Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Plaza Health Services At Santa Marta during CMS and state inspections, most recent first.
Failure to Assess Resident for Self-Administration of Medication: A resident with pulmonary fibrosis, COPD, interstitial pulmonary disease, chronic hypoxia, anxiety, vertigo, and TIA had intact cognition but also needed assistance with many ADLs. Staff placed Flonase in her room at her request without an interdisciplinary assessment or order confirming she could safely self-administer or keep the medication at bedside, and a nurse later confirmed the resident had not been assessed.
Failure to notify the LTCO of a resident discharge. A resident with traumatic subarachnoid hemorrhage, a humerus fracture, A-fib, muscle weakness, and cognitive communication deficit had a BIMS score of 10 and was discharged after signing a written transfer notice. The facility documented family discussions and IDT notification, but could not provide evidence that the LTCO was notified, and an admin nurse confirmed the omission.
Failure to implement and monitor effective fall prevention interventions for a resident at high risk for falls. The resident had dementia, weakness, gait and mobility problems, repeated falls, and required a wheelchair or walker with extensive help for ADLs and transfers. Her care plan listed multiple falls and interventions such as staying with her during toileting, checking her around shift change, and supervising her in common areas, yet incident notes showed she was found on the bathroom floor after an unwitnessed fall and later tried to transfer herself into her wheelchair, which was unlocked and beside the bed. Staff said residents were checked frequently and interventions were added after each fall, but an admin nurse stated that checking residents before and after shift change was not an appropriate fall intervention.
Failure to Complete Post-Dialysis Assessments: A resident with ESRD and a dialysis fistula did not receive required post-dialysis assessments after returning from dialysis, and the dialysis communication book showed missing site assessments on multiple dialysis days. Staff interviews confirmed the post-dialysis checks were not completed, despite orders to document the dialysis communication book, assess bruit and thrill, and monitor the site for infection or bleeding.
Inaccurate daily nurse staffing information was posted near the admin offices, with a staffing sheet displayed under the wrong date before being updated later that morning. The ADON reported staffing oversight was split between two people, a charge nurse would post the sheet if a staffing coordinator was unavailable, and the sheet was expected to be updated daily. The facility also reported it did not have 18 months of staffing sheets and could only provide records from late December forward, despite policy requiring daily posting of direct care staffing data.
A resident with a history of falls and cognitive impairment experienced multiple unwitnessed falls, including one resulting in a pelvic fracture, due to inadequate supervision. Additionally, hazardous materials and oxygen cylinders were improperly stored, posing risks to residents. Staff failed to adhere to safety protocols, such as using foot pedals during wheelchair transport, contributing to preventable accidents.
The facility failed to provide a method for residents to submit grievances anonymously, despite having a policy that allowed for anonymous submissions via a comment box. Observations and staff interviews revealed that residents were encouraged to talk to staff to file grievances, which did not ensure anonymity. This practice risked loss of resident rights and unresolved grievances.
The facility failed to follow infection prevention standards, including improper disinfection of shared equipment and inadequate storage of oxygen tubing. A resident with COVID-19 did not have appropriate isolation signage, and the facility lacked a Legionella water management plan, placing residents at risk for infectious diseases.
A resident with severe cognitive impairment and multiple medical conditions was found without a call light within reach, despite being at high risk for falls. Staff interviews confirmed the expectation for call lights to be accessible, yet the facility failed to adhere to this protocol, compromising the resident's ability to communicate needs and increasing the risk of preventable injuries.
A facility failed to issue the CMS Notification of Medicare Non-Coverage (NOMNC) to a resident whose Medicare Part A episode ended, resulting in a risk to the resident's autonomy and appeal rights. Despite a planned discharge discussed in a care plan meeting, the facility did not provide the required NOMNC, mistakenly believing it was unnecessary if the resident initiated the discharge. This oversight violated the facility's policy and CMS requirements.
