Plaza Healthcare & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF678Mar 17, 2022

  Based on interviews, record review, and document review, it was determined that the facility failed to ensure: 1.) the emergency response system was activated to call a code, 2.) 911 was enacted, 3.) the automatic external defibrillator (AED) was utilized for a resident who was found unresponsive (Resident #7) and was a full code status (all resuscitation procedures will be provided when a person stops breathing or heart stops beating). This deficient practice occurred for 1 of 3 residents (Resident #7) reviewed for unexpected deaths and 4.) failed to ensure a system was in place to appropriately track and maintain cardiopulmonary resuscitation (CPR) certifications to ensure that staff maintain the appropriate CPR certification. […]

• Actual harm, isolatedF689Mar 17, 2022

  Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility 1.) failed to ensure: that the facility policy for Accident/Incident Reports was followed to determine the causal factor and to update interventions to prevent recurrent falls, for a visually impaired ambulatory resident who was identified as a high fall risk, and sustained multiple falls, including a fall that resulted in a head injury on [DATE], and 2.) failed to ensure; that the emergency crash cart (a set of trays /drawers /shelves on wheels) used for transportation and dispensing of emergency medications and equipment, was secured and not easily accessible to residents and non-licensed staff. […]

• No harm, potential for more than minimal, widespreadF880Jun 5, 2025

  Based on observation, interview, and a review of facility documentation, it was determined that the facility failed to ensure laundry staff had the proper personal protection equipment (PPE) necessary to handle linens to prevent the spread of infection. This deficient practice was evidenced by the following: On 6/4/25 at 11:10 AM, the surveyor toured the laundry room along with the Infection Preventionist (IP). Upon entry to the clean laundry area, two laundry aides were emptying a dryer. The laundry room consisted of an area with two front loading washers, both which were running. There was another area with three dryers and room for folding laundry. The surveyor asked the laundry aides, what they needed to do when loading the dirty laundry into the washers. […]

• No harm, potential for more than minimal, widespreadF563Mar 17, 2022

  Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the facility visitation process did not restrict visitation as per executive directive from Center for Medicare Services (CMS) QSO-20-39-NH revised 11/12/2021. This deficient practice was identified for 1 of 18 residents (Resident #5) reviewed. The deficient practice was evidenced by the following: On 02/28/22, at 9:45 AM the surveyor toured the second floor of the facility. Resident #5 approached the surveyor and requested information regarding visitation. On 02/28/22 at 10:28 AM, during the entrance conference with the Administrator (LNHA) and the Director of Nursing (DON), the DON stated that visitors must be tested for COVID-19. […]

• No harm, potential for more than minimal, widespreadF730Mar 17, 2022

  Based on interview and review of pertinent facility documentation, it was determined that the facility failed to conduct performance evaluations in a timely manner and to provide documented education for areas of improvement identified on the performance evaluations, for 4 of 5 Certified Nursing Assistants (CNA #1, #2, #3, and #5) reviewed. This deficient practice was evidenced by the following: On 03/02/22 at 8:13 AM, the Surveyor requested the CNA performance evaluations and education information from the Registered Nurse (RN) Staff Educator. On 03/02/22 at 10:11 AM, the RN Staff Educator provided the Surveyor with some CNA competencies and nothing else. The RN Staff Educator stated that the in-services she had provided the surveyor are the yearly education for all CNAs. […]