Plaza West Healthcare and Rehab

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Feb 23, 2023

  The facility identified a census of 126 residents. The sample included three residents reviewed for neglect. The facility failed to ensure resident (R) 1 remained free from neglect when staff failed to follow physician orders, prevent medication errors, ensure physician ordered labs were collected, and abnormal results reported to the physician and subsequent orders acted upon. The facility failed to report abnormal vital signs as directed by a defined physician ordered parameter results and failed to provide an ongoing assessment of resident condition after an acute change or abnormal results were identified. On [DATE] resident (R)1's potassium (K) level was high at 5.5 and the staff received an order to discontinue the supplemental K and recheck the K level on [DATE]. […]

• Immediate jeopardy, isolatedF684Feb 23, 2023

  The facility identified a census of 126 residents. The sample included seven residents. Based on record review, interview, and observation, the facility failed to ensure staff implemented care and treatment consistent with standards of care when staff failed to follow physician orders, prevent medication errors, ensure physician ordered labs were collected, and abnormal results were reported to the physician, and subsequent orders were acted upon. The facility failed to report abnormal vital signs as directed by a defined physician ordered parameter and failed to provide an ongoing assessment of a resident's condition after an acute change or abnormal results were identified. […]

• Immediate jeopardy, isolatedF760Feb 23, 2023

  The facility identified a census of 126 residents. The sample included seven residents. The facility failed to prevent a significant medication error when facility staff wrongly administered potassium to Resident (R) 1, who had a high potassium level. On [DATE] R1's potassium level was abnormally high at 5.5 millimoles per liter (mmol/L). The physician ordered to discontinue the potassium 20 milliequivalents (meq) daily. The facility staff failed to remove the medication card from the medication cart and staff continued to administer the medication from the card without checking the actual orders. As a result, R1 received potassium, despite her already elevated levels, for four additional days from [DATE] through [DATE]. On [DATE], R1's potassium level was even more elevated at 5.9 mmol/L. […]

• Actual harm, isolatedF686Oct 9, 2023

  The facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to prevent pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 84 who developed two stage 3 pressure ulcers (full thickness pressure injury extending through the skin into the tissue below) and one stage 4 pressure ulcers (a deep wound that reaches the muscles, ligaments, or even bone) and R32 who developed a stage 4 pressure ulcer. The facility also failed to promote healing of the pressure injury for R32. […]

• Actual harm, isolatedF689Feb 23, 2023

  The facility identified a census of 126 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observation the facility failed to ensure one resident was free from accidents and injury when staff failed to provide the necessary services as directed by Resident (R) 2's plan of care. R2 required physical assistance from two staff members with the use of a sit to stand lift to safely transfer R2. On 02/07/23, Certified Nurse Aide (CNA) M operated the sit to stand lift without use of a second staff member to transfer R2 between the wheelchair to her bed. […]