The Plaza Health Services at Santa Marta

In the surveyor’s words

From the most serious findings on record at The Plaza Health Services at Santa Marta, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 31, 2024

  The 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. […]

• No harm, potential for more than minimal, widespreadF585Jul 31, 2024

  The 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. Findings included: - On 07/29/24 at 07:05 AM, entry into the skilled facility involved going through locked double doors from the main entrance area that Assisted Living shared. […]

• No harm, potential for more than minimal, widespreadF880Jul 31, 2024

  The 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. […]

• No harm, potential for more than minimal, patternF755Oct 24, 2022

  The 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. Findings included: - On 10/24/22 at 09:12 AM, observation of the 1700 front-hall medication cart revealed staff had not signed the Eight Hour Verification of Controlled Substance Count Sheet at shift change 33 times from 10/01/22 to 10/24/22. On 10/24/22 at 09:12 AM, observation of the 1700 back-hall medication cart revealed staff had not signed the Eight Hour Verification of Controlled Substance Count Sheet at shift change 19 times from 10/01/22 to 10/24/22. […]

• No harm, potential for more than minimal, patternF812Jun 21, 2021

  The facility had a census of 35 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to ensure one of three facility kitchens had a sanitary food preparation area to prepare foods for 34 residents who received food from the kitchens. Findings included: - On 06/16/21 at 11:40 AM, observation in the facility's main kitchen revealed a magnetic knife holder above the food preparation sink with dried food on the top and the face where three knives were held. Further observation revealed the shelf above the preparation counter, the backsplash and wall with dried crumbs of food stuck to them. On 06/16/21 at 11:45 AM, Dietary Staff (DS) BB verified the observation and stated staff were to follow the facility's cleaning schedule. […]