The facility failed to provide written notification of transfer for two residents, R12 and R29, or their representatives, as required by policy. R12 was transferred to the hospital after becoming unresponsive, and R29 was transferred due to lethargy and no urine output. The facility's policy mandates written notification and notification to the State Long Term Care Ombudsman, which was not followed, placing the residents at risk for miscommunication and potential missed healthcare services.
The facility failed to provide bed hold policy notices to two residents or their representatives during hospital transfers, as required by their policy. One resident was transferred due to unresponsiveness, and another due to lethargy and no urine output. Staff interviews confirmed the absence of bed hold notices, posing a risk to the residents' ability to return to their previous rooms.
The facility failed to document a recapitulation of stay for two residents at the time of their planned discharge, omitting a detailed account of services received during their stay. This deficiency was identified through record reviews and interviews, revealing that the discharge summaries lacked necessary information, placing the residents at risk for miscommunication regarding their post-discharge care needs.
A facility failed to implement timed toileting interventions for a resident with a history of CHF, hypertension, dementia, and BPH, who was always incontinent of bowel and bladder. Despite being identified as a candidate for scheduled toileting, the resident's care plan lacked necessary interventions. Observations and interviews indicated that the resident was not receiving appropriate toileting care, and staff were unsure of any specific program in place. This failure to adhere to the facility's Quality of Care policy placed the resident at risk for complications.
A resident's bed rails were not removed as indicated by her assessment, placing her at risk for safety issues. Despite the assessment showing no need for side rails, they were still present on her bed. Staff interviews revealed inconsistencies in the assessment and inspection process for bed rails, contrary to the facility's policy.
A resident with hypertension and atrial fibrillation experienced 35 instances of elevated systolic blood pressure without physician notification or consistent administration of PRN antihypertensive medication. Despite care plan directives and staff expectations, the facility failed to document or follow through on necessary actions, risking the resident's health.
A resident with terminal dementia receiving hospice services was at risk for inappropriate end-of-life care due to the facility's failure to coordinate a care plan with hospice services. The resident's care plan lacked specific instructions on hospice services, and staff interviews revealed uncertainty about hospice information inclusion. The facility's policy required a coordinated plan of care with hospice, which was not followed.
A facility failed to offer or document a declination for the Prevnar 20 pneumococcal vaccination for a resident, despite having a policy to ensure residents received education and documentation regarding immunizations. The resident's record showed previous vaccinations, but no evidence of being offered Prevnar 20. Staff interviews revealed gaps in knowledge of current recommendations and inconsistencies in following procedures for immunization tracking and consent documentation.
The facility failed to protect residents' rights to personal property by not waiving liability in their admissions agreement. The agreement stated the facility was not responsible for loss, theft, or damage to personal items, including valuable items like money and jewelry. Administrative Staff A confirmed the facility's stance on not accepting responsibility for lost or stolen items of excess value, and the Admission Orientation policy did not address the admission agreement.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure interdisciplinary staff assessed a resident for the ability to safely self-administer medication before staff gave her Flonase nasal spray to keep in her room at her request. The resident had diagnoses including pulmonary fibrosis, COPD, interstitial pulmonary disease, chronic hypoxia, anxiety, vertigo, and TIA. Her MDS documented a BIMS score of 14, indicating intact cognition, and her care plan noted a self-care deficit related to limited immobility and generalized weakness, with partial to moderate assistance needed for many ADLs. The EMR showed an order for staff to administer Flonase nasal suspension once daily for 15 days, but there was no order confirming the resident could self-administer medications and no evidence that the interdisciplinary team assessed her ability to safely self-administer or keep medication at bedside. During observation, a small white bottle of Flonase with the resident’s name and pharmacy information was seen on the table next to her bed. A nurse confirmed the resident was in possession of the bottle and stated the resident wanted to keep it in her room. An administrative nurse later confirmed the resident had not been assessed and that the required steps for self-administration had not been completed.
