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Deficiency Records for Plaza West Healthcare and Rehab
View the most recent health deficiencies and inspection results for Plaza West Healthcare and Rehab. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Plaza West Healthcare and Rehab. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-03-19 | 2025-05-16 | 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 | 2025-03-19 | 2025-05-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-03-19 | 2025-05-16 | 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 | 2025-03-19 | 2025-05-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-03-19 | 2025-05-16 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2025-03-19 | 2025-05-09 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-03-19 | 2025-05-09 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2025-03-19 | 2025-05-09 | 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 | 2025-03-19 | 2025-05-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-03-19 | 2025-05-09 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-03-19 | 2025-05-09 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2025-03-19 | 2025-05-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-03-19 | 2025-05-09 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2025-03-19 | 2025-05-09 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2025-03-19 | 2025-05-09 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-03-19 | 2025-05-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-03-19 | 2025-05-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-19 | 2025-05-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-03-19 | 2025-05-09 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-03-19 | 2025-05-09 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2025-03-19 | 2025-05-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-03-19 | 2025-05-09 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-03-19 | 2025-05-09 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2025-03-19 | 2025-05-09 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-03-19 | 2025-05-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-03-19 | 2025-05-09 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-19 | 2025-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-03-19 | 2025-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-01-28 | 2025-02-21 | Y |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-09-30 | 2024-10-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-30 | 2024-10-29 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-09-30 | 2024-10-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-09-30 | 2024-10-29 | 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 |
| 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 |
| 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 |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Meet other general requirements. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-09 | 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 | 2023-10-09 | 2023-12-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-10-09 | 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 | 2023-10-09 | 2023-12-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-09 | 2023-12-19 | N |
| Provide appropriate foot care. | Health | 2023-10-09 | 2023-11-06 | N |
| 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 |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | 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 |
| 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 |
| 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 |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-10-09 | 2023-11-06 | Y |
| Post nurse staffing information every day. | 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 |
| Provide care or services that was trauma informed and/or culturally competent. | 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 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 appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-09 | 2023-11-06 | Y |
| 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 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 |
| 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 |
| 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 proper usage of power strips and extension cords. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Meet other general requirements. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2022-04-21 | 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 | 2022-04-21 | 2022-06-11 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-04-21 | 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 | 2022-04-21 | 2022-06-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-04-21 | 2022-06-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-21 | 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 | 2022-04-21 | 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 | 2022-04-21 | 2022-06-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-21 | 2022-06-11 | 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 food and drink is palatable, attractive, and at a safe and appetizing temperature. | 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 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 |
| Provide safe and appropriate respiratory care for a resident when needed. | 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 |
| 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 pressure ulcer care and prevent new ulcers from developing. | 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 |
| 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 |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-04-21 | 2022-06-02 | 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 |