A list of the most recent deficiencies for Plaza West. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-12 | 2023-06-12 | 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 | 2023-05-12 | 2023-06-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-12 | 2023-06-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-12 | 2023-06-12 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-09 | 2023-06-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-09 | 2023-06-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-09 | 2023-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-09 | 2023-06-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-09 | 2023-06-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-09 | 2023-06-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-09 | 2023-06-12 | 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 | 2021-07-23 | 2021-08-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-23 | 2021-08-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-23 | 2021-08-23 | 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 | 2021-07-23 | 2021-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-23 | 2021-08-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-07-21 | 2021-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-21 | 2021-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-21 | 2021-08-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-21 | 2021-08-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-21 | 2021-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-21 | 2021-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-21 | 2021-08-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-12-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-31 | 2019-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-31 | 2019-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-12-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-29 | 2019-12-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-29 | 2019-12-01 | N |
