Plaza Health and Rehab

In the surveyor’s words

From the most serious findings on record at Plaza Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Jun 30, 2022

  Based on interview and record review, the facility failed to act in accordance with a resident's advance directive and to honor the resident's wishes of Do Not Resuscitate when found unresponsive and without respirations or a pulse for 1 of 3 residents, Resident #1. This has the potential to affect the current 149 residents who reside in the facility if their advance directive wishes are not verified. Findings include: Review of the admission record for Resident #1 documented the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Florida Department of Health State of Florida Do Not Resuscitate Order documented the advanced directive was signed by the Resident #1's representative and the physician dated [DATE]. […]

• Immediate jeopardy, isolatedF835Jun 30, 2022

  Based on interview and record review the facility administration failed to conduct a thorough investigation of an identified concern to determine a root caused analysis, failed to bring the incident to the QAPI (Quality Assurance Performance Improvement) committee, provided limited staff training and did not effectively and efficiently attain and maintain the highest practicable physical well-being of each resident by not honoring resident's right for advance directive of Do Not Resuscitate when found unresponsive and without respirations or a pulse for 1 of 3 residents, Resident #1. Findings include: Review of the Job Description for Job Title Executive Director, revised [DATE], reads Position Purpose: Operates the facility in accordance with Company vision, mission, and values. […]

• Immediate jeopardy, isolatedF867Jun 30, 2022

  Based on interview, and record review, the quality assessment and assurance committee failed to identify, develop, and implement appropriate plans of action to correct the quality deficiencies to honor the resident's wishes of Do Not Resuscitate when found unresponsive and without respirations or a pulse for 1 of 3 residents, Resident #1. This has the potential to affect the current 149 residents who reside in the facility if their advance directive wishes are not verified. Findings include: Review of the admission record for Resident #1 documented the resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF761Aug 26, 2021

  Based on observation, interview, and record review, the facility failed to ensure that the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles and included the expiration date when applicable in 6 of 6 medication carts and 2 of 3 medication rooms reviewed. Findings: On 8/23/2021 at 9:05 AM an observation of medication cart #1 with Staff F, Licensed Practical Nurse (LPN), showed two opened [MEDICATION(S)] 0.05% eye drops with no opened or expiration dates, and one opened [MEDICATION(S)] insulin with no opened or expiration dates. During an interview on 8/23/2021 at 9:10 AM, Staff F, LPN, stated, All medications should have the date they are opened and when they expire. […]

• No harm, potential for more than minimal, widespreadF812Aug 26, 2021

  Based on observation, interview, and record review, the facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety. Findings: 1. On 8/23/2021 at 9:30 AM, a tour of the E Wing nourishment room with the Dietician showed an undated/ unlabeled 8-ounce cup of liquid, an undated/ unlabeled 33.8-ounce bottle of liquid stored in the refrigerator, an undated/ unlabeled plastic container of a food substance stored on top of the microwave oven, and a splattered brown substance inside the microwave oven. During an interview on 8/23/2021 beginning at 9:30 AM, the Dietician confirmed the undated/ unlabeled items should be dated and labeled. She confirmed the microwave oven was in need of cleaning. […]