delays, medication errors, and documentation issues |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 1
Date: Feb 6, 2023
Visit Reason
The inspection was conducted to investigate infection control practices related to a Covid-19 outbreak and to assess the facility's compliance with infection prevention and control requirements.
Complaint Details
The investigation was complaint-related, focusing on infection control during a Covid-19 outbreak. The complaint was substantiated as the facility cohorted Covid-19 positive and negative residents together, contrary to CDC guidance.
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 cohorted in the same rooms with positive residents, increasing their risk of infection.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program. Seven residents were exposed to Covid-19 positive roommates without appropriate isolation, increasing their risk of infection.
Report Facts
Census: 124
Residents reviewed for infection control: 17
Residents tested positive for Covid-19: 9
Residents exposed to Covid-19 positive roommates: 7
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 the 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
Complaint Investigation
Census: 124
Deficiencies: 1
Date: Feb 6, 2023
Visit Reason
The inspection was conducted due to concerns about infection prevention and control related to Covid-19 exposure and cohorting practices in the facility.
Complaint Details
The investigation was complaint-related, focusing on infection control practices during a Covid-19 outbreak. The complaint was substantiated as the facility failed to follow CDC guidance on cohorting Covid-19 positive and negative 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. Several residents who tested negative were cohorted with positive residents, increasing their risk of infection.
Deficiencies (1)
F 0880: The facility failed to provide and implement an effective infection prevention and control program. Seven residents were exposed to Covid-19 due to improper cohorting of positive and negative residents in shared rooms.
Report Facts
Census: 124
Residents reviewed for infection control: 17
Residents tested positive for Covid-19: 9
Residents exposed to Covid-19 due to cohorting: 7
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: 12
Date: Apr 21, 2022
Visit Reason
Routine inspection of Plaza West Healthcare and Rehab to assess compliance with regulatory requirements related to resident care, safety, medication management, and food safety.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity, inconsistent bathing and toileting care, inadequate pressure ulcer prevention, fall prevention failures, improper catheter care, unsafe respiratory care practices, medication errors related to blood pressure management, and food safety violations including improper food holding temperatures and unsanitary food storage.
Deficiencies (12)
F 0550: The facility failed to treat residents R96 and R13 with dignity by not covering urinary catheter bags, exposing them to other residents and guests.
F 0552: The facility failed to honor resident R15's choice to have a female staff member assist with bathing, placing her at risk for an undignified bathing experience.
F 0657: The facility failed to revise the care plan with interventions to prevent further falls for resident R60, placing her at risk for inadequate care.
F 0677: The facility failed to provide consistent bathing services for residents R14 and R15, placing them at risk for complications related to poor hygiene.
F 0686: The facility failed to provide appropriate pressure ulcer care for resident R57 by not applying offloading boots to both feet as ordered, increasing risk for wound complications.
F 0689: The facility failed to provide fall prevention interventions for residents R60 and R95, resulting in falls and placing them at risk for injury.
F 0690: The facility failed to provide appropriate bowel and bladder care for residents R15, R60, and R13, including failure to follow toileting care plans and improper catheter care, placing residents at risk for infections and skin breakdown.
F 0695: The facility failed to provide safe and appropriate respiratory care for residents R11, R36, R51, and R88 by storing nebulizer masks uncovered on nebulizer machines, increasing risk for infection.
F 0756: The facility's consultant pharmacist failed to identify and report multiple episodes of resident R15's systolic blood pressures outside physician ordered parameters, placing the resident at risk for physical decline.
F 0757: The facility failed to hold amlodipine medication for resident R15 when systolic blood pressures were below ordered parameters, placing the resident at risk for complications related to low blood pressure.
F 0804: The facility failed to hold food at safe temperatures above 135°F during meal service, placing residents at risk for foodborne illness.
F 0812: The facility failed to store, prepare, and serve food under sanitary conditions, including storing food on the floor and personal items near food prep areas, placing residents at risk for foodborne illness.
Report Facts
Resident census: 122
Sample size: 25
Fall Risk Assessment score: 80
Food temperature: 112
Food temperature: 120
Food temperature: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Verified catheter care and dignity issues, fall prevention, respiratory care, medication errors, and food safety findings | |
| Licensed Nurse G | Verified medication administration and catheter care deficiencies | |
| Certified Nurse Aide P | Mentioned resident bathing and toileting preferences and refusals | |
| Consultant Pharmacist JJ | Consultant Pharmacist | Did not identify or report blood pressure irregularities for resident R15 |
| Certified Nurse Aide M | Observed catheter bag uncovered | |
| Licensed Nurse I | Verified catheter bag positioning and respiratory care | |
| Certified Medication Tech R | Verified medication administration errors related to blood pressure | |
| Dietary Staff BB | Notified staff of unsafe food temperatures and verified food storage violations |
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