Failure to Notify LTCO of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the Long-term Care Ombudsman (LTCO) of Resident 46's discharge. Resident 46 had diagnoses including traumatic subarachnoid hemorrhage, right upper humerus fracture, cardiomegaly, atrial fibrillation, muscle weakness, and a cognitive communication deficit. The resident's discharge MDS documented a BIMS score of 10, indicating moderate cognitive impairment, and there was no diagnosis of dementia. A progress note documented a conversation with the resident's daughter on 03/18/26 about plans for the resident to move back to an independent living apartment on 03/19/26, and the interdisciplinary team was notified. A discharge summary note on 03/19/26 documented that the resident reviewed and signed a written notice of transfer, and the facility discharged the resident at approximately 02:20 PM that day. When asked, the facility could not provide evidence that the LTCO had been notified of the discharge, and an administrative nurse confirmed that the LTCO had not been notified.
Failure to Implement and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to identify and implement resident-centered interventions and failed to monitor the effectiveness of interventions to prevent falls for a resident who was at high risk for falls. The resident’s record documented anemia, major depressive disorder, weakness, abnormalities of gait and mobility, cognitive communication deficit, repeated falls, and dementia. Her assessments showed a change in cognition over time, with a BIMS score of 14 on the annual MDS and a BIMS score of 5 on the quarterly MDS, and she required a wheelchair or walker for mobility along with varying levels of assistance for ADLs and transfers. The resident’s care plan identified her as high risk for falls related to injury related to falls, weakness, and impulsive nature. The care plan documented multiple falls, including an unwitnessed fall while trying to transfer herself from the toilet back to her wheelchair, a witnessed fall when she tried to transfer from her bed to her wheelchair, and another unwitnessed fall. Interventions included remaining with her during toileting, checking on her before and after shift change, bringing her into the common area during shift change, using her recliner for shorter periods, offering activities in the common area, and keeping her door open if she wanted to nap. The resident’s fall risk evaluations documented balance problems, decreased muscular coordination, and instability when turning, and later balance problems while standing and walking. An incident note documented that a CNA found her on the bathroom floor after she had increased confusion, and another incident note documented that a CNA discovered her trying to transfer herself into her wheelchair and had to lower her to the floor because she was not positioned correctly and the wheelchair was unlocked beside the bed. Survey observations showed the resident in the common area and later eating breakfast with staff assistance. Staff stated that fall-risk residents were checked frequently and that new interventions were added after each fall, while administrative staff stated that checking residents before and after shift change was not an appropriate fall intervention. The facility policy required identification of residents at risk for falls, implementation of appropriate preventative interventions, prompt response to falls, and monitoring of outcomes to reduce fall-related injuries and complications.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide required dialysis post-assessment, care, and services for a resident with ESRD and multiple other diagnoses, including infection and inflammatory reaction due to a peritoneal dialysis catheter, spontaneous bacterial peritonitis, diabetes mellitus, hypothyroidism, atrial fibrillation, hypertension, anemia, femur fracture, and obstructive sleep apnea. The resident’s care plan directed staff to encourage attendance at dialysis, monitor for signs or symptoms of renal insufficiency, changes in level of consciousness, changes in skin turgor and oral mucosa, changes in heart and lung sounds, and new or worsening peripheral edema. Physician orders also required a dialysis communication book to be completed and sent with the resident, with information reviewed twice daily on dialysis days, and required auscultation of thrill and bruit and dialysis precautions for the left upper extremity fistula. The dialysis communication book showed that the assessment of the site after return to the facility was not completed on two dialysis days. The communication form from one dialysis treatment noted that ordered IV medication was received at the dialysis center. During observation, the resident’s husband was applying medication to the resident’s left lower arm and then wrapping the area with plastic wrap, stating he had been doing this treatment since dialysis began. Staff interviews confirmed that the resident had not been assessed after returning from dialysis, and the administrative nurse stated that the expectation was for charge nurses to complete the post-dialysis assessment, including checking the dialysis site for bruit, thrill, infection, and bleeding.
