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Deficiency Records for Plaza West Healthcare and Rehab
A list of the most recent deficiencies for Plaza West Healthcare and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Plaza West Healthcare and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-28 | 2024-01-26 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-12-28 | 2024-01-26 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-12-28 | 2024-01-26 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Meet other general requirements. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-15 | 2023-12-19 | N |
| Provide appropriate foot care. | Health | 2023-10-09 | 2023-11-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-09 | 2023-11-06 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-10-09 | 2023-11-06 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-09 | 2023-11-06 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-09 | 2023-11-06 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-09 | 2023-11-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-09 | 2023-11-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-09 | 2023-11-06 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-10-09 | 2023-11-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-09 | 2023-11-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-09 | 2023-11-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-09 | 2023-11-06 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-09 | 2023-11-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-09 | 2023-11-06 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-09 | 2023-11-06 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-10-09 | 2023-11-06 | Y |
| Post nurse staffing information every day. | Health | 2023-10-09 | 2023-11-06 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-10-09 | 2023-11-06 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-10-09 | 2023-11-06 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-09 | 2023-11-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-09 | 2023-11-06 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-09 | 2023-11-06 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-09-15 | 2023-09-19 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-08-31 | 2023-09-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-20 | 2023-07-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-20 | 2023-07-27 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-20 | 2023-07-27 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-06-20 | 2023-07-27 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-30 | 2023-07-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-30 | 2023-07-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-23 | 2023-03-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-23 | 2023-03-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-23 | 2023-03-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-23 | 2023-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-06 | 2023-03-06 | Y |
| Meet other general requirements. | Fire Safety | 2023-01-09 | 2023-02-10 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-01-09 | 2023-02-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-23 | 2023-02-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-28 | 2022-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-28 | 2022-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-28 | 2022-11-10 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Meet other general requirements. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-05-12 | 2022-06-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-21 | 2022-06-02 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-04-21 | 2022-06-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-21 | 2022-06-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-21 | 2022-06-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-21 | 2022-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-06-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-21 | 2022-06-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-21 | 2022-06-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-04-21 | 2022-06-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-21 | 2022-06-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-21 | 2022-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-21 | 2022-06-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-27 | 2021-11-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-02-04 | 2021-02-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-02-04 | 2021-02-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-04 | 2021-02-19 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-03-11 | 2020-04-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-03-11 | 2020-04-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-03-11 | 2020-04-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-11 | 2020-04-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-03-11 | 2020-04-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-11 | 2020-04-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-03-11 | 2020-04-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-03-11 | 2020-04-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-11 | 2020-04-21 | N |
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