Plaza West

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF628Jul 31, 2025

  Based on record review and interview, the facility failed to complete the Nursing Home Transfer and Discharge Notice, notify the receiving facility, and document a discharge summary for two residents (#98 and #8) out of two residents sampled.Findings included:1. Review of Resident #98's admission record revealed an admission date of 05/22/2025 and was discharged to an acute care hospital on [DATE]. Resident #98 was admitted to the facility with diagnosis to include nonrheumatic aortic (valve) stenosis, encounter for surgical aftercare following surgery on the nervous system, and acute on chronic diastolic (congestive) heart failure.Review of Resident #98's Nursing Home Transfer and Discharge Notice dated 05/29/2025 revealed Resident #98 was discharged to a hospital because Residents… […]

• No harm, potential for more than minimal, patternF684Jul 31, 2025

  Based on observations, interviews and record review, the facility failed to provide quality care and services related to wound care for three residents (#56, #58, #11) out of three sampled residents. Findings Included: 1. During an observation on 07/28/2025 at 12:23 p.m., Resident #56 was observed sitting in a wheelchair with undated white bandages around both of her lower legs. Review of Resident #56's admission record revealed an initial admission date of 04/17/2025. Resident #56 was admitted with diagnosis to include partial intestinal obstruction, unspecified as to cause, acute embolism and thrombosis of unspecified deep veins of left lower extremity, and peripheral vascular disease, unspecified. Review of Resident #56's Medicare 5-day Minimum Data Set (MDS) revealed Section M. […]

• No harm, potential for more than minimal, patternF689Jul 31, 2025

  Based on observations, record reviews, and interviews the facility failed to accurately assess and implement appropriate interventions for two residents (#2 and #8) of six residents sampled for accidents. Findings included: On 07/28/25 at 9:53 a.m. Resident #2 was observed sitting in a wheelchair alone at table in the common area between rooms [ROOM NUMBERS]. The resident’s wheelchair was pushed up to table with both wheelchair brakes in a locked position. The resident was observed pushing at the table. During the observation, Staff N, Licensed Practical Nurse (LPN) reported the resident’s diagnosis and was Spanish-speaking only. On 07/28/25 at 11:04 a.m. Staff L, Certified Nursing Assistant (CNA) was observed unlocking both of Resident #2’s wheelchair brakes. […]

• No harm, potential for more than minimal, patternF812Jul 31, 2025

  Based on observations and interviews the facility did not ensure food service standards were followed related to hand hygiene and sanitary practices in the main kitchen and in one of three satellite kitchens. Findings included: On 07/28/25 at 9:10 a.m., an initial tour of the kitchen was conducted with the Associate Dining Director. An observation of Staff F, Utility Technician revealed he was using the high temperature dish machine. He was the only staff member using the dish machine during the observation. Staff F was taking the test strip out of a clear tube to check the temperature of the dish machine. He was observed to drop the test strip on the floor and used the same one to verify the final rinse temperature. During the observation he did not have gloves on. […]

• No harm, potential for more than minimal, patternF880Jul 31, 2025

  Based on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to the storage of urinary catheters for one resident (#104) of one resident sampled, failed to perform appropriate hand hygiene during the administration of medications for one resident (#33) of six residents observed during medication administration observation, failed to ensure one Staff (C) out of 25 staff fingernails were kept in a manner that allowed for hand hygiene to be completed in a sanitary manner, and failed to implement Enhanced Barrier Precautions (EBP) for three residents (#56, #58 and #11) of seven residents sampled for infection control practices. 1. Review of Resident #56's admission Record revealed an initial admission date of 04/17/2025. […]