Inaccurate Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to display accurate and identifiable posted nurse staffing information. On 05/12/26 at 07:25 AM, observation showed a daily staffing sheet hanging near the administrative offices, and review of the Daily Nursing Staffing Information sheet revealed it did not have the correct posting date; the sheet posted that day was dated 05/08/26. Later that morning, at 08:54 AM, the daily nursing staffing information sheet was observed posted with the date 05/12/26. On 05/14/26, Administrative Nurse A stated they oversee the staffing coordinators, that the position is split between two people, and that a charge nurse would post the daily nursing staffing sheet if a staffing coordinator was unavailable. Administrative Nurse A stated it was expected that the daily nursing staffing sheet be changed and updated daily. The same day, Administrative Nurse A reported the facility did not have 18 months of staffing sheets and could only provide posted staff sheets from 12/25/25 forward. Facility policy, Posting Direct Care Daily Staffing Numbers, version 1.2, dated August 2022, stated the facility would post daily for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.
Inadequate Supervision and Unsafe Storage Practices
Penalty
Summary
The facility failed to provide adequate supervision and prevent accidents for a resident, identified as R29, who experienced multiple falls resulting in a pelvic fracture. R29 had a history of repeated falls, cognitive impairment, and required substantial assistance for mobility and daily activities. Despite being identified as a high fall risk, the facility did not ensure consistent supervision, leading to several unwitnessed falls, including one that resulted in a significant injury. Observations revealed that staff did not always adhere to safety protocols, such as using foot pedals when transporting R29 in a wheelchair, further increasing the risk of accidents. Additionally, the facility did not secure hazardous materials and oxygen cylinders properly, posing a risk to residents, particularly those who were cognitively impaired and ambulatory. Hazardous cleaning chemicals were found unsecured in areas accessible to residents, and oxygen cylinders were improperly stored outside designated racks. Staff interviews confirmed that these practices were not in line with the facility's policies, which required secure storage of such materials to prevent accidents and injuries. The facility's failure to adhere to its own policies and provide adequate supervision and safe storage of hazardous materials and equipment resulted in significant risks to resident safety. The lack of proper supervision and adherence to safety protocols contributed to preventable accidents and injuries, highlighting deficiencies in the facility's care and safety practices.
Failure to Provide Anonymous Grievance Submission Method
Penalty
Summary
The facility failed to provide a method for residents to submit grievances anonymously, which is a violation of residents' rights. During an initial tour of the skilled facility, it was observed that there was no submission box or method for filing anonymous grievances. Interviews with various staff members, including Social Services, Licensed Nurse, and Administrative Staff, revealed that the facility encouraged residents to talk to staff if they wanted to file a grievance anonymously. However, this process did not ensure anonymity as the grievances were submitted through staff members. The facility's policy, revised in November 2017, stated that residents or their representatives wishing to remain anonymous could place their grievances in a comment box. Despite this policy, the facility did not have a comment box available for residents in the skilled facility, although the Assisted Living side did have one. This lack of a proper method for anonymous grievance submission posed a risk of loss of resident rights, unresolved grievances, and a loss of dignity for the residents.
Infection Control Deficiencies in Equipment Disinfection and Isolation Protocols
Penalty
Summary
The facility failed to adhere to infection prevention standards, particularly in the areas of disinfecting shared equipment and proper storage of oxygen tubing. Observations revealed that a resident's oxygen tubing was improperly stored in the handle of an oxygen concentrator instead of a mesh bag. Additionally, a glucometer was used without being disinfected before and after use, and it was placed on surfaces without a clean barrier. Furthermore, a Hoyer lift was observed being used between residents without being disinfected, increasing the risk of cross-contamination. The facility also failed to implement appropriate isolation measures for a resident who tested positive for COVID-19. Although an isolation cart was placed outside the resident's room, there was initially no signage to alert staff and visitors of the necessary transmission-based precautions and required personal protective equipment (PPE). This oversight was confirmed by a licensed nurse who acknowledged the absence of the required signage. Moreover, the facility did not have a Legionella water management plan in place, which is crucial for identifying and mitigating risks associated with Legionella and other waterborne pathogens. Administrative staff admitted to the lack of a testing procedure and were in the process of reaching out to a company to establish one. This deficiency in infection control practices placed residents at risk for infectious diseases.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R23, had a call light within reach to communicate his need for staff assistance. R23 had multiple medical diagnoses, including Parkinson's disease, overactive bladder, cognitive communication deficit, and anxiety disorder, which contributed to his severe cognitive impairment and functional limitations. His care plan indicated that he was at high risk for falls due to his cognitive and physical limitations and required substantial assistance for activities of daily living. The care plan specifically instructed staff to ensure that his call light was always within reach, yet during an observation, R23 was found calling out for help with his call light attached to his bed and out of reach. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that the expectation was for call lights to be stored within reach and attached to residents' clothing or chairs to prevent them from falling. Despite these instructions, the facility's failure to adhere to this protocol resulted in R23 being unable to effectively communicate his need for assistance, placing him at risk for preventable falls and injuries. The facility's Quality of Care policy emphasized the importance of providing necessary services and maintaining a safe and functional environment, yet this was not upheld in R23's case.
