Plaza Community Living Center

In the surveyor’s words

From the most serious findings on record at Plaza Community Living Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 17, 2021

  Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to provide adequate staff supervision to prevent the elopements of Resident #1 and Resident #5 from the facility and prevent a fall for Resident #6 for three (3) of ten (10) sampled residents identified at risk for wandering/elopement and falls. Resident #1 left the facility unsupervised and was away for approximately 88 minutes when he was found lying on his back on the asphalt parking lot of the building next door to the facility by a staff member who was walking by on the way to work and heard the Resident yell hey. Resident #1 had minor abrasions of the left arm and leg, a quarter size bruise on the top of the left hand and a skin tear on the left knee. […]

• Actual harm, patternF725May 25, 2023

  Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure there were sufficient staff to meet the needs of residents for one (1) of two (2) Units in the facility, the South Wing. This deficient practice had the potential to affect 55 residents who reside on the South Wing. Findings include: Review of the facility's policy, Staffing, revised October 2017, revealed, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation .2. […]

• Actual harm, isolatedF656May 25, 2023

  Based on interviews, record review and facility policy review the facility failed to develop and/or implement an individualized person-centered care plan for two (2) of 22 care plans reviewed. Resident's #7 and #25 Findings include: A record review of the facility's policy Using the Care Plan with no date revealed, . It is the policy of this facility that the care plan be used in developing the resident's daily care routines . 3. Changes in the resident's condition should be reported to the MDS (Minimum Data Set) assessment coordinator and or nurse supervisor so that a review of the resident's assessment and care plan can be made. 4. […]

• Actual harm, isolatedF677May 25, 2023

  Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident who was dependent on staff for incontinence care received those services for one (1) of five (5) residents reviewed for incontinence care. Resident #25. Findings Include: A review of the facility's policy Routine Resident Checks, dated 6/1/2000, revealed, .It is the policy of this facility to make routine resident checks to assure that the resident's safety and wellbeing are maintained. Procedure 1. […]

• Actual harm, isolatedF684May 25, 2023

  Based on observation, interviews, record reviews and facility's policy review the facility failed to administer intravenous (IV) antibiotics per Physician's Orders for one (1) of two (2) Residents reviewed for hospitalization . Resident #35. Findings Include: A record review of the facility's policy Admission Criteria with a review date of 4/25/23 revealed .Our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation 1. The objectives of our admission criteria policy are to: . b. admit residents who can be cared for adequately by the facility . 7. Some examples of nursing/medical needs that can be met adequately include a. […]