Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Plaza West during CMS and state inspections, most recent first.
Incomplete transfer and discharge documentation was found for two residents sent to the hospital. The Nursing Home Transfer and Discharge Notice had blank physician/designee, resident/representative, and notice date fields, and the chart lacked discharge summaries and documentation that the receiving facility was notified. Staff interviews showed confusion about who completed the form and how hospital transfers were documented.
Surveyors found that three residents did not receive wound care according to physician orders, including undated or improperly labeled dressings and delays in starting prescribed wound care. Interviews confirmed that staff did not consistently follow procedures for documenting and implementing wound care orders, and the facility could not provide a wound care policy when requested.
Two residents with significant cognitive and mobility impairments, both at high risk for falls, did not receive timely or appropriate fall prevention interventions. Staff inconsistently assessed one resident’s ability to unlock wheelchair brakes and failed to include necessary interventions in the care plan, while another resident experienced multiple falls before comprehensive fall prevention measures were implemented. The facility did not ensure individualized care planning or consistent staff communication, resulting in inadequate supervision and accident prevention.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, resulting in a deficiency related to food safety and handling.
Surveyors found that the facility failed to implement Enhanced Barrier Precautions for multiple residents with wounds or indwelling devices, did not ensure proper hand hygiene during medication administration, and allowed improper storage of urinary catheter drainage bags. Staff were observed with long fingernails and inconsistent use of PPE, and facility policies did not adequately address these infection control practices.
A resident with a history of dysphagia, malnutrition, and cognitive impairment received enteral tube feedings with the head of bed elevated less than the 45 degrees specified in the care plan. Multiple observations confirmed the intervention was not followed, and staff interviews revealed inconsistent knowledge of the required positioning. Facility policy required 30 to 45 degrees elevation, but the care plan called for 45 degrees, and there were no physician orders specifying the degree.
A resident was not provided assistance to obtain needed vision and hearing services, resulting in a lack of access to appropriate care.
A resident with multiple chronic conditions reported ongoing, severe pain and stated that the prescribed opioid was ineffective, preferring acetaminophen, which was not provided. The LPN was aware of the resident's complaints but failed to successfully notify the physician or follow up, and pain assessments were inconsistently documented. Non-pharmacological interventions were not attempted, and the care plan for pain management was not fully implemented.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident was administered lorazepam (Ativan) for an inappropriate diagnosis of Alzheimer's disease, without evidence of anxiety or a proper clinical indication. Staff interviews confirmed the medication was not justified, and facility policy requiring specific indications for psychotropic medications was not followed.
Incomplete transfer and discharge documentation for hospital discharges
Penalty
Summary
The facility failed to complete the Nursing Home Transfer and Discharge Notice, notify the receiving facility, and document a discharge summary for two residents who were sent to the hospital. Resident #98 was admitted with diagnoses including nonrheumatic aortic valve stenosis, encounter for surgical aftercare following surgery on the nervous system, and acute on chronic diastolic congestive heart failure, and was later discharged to an acute care hospital because the resident’s medical needs were unable to be met. The transfer and discharge notice for this resident had blank fields for the physician/designee name and signature, the resident or representative name and signature, the date the notice was given, the local Long Term Care Ombudsman Council date, and the resident clinical record date. Resident #8 was admitted with diagnoses including traumatic subarachnoid hemorrhage without loss of consciousness, contusion and laceration of the right cerebrum without loss of consciousness, and unspecified dementia. After a change of condition documented a fall and the primary care provider directed that the resident be sent to the emergency room for evaluation, the resident was discharged to the hospital. The medical record did not contain a discharge summary or documentation that the receiving facility was notified of the discharge. The Nursing Home Transfer and Discharge Notice for Resident #8 also contained blank fields for the physician/designee name and signature, the resident or representative name and signature, the date the notice was given, the local Long Term Care Ombudsman Council date, and the resident clinical record date. Staff interviews showed LPNs were unsure what the transfer and discharge form was, medical records staff stated the form was mailed to the resident’s representative after discharge, social services stated physician signatures were not obtained for hospital transfers, and the DON stated nurses were expected to document the discharge in the chart and that social services and medical records were responsible for the form.
Failure to Provide Proper Wound Care and Documentation
Penalty
Summary
Surveyors identified that the facility failed to provide quality wound care for three residents, as evidenced by observations, interviews, and record reviews. One resident was observed with undated white bandages on both lower legs, despite physician orders specifying wound care procedures and dressing changes for skin tears on both legs. Another resident was seen with a bandage on the left forearm that was not dated according to the daily dressing change order. A third resident had a discrepancy between the handwritten wound care order and the electronic medical record, resulting in a delay in the initiation of the prescribed wound care regimen for a surgical wound on the right hip. Interviews with the ADON and DON confirmed that bandages should be labeled with the date, nurse's initials, and shift, and that nurses are responsible for entering handwritten orders into the electronic medical record. The facility was unable to provide a policy related to wound care when requested. The deficiencies were directly related to the failure to follow physician orders for wound care, improper documentation and labeling of dressings, and a lack of timely implementation of wound care orders.
Failure to Implement and Update Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to accurately assess and implement appropriate interventions to prevent accidents for two residents identified as being at high risk for falls. For one resident with a history of Parkinson’s disease, dementia, and a recent femur fracture, staff inconsistently assessed the resident’s ability to unlock wheelchair brakes and did not include specific interventions in the care plan regarding the placement of the resident at a table with both wheelchair brakes locked. Observations showed the resident was often left alone in a wheelchair with brakes locked, and staff provided conflicting information about the resident’s ability to unlock the brakes. The care plan did not address the use of locked brakes or proximity to the table as interventions, and the DON acknowledged that locking both brakes and pushing the resident up to the table would constitute a restraint, which was not care planned. Another resident, admitted after a fall resulting in a brain injury, experienced multiple falls within the facility. The resident had severe cognitive impairment, was dependent on staff for mobility and transfers, and had a documented history of vertigo and unsteadiness. Despite repeated falls, initial care plan interventions were limited to call light use and non-skid footwear, and only after subsequent falls were additional interventions such as therapy screens, anti-rollback devices, and increased monitoring implemented. Staff interviews revealed inconsistent awareness of the resident’s fall history and interventions, and the care plan was not promptly updated to reflect the resident’s high fall risk and need for individualized precautions. The facility’s fall prevention policy requires comprehensive assessment, individualized care planning, and prompt intervention following falls, including root cause analysis and care plan updates. However, in both cases, there were delays and omissions in care planning and intervention implementation, as well as inconsistent communication among staff regarding residents’ fall risks and required precautions. These failures resulted in the facility not ensuring a safe environment free from accident hazards and not providing adequate supervision and interventions to prevent accidents for residents at high risk for falls.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events leading to the deficiency are provided in the report.
Infection Control Program Deficiencies: EBP, Hand Hygiene, and Catheter Storage
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control program. The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents with wounds or indwelling devices, as required by both facility policy and CDC guidance. For example, one resident with venous and arterial ulcers and another with a surgical wound and positive wound cultures for pseudomonas and E. coli were not placed on EBP at admission, and there were no physician orders for EBP for these residents. Staff interviews revealed inconsistent understanding and application of EBP, with decisions often based on wound drainage rather than the presence of wounds or devices, contrary to policy. Additionally, the facility was unable to provide a policy related to EBP when requested. Observations also revealed improper storage of urinary catheter drainage bags. In one instance, a resident's large urinary catheter drainage bag was found hanging from a shower handrail in a shared bathroom, with urine present in the tubing and the bag near other stored items. Staff interviews confirmed that the bag should have been stored in a plastic bag in a drawer, not on the handrail, and the facility's urinary catheter care policy did not address storage of drainage bags when not in use. Further deficiencies were noted in hand hygiene and staff grooming practices. During medication administration, an LPN failed to perform hand hygiene before and after glove use and between resident care activities, despite acknowledging the requirement. Another LPN was observed with long, colored fingernails extending past the fingertips, which is not compliant with CDC recommendations for hand hygiene and infection control. Additionally, a CNA was observed entering and exiting a resident's room with a wound without appropriate PPE, and PPE caddies were not consistently available outside resident rooms as required for EBP implementation.
Failure to Implement Care Plan for Enteral Nutrition Positioning
Penalty
Summary
The facility failed to implement care plan interventions for a resident requiring enteral nutrition via tube feeding. The resident's care plan specified that the head of bed (HOB) should be elevated to 45 degrees during and for thirty minutes after tube feeding to prevent complications. However, multiple observations showed the resident receiving tube feedings with the HOB elevated less than 45 degrees, sometimes as low as approximately 30 degrees. These observations occurred while the enteral nutrition pump was administering the feeding. Review of the resident's medical record indicated diagnoses including protein calorie malnutrition, dysphagia, aphasia, cognitive communication deficit, and gastrostomy status, with a moderately impaired cognitive status. Staff interviews revealed inconsistent understanding of the required HOB elevation, with some staff stating the range should be 30 to 45 degrees, and others unable to specify the policy. The facility's policy required the HOB to be positioned at 30 to 45 degrees unless contraindicated, but the care plan specifically called for 45 degrees. There were no physician orders specifying the degree of elevation, and staff confirmed the care plan intervention was not consistently implemented.
Failure to Assist Resident with Access to Vision and Hearing Services
Penalty
Summary
A resident was not assisted in gaining access to necessary vision and hearing services. The facility failed to ensure that the resident received support to obtain these services, as required, resulting in the resident not having access to appropriate vision and hearing care.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A resident with a history of peripheral vascular disease, cellulitis, systemic lupus erythematosus, osteoarthritis, and spinal stenosis experienced ongoing pain that was not effectively managed by the facility. The resident reported a jabbing pain and expressed that the prescribed opioid pain medication was ineffective, preferring acetaminophen instead. Despite these complaints, the resident did not receive acetaminophen and reported delays in receiving pain medication. Documentation showed that the resident's pain was rated as high as 8 out of 10, and the resident was cognitively intact, able to clearly communicate pain and preferences to staff. Staff interviews and record reviews revealed that the assigned LPN was aware of the resident's complaints about the ineffectiveness of the opioid medication and had attempted to notify the physician, but the message did not go through and no follow-up occurred. The Medication Administration Record indicated that pain assessments were inconsistently documented, with staff sometimes recording low pain scores despite resident reports of significant pain. Non-pharmacological interventions were not attempted or documented, and the care plan interventions for pain management were not fully implemented, including timely physician notification and use of alternative pain management strategies.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Inappropriate Use of Anti-Anxiety Medication Without Clinical Indication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by administering an anti-anxiety medication, lorazepam (Ativan), without an appropriate clinical indication. The resident was admitted with diagnoses including Alzheimer's disease, vascular dementia, and major depressive disorder. The physician's order for lorazepam was documented as being related to Alzheimer's disease, which is not an appropriate indication for this medication. Staff interviews revealed that the resident did not exhibit behaviors consistent with anxiety, and staff acknowledged that Ativan is not typically prescribed for Alzheimer's disease. The order for lorazepam was carried over from the resident's admission documentation without proper review or correction of the diagnosis. Facility policy requires that psychotropic medications, including anti-anxiety drugs, be prescribed only when clinically indicated for specific, documented conditions. The policy also mandates comprehensive evaluation of residents before initiating such medications. Despite these requirements, the resident received lorazepam based on an inappropriate diagnosis, and staff failed to identify and correct the error during routine medication reconciliation and order review processes.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 277 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sun City Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Garden Of Sun City | 0.4 mi | ★★★★★ | 2 | 0 |
| Sun Terrace Health Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Bayshore Pointe Nursing And Rehab Center | 14.4 mi | ★★★★★ | 1 | 0 |
| Hawthorne Center For Rehabilitation And Healing Of | 14.6 mi | ★★★★★ | 0 | 0 |
| Aviata At Central Park | 15 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.