Failure to Issue NOMNC to Resident
Penalty
Summary
The facility failed to issue the CMS Notification of Medicare Non-Coverage (NOMNC) Form 10123 to a resident, identified as R193, whose Medicare Part A episode began on January 13, 2024, and ended on February 1, 2024. The resident was discharged home from the facility, but there was no evidence that the NOMNC was provided. This form is crucial as it informs Medicare A participants of their rights to appeal and the last covered date of service. The absence of this notification placed the resident at risk for decreased autonomy and impaired their right to appeal. During a care plan meeting on January 22, 2024, involving the resident, the interdisciplinary team, and the resident's family, a discharge date was discussed, indicating a planned discharge rather than a spontaneous one. Social Services X confirmed that the facility did not have a NOMNC for the resident and mistakenly believed that if a resident initiated the discharge, the NOMNC was not required. However, the facility's policy clearly states that a NOMNC should be issued at least two calendar days before the end of Medicare-covered services, even if the discharge is planned. The failure to provide this notice was a direct violation of the facility's policy and CMS requirements.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide written notification of transfer to two residents, R12 and R29, or their representatives, as required by their policy. R12 was admitted to the facility and later discharged to the hospital after becoming unresponsive. Despite the transfer, there was no evidence in R12's medical record of a written notification being sent to her or her representative. Interviews with facility staff, including Administrative Nurse D and Social Services X, confirmed that the facility did not complete a written notification of transfer for R12. Similarly, R29 was admitted to the facility and later transferred to the hospital due to lethargy and no urine output. The facility's records lacked documentation of a written notification of transfer to R29 or her representative. Additionally, the facility did not notify the State Long Term Care Ombudsman of R29's transfer, as required. Interviews with staff, including Administrative Nurse D and Licensed Nurse G, revealed that the facility's practice was to call the family and notify the physician, but not to send a written notification. The facility's policy, revised in November 2017, mandates that residents and their representatives receive a notice of transfer or discharge, including the reason for the move and the resident's right to appeal. The policy also requires notification to the State Long Term Care Ombudsman. The failure to adhere to this policy placed both R12 and R29 at risk for miscommunication and potential missed healthcare services.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy notice to two residents, R12 and R29, or their representatives when they were transferred to the hospital. This deficiency was identified during a survey that included a sample of 12 residents out of a census of 37. The facility's policy, revised in November 2017, required that a written bed hold notice be given to residents and their representatives both upon admission and at the time of transfer. However, the facility did not adhere to this policy for the transfers of R12 on 07/01/24 and R29 on 03/30/24. R12 was admitted to the facility with diagnoses including a fracture of the lower end of the right femur, weakness, and pain in the right hip. On 07/01/24, R12 became unresponsive and was transferred to the hospital for further evaluation. Despite the transfer, the facility did not provide a bed hold notice to R12 or her representative. Interviews with facility staff, including Administrative Nurse D and Social Services X, confirmed that the facility did not send a bed hold notice for R12's transfer. Similarly, R29, who had diagnoses including right and left femur fractures and dementia, was transferred to the hospital on 03/30/24 due to lethargy and no urine output. The facility also failed to provide a bed hold notice for R29's transfer. Staff interviews revealed that the facility typically called the family and notified the physician during transfers but did not send bed hold notices. The facility's failure to provide these notices posed a risk of impaired ability for R12 and R29 to return to the facility and their previous rooms.
