Spanish Trails Wellness & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to protect 1 (R #1) of 1 (R #1) resident reviewed from neglect. The facility failed to ensure that a resident was provided care and assistance by staff during the night of 08/29/25.Failure to prevent neglect of residents can result in residents' frustration and fear of being left alone and not assisted with care needs.The findings are:A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE] with multiple diagnoses including:Parkinsonism (a chronic, progressive disease of the nervous system).Acute Respiratory Failure (failure of the lungs to inflate and deflate properly) with hypoxia (low blood oxygen level).R #1 was discharged from the facility on 09/22/25 to return home.B. Record review of R #1's 5-day Minimum Data Set assessment (a collection of assessments that determines a person's abilities and needs dated 08/25/25 revealed the following:Brief Interview for Mental Status (a test that measures a person's memory and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to thoroughly document the investigation of neglect of for 1 (R #1) of (R #1) resident reviewed for abuse or neglect. The facility was notified of an instance of neglect and investigated the allegation of neglect but failed to document the completed investigation.Failure to document reported investigations could result in confusion and misunderstanding of investigation results.The findings are:A. Record review of R #1 face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:Heart Failure (Failure of the heart to properly move blood through the body).Parkinson's Disease (a chronic medical condition that affects motor and non-motor systems of the body).Respiratory Failure (difficulty breathing).R #1's face sheet also revealed she was discharged from the facility on 09/22/25.B. Record review of New Mexico Health Care Authority Complaint and Incident records revealed incident #2604414 dated 08/30/25 stated R #1 was neglected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive care plan for 1 (R #1) of 3 (R #1, #2, and #3) residents. Failure to develop a comprehensive care plan could result in residents not receiving optimal care that meets their daily needs and preferences.The findings are: A. Record review of R #1 face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:Heart Failure (Failure of the heart to properly move blood through the body).Parkinson's Disease (a chronic medical condition that affects motor and non-motor systems of the body).Respiratory Failure (difficulty breathing).R #1's face sheet also revealed she was discharged from the facility on 09/22/25.B. Record review of R #1's Minimum Data Set (MDS-a collection of assessments that describes a person's abilities and needs) 5-day admission dated 08/25/25 revealed that the MDS assessment was completed and signed by the MDS Registered Nurse on 09/04/25. C. Record review of R #1's Electronic Medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to follow physician orders for 1 (R #1) of 1 (R #1) resident. This deficient practice is likely to result in residents receiving care that is not medically appropriate. The findings areA. Record review of R #1's face sheet dated 07/10/25 revealed he was admitted to the facility on [DATE] with the following diagnoses:-Gastro Esophageal Reflux Disease (GERD) (a digestive disease in which acid is often regurgitated during/after eating).-Cognitive (mental) Communication Deficit.-Type 2 Diabetes Mellitus (chronic disease affecting blood sugar levels).-Generalized Anxiety (nervousness) Disorder.B. Record review of R #1's physician orders revealed an order dated 01/29/25 to give all medications that are appropriate with food or snack. Ordered by (Name of Medical Doctor).C. On 07/10/25 at 9:20 am during observation and interview with R #1, he was seen in his room, in his bed. He stated he had already received and eaten his meal. He stated he was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately document the changing conditions of 1 (R #3) of 3 (R #2, 3, 4) residents. The facility documented conflicting resident daily assessments for R #3's conditions. This deficient practice is