Plaza Assisted Living

Based on documentation review, record review, and interview, for one resident reviewed, the manager failed to ensure a resident was treated with dignity, respect, and consideration. Findings include: 1. During an interview, R1 was alert and oriented and agreed to an interview. R1 reported the facility was a "shitshow," and E3 "was aggravating," however, did not provide specific details. 2. In record review, R1's medical record indicated R1 received personal care services, and had diagnoses of "Dementia, A-fib, Arthritis, Depression, GERD, Hypertension and CAD". R1's record did not indicate R1 had behavioral issues. 3. During an interview, O1 reported O2 visited the facility a couple of weeks ago and observed "a screaming match between E3 and R1," which made O2 feel uncomfortable... E4 jumped in and pulled R1 away... E3 said to R1, "I'm sick of you and I don't want you here anymore..." 4. During an interview, O1 reported (during a visit at the facility), O1 observed R1 in a chair at the dining room table, "E3 jumped up and yelled, open your eyes, open your eyes, do you want to fall asleep and fall from the chair like [R2] did." R1 said, "I did not close my eyes." E3 said "you cannot do this, you have no family, I'm the only one who cares for you... I'm going to take [O3] and throw [O3] outside..." 5. In documentation review, a video of a part of the interaction revealed E3 standing above R1 (R1 was sitting in a chair), speaking in a harsh berating tone of voice, pointing finger and using arm gestures, and said ..." I have to care for you, you can sleep over there, why do you have to sleep over here... I'm trying to explain to you nicely, you're going to get mad at me... I'm not going to back off from you because I don't want to get you in trouble, that's what I always keep telling you everyday... Nobody cares for you [R1] remember that, but we are here to care for you, but when you act like that.... stand up now, move, go there, or if you want you can go to your room... ... Answer me... I want to protect you... otherwise... I will get in trouble for everybody... your family doesn't care for you, you know that... now move, go there, if you're not going to listen to me, I'm going to grab [O3] and throw [O3] outside." R1 responded oh you shut up... E3 said, "I'm not going to shut up until you understand what I'm telling you..." R1 upset and yelled "Shut up." 6. During an interview, E1 reported R1 had "anger issues," and had been seen by a psychiatric nurse. E3 reported there was an incident with R1; however, E3 did not speak inappropriately to R1. E1 acknowledged the requirements of R9-10-803.J., and reported an investigation would be initiated.

Based on observation, record review, and interview, the manager failed to ensure the premises were free from a condition or situation that could pose a hazard. The deficient practice posed a safety risk to residents. Findings include: 1. In documentation review, an "Incident Report," dated June 16, 2024, documented, "... R2 fell down on the chair when ... about to stand up for the chair was broken, checked everything for bruise or cuts or abrasions.... Helped... up and checked vitals and reported to the manager, POA and Hospice." 2. During an interview, E3 reported the facility had broken dining room chairs; however, the broken chairs were removed from the facility. 3. The Compliance Officer observed two dining room chairs outside on the patio, up against the wall. One chair was obviously broken and the other was unstable. 4. During an interview, E1 and E3 acknowledged the dining room chairs were a safety concern for residents, and one resident fell from one when the leg of the chair broke.