Failure to Document Recapitulation of Stay in Discharge Summaries
Penalty
Summary
The facility failed to document a recapitulation of stay for two residents, identified as R38 and R39, at the time of their planned discharge. This deficiency was identified through record reviews and interviews, which revealed that the discharge summaries for both residents did not include a detailed account of the services they received during their stay at the facility. This omission placed both residents at risk for miscommunication regarding the services they received and their post-discharge care needs. Resident R38 was admitted with diagnoses including essential hypertension, anxiety disorder, and generalized muscle weakness. Her care plan indicated a discharge back to her apartment after rehabilitation, with arrangements made for home health physical and occupational therapy services. Despite these plans, the discharge summary failed to include a recapitulation of the services provided during her stay, which was a necessary component according to the facility's discharge procedures as described by the staff. Similarly, Resident R39, who was admitted with end-stage renal disease and generalized muscle weakness, also had a discharge plan to return to her apartment. Her discharge summary, like R38's, did not document the services she received during her stay. Interviews with the facility's licensed nurse and administrative nurse confirmed that the discharge summaries should have included a recapitulation of stay, but this was not reflected in the facility's discharge plan policy, which did not address this requirement.
Failure to Implement Timed Toileting Interventions for a Resident
Penalty
Summary
The facility failed to implement timed toileting interventions and assess ongoing patterns of incontinence for a resident, identified as R21, who was at risk for complications related to incontinence. R21's medical history included diagnoses of congestive heart failure, hypertension, dementia, and benign prostatic hyperplasia. The resident's Minimum Data Set (MDS) indicated a need for substantial to maximal assistance with various activities of daily living, including toileting, and noted that R21 was always incontinent of bowel and bladder but not on a toileting program. Despite being identified as a candidate for scheduled toileting, the care plan lacked interventions to manage or improve R21's bowel or bladder needs. Observations and interviews revealed that R21 was not receiving the necessary toileting interventions. On one occasion, R21 reported being incontinent and waiting for staff assistance, while a Certified Nurse Aide was unsure if R21 had a specific toileting program. An Administrative Nurse confirmed that residents should be screened for incontinence and that care plans should include interventions for incontinence management. The facility's Quality of Care policy required the implementation of interventions to manage bowel and bladder incontinence, which was not adhered to in R21's case, placing the resident at risk for complications.
Failure to Remove Unnecessary Bed Rails for Resident
Penalty
Summary
The facility failed to ensure the removal of bed rails for Resident 14, as indicated by her side rail assessment. Despite the assessment revealing that side rails or assist bars were not necessary, the resident's bed was observed with bilateral grab bars. This oversight placed the resident at risk for impaired safety due to the potential hazards associated with the use of side rails. The resident's medical history included conditions such as dysphagia, encephalopathy, muscle weakness, and difficulty walking, and she required substantial assistance for daily activities and mobility. Interviews with facility staff revealed a lack of clarity and consistency in the assessment and inspection of bed rails. A Certified Nurse Aide was unsure about the frequency of inspections, while a Licensed Nurse indicated that assessments should be reported to the interdisciplinary team but was uncertain about their regularity. The Administrator Nurse mentioned that side rails should be assessed quarterly and checked each shift for safety, yet this protocol was not followed for Resident 14. The facility's Quality of Care policy mandates the safe use of treatment equipment, including bed rails, but this was not adhered to in this instance.
Failure to Notify Physician and Administer Antihypertensive Medications
Penalty
Summary
The facility failed to notify the physician of elevated blood pressure readings and did not administer antihypertensive medications as needed for a resident identified as R26. R26 was admitted with diagnoses of essential hypertension and permanent atrial fibrillation. The resident's care plan required staff to administer medications as ordered and report abnormal blood pressure readings to the physician. However, from April to July, there were 35 instances where R26's systolic blood pressure (SBP) exceeded 160 mmHg, yet the facility's records lacked evidence of physician notification for these elevated readings. Additionally, the Medication Administration Record (MAR) indicated that R26 received PRN hydralazine only four times despite multiple instances of elevated SBP. Interviews with facility staff revealed an expectation to notify the physician and administer PRN medication when SBP exceeded 160 mmHg, but this was not consistently documented or followed. The facility's policy on administering medications required adherence to prescriber orders, but there was no specific policy provided on notifying the physician. This oversight placed R26 at risk for unnecessary medications and potential physical complications due to uncontrolled blood pressure.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure a coordinated plan of care for a resident receiving hospice services, which placed the resident at risk for inappropriate end-of-life care. The resident, identified as R24, had diagnoses including Parkinson's disease, dementia, and diabetes mellitus, and was receiving hospice services due to a terminal diagnosis of dementia. The resident's care plan, dated March 29, 2024, included various interventions to support the resident's needs but lacked specific instructions on the services provided by hospice, such as hospice staff visits, supplies, medical equipment, and medications covered by hospice. The facility's failure to coordinate care was evident as the resident's electronic medical record showed no evidence of coordination between hospice and the facility, despite the hospice plan of care being available in a binder at the nurse's station. Interviews with staff, including a CNA and a licensed nurse, revealed uncertainty about the inclusion of hospice-specific information in the care plan. An administrative nurse confirmed the absence of a coordinated care plan with hospice services. The facility's policy required a coordinated plan of care reflecting hospice participation, which was not adhered to, leading to the deficiency.
Failure to Offer or Document Declination of Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer or obtain a signed declination for the Prevnar 20 pneumococcal vaccination for Resident 23, despite having a policy in place that directed staff to ensure all residents received education regarding immunization and that their responses or refusals were documented. Resident 23's clinical record showed that he had previously received Prevnar 13 and Pneumovax 23 vaccinations, but there was no evidence that he was offered the Prevnar 20 vaccination. This oversight was identified during a review of the resident's clinical records and interviews with facility staff. Licensed Nurse G stated that upon a resident's admission, she obtained their immunization history and offered the pneumococcal vaccination, entering the order into the computer if consent was given. Administrative Nurse E confirmed that the facility offered influenza and pneumococcal vaccinations yearly and obtained consents, but admitted to not knowing the current pneumococcal recommendations. Administrative Nurse D mentioned that residents' immunizations were checked on admission and reviewed quarterly with their Minimum Data Set (MDS). Despite these procedures, the facility did not obtain a signed consent or declination for Resident 23, placing him at risk of acquiring and spreading pneumococcal disease.
Failure to Protect Residents' Personal Property Rights
Penalty
Summary
The facility failed to establish and implement an admissions agreement that protected residents' rights to personal property by not waiving the facility's liability. The Nursing Admission and Care Agreement included a section that stated the facility could not guarantee the safety of personal items and was not responsible for loss, theft, or damage to residents' personal property. This agreement also specified that items of significant monetary value, such as money, jewelry, documents, and furs, were not the responsibility of the facility if brought in by residents or their guests. During an interview, Administrative Staff A stated that the facility reviewed the admission agreement annually and made changes as needed. He mentioned that if a resident lost an item, the facility would make efforts to locate it but did not immediately replace it. In cases where the item was of value, the facility would report it to the police. Administrative Staff A also noted that the facility did not necessarily accept responsibility for items of excess value that were lost or stolen. The facility's Admission Orientation policy, revised in October 2012, did not address the admission agreement, further contributing to the deficiency.
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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.
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Nursing homes near Olathe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delmar Gardens Of Overland Park | 1.4 mi | ★★★★★ | 15 | 0 |
| Stratford Commons Rehab & Health Care Center | 1.6 mi | ★★★★★ | 21 | 1 |
| Villa St Francis Catholic Care Center Inc | 2.1 mi | ★★★★★ | 0 | 0 |
| Aberdeen Village | 2.4 mi | ★★★★★ | 7 | 0 |
| Delmar Gardens Of Lenexa | 2.4 mi | ★★★★★ | 10 | 0 |
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