The Plaza Health Services at Santa Marta

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interdisciplinary staff assessed Resident (R) 8 for the ability to safely self-administer medication before the staff gave R8 her Flonase nasal spray, to keep in her room, per R8's request.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the Office of the Long-term Care Ombudsman (LTCO) for the discharge of Resident (R) 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and implement resident-centered interventions and monitor effectiveness of interventions to prevent falls for Resident (R) 27, who was at high risk for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary dialysis post assessment, care, and services for Resident (R) 23 when staff failed to provide post-dialysis assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to display accurate and identifiable posted nurse staffing information.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with three reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure adequate supervision resulting in preventable falls for Resident (R) 29. This deficient practice resulted in a pelvic fracture for R29 and created the risk for pain and impaired mobility. The facility additionally failed to safely secure hazardous materials, cleaning chemicals, and supplemental oxygen cylinders from eight cognitively impaired ambulatory mobile residents. This placed the residents at risk for preventable accidents and injuries. Findings Including: [...]

Inspectors wroteThe facility identified a census of 37 residents. Based on observations, record reviews, and interviews, the facility failed to provide a method for residents to submit grievances anonymously. This deficient practice had the risk of loss of resident rights, unresolved grievances, and a loss of dignity for the residents in the facility.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on observations, record review, and interviews, the facility failed to follow infection prevention standards related to disinfecting shared equipment and oxygen tubing storage and failed to place the appropriate isolation signage outside of Resident (R) 192's room after he tested positive for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death). The facility further failed to assess, identify risks, and create a plan to address the risk for Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens. This deficient practice placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with one reviewed for accommodation of needs. Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 23 had a call light within reach to communicate his need for staff assistance. This deficient practice placed the residents at risk for preventable falls and injuries. Findings Including: - The Medical Diagnosis section within R23's Electronic Medical Records (EMR) included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), overactive bladder, cognitive communication deficit, and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). [...]

Inspectors wroteThe facility identified a census of 37 residents with 12 residents included in the sample. Based on interview and record review the facility failed to issue the CMS (Center for Medicare/Medicaid Services) Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) Form 10123 which contained the required information for Resident (R) 193. This failure placed the resident at risk for decreased autonomy and impaired right to appeal.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Two residents were reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of transfer to Resident (R) 12 and R29 or their representatives. The facility further failed to notify the State Long Term Care Ombudsman of transfers/discharges for R29. This deficient practice had the risk of miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services for R12 and R29 and placed R29 at risk for impaired rights.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Two residents were reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a bed hold policy notice to Resident (R) 12 and R29 or their representatives when they transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R12 and R29.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Two residents were reviewed for discharge. Based on record review and interviews, the facility failed to document a recapitulation of stay for Resident (R) 38 and R39. This deficient practice placed R38 and R39 at risk for miscommunication of services received during their stay in the facility and of their post-discharge care needs.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with one reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement timed toileting interventions as indicated in the assessment and failed to assess ongoing patterns of incontinence to establish bowel and bladder patterns to maintain or improve Resident (R)21's incontinence. This deficient practice placed R21 at risk for complications related to incontinence. Findings Including: [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R)14's bed rails were removed as indicated per her side rail assessment. This placed R14 at risk for impaired safety related to the risks associated with the use of side rails. Findings Including: - The Medical Diagnosis section within R14's Electronic Medical Records (EMR) included diagnoses of dysphagia (difficulty swallowing), encephalopathy (inflammatory condition of the brain), muscle weakness, overactive bladder, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and difficulty walking. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to notify the physician of elevated blood pressure as directed and failed to administer antihypertensive (medication used to treat high blood pressure) medications as needed for Resident (R) 26. This deficient practice placed R26 at risk for unnecessary medications and physical complications related to uncontrolled blood pressure.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)24. This placed R24 at risk for inappropriate end-of-life care.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with five residents reviewed for pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer or obtain a signed declination for the Prevnar 20 (pneumococcal vaccination used for the prevention of pneumococcal disease caused by 20 serotypes of Streptococcus pneumoniae) pneumococcal vaccination for Resident (R) 23. This deficient practice placed R23 at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.

Inspectors wroteThe facility identified a census of 37 residents. Based on record review and interviews, the facility failed to establish and implement an admissions agreement that protected the residents' right to personal property by not waiving the facility's liability.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to provide an accurate reconciliation of controlled drugs at the end of daily work shifts. This placed residents at risk for misappropriation of medications by staff.