Plaza Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF600Jun 25, 2026

  Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 1) was protected from sexual abuse. * On 5/30/26, Resident 2 was found on top of Resident 1, in Resident 1's room. Residents 1 and 2 were face to face in bed and Resident 2 was observed humping on top of Resident 1. Resident 1 lacked the cognitive capacity to provide informed consent or make reasonable decisions regarding personal safety. Considering Resident 1's cognitive ability, a reasonable person would consider this as severe emotional trauma and may go through post traumatic issues, violation of personal rights, and potential physical injury due to the unsafe positioning of Resident 2 on top of Resident 1. […]

• Actual harm, isolatedF600Dec 4, 2023

  Based on interview and medical record review, the facility failed to protect the residents' (Residents 1 and 3) right to be free from physical abuse by Residents 2 and 4. * Resident 2 had episodes of aggressive behaviors and refused the antipsychotic medications ordered by the physician. The facility failed to notify the psychiatrist that Resident 2's refusal as ordered which resulted in Resident 2's increase in agitation. Resident 2 struck Resident 1 on the face with a pitcher which resulted in Resident 1 sustaining head trauma and injuries on her face, arms, and legs. * Resident 4 punched Resident 3 in the face when Resident 3 refused to turn off a room light. This caused injuries to Resident 3's nose and upper lip. Findings: 1. […]

• Actual harm, isolatedF600Nov 15, 2023

  Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect Resident 1 who was known to have wandering and behaviors of taking other people's foods and on 1:1 supervision from the physical abuse by Resident 2. Resident 2 had struck Resident 1 in the face during an altercation whenResident 1 had wandered into Resident 2's room and attempted to take Resident 2's milk. This failure resulted in Resident 1 suffering a left nasal bone fracture, blunt head and facial trauma, a cerebral concussion (a type of traumatic brain injury caused by a bump, blow, or jolt to the head which may cause damage to brain cells). […]

• Actual harm, isolatedF600Jun 6, 2023

  Based on interview, medicalrecord review, facility document review, and facility P&P review, the facility failed to protect Resident 1 to be free from the physical abuse by Resident 2. Resident 2 had pushed Resident 1 during an altercation while standing in line waiting to smoke. This failure resulted in Resident 1 suffering a broken right hip, significant pain, required the resident to be sent to the acute care hospital, and underwent a major surgical surgery. Findings: Review of the facility ' s P&P titled Abuse-Prevention Program revised 9/2017 showed the facility does not condone any form of resident abuse and develops facility P&Ps , training programs, and systems to promote an environment free from abuse and mistreatment. […]

• No harm, potential for more than minimal, widespreadF803Aug 31, 2021

  Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed as evidenced by: * Cook 1 failed to follow the recipe for the preparation of pureed Salisbury Steak. In addition, Cook 1 failed to ensure the correct portion sizes as shown in the recipe were provided the residents' meal tray. * Cook 2 failed to follow the recipe for nectar thick consistency in the preparation of the pureed salad. Cook 2 failed to ensure the correct portion sizes as shown in the recipe were provided to the residents' meal tray during tray line observation. In addition, Cook 2 added seasoned salt (not in the recipe) to the Fiesta Rice. * The facility failed to provide the appropriate portion size for Resident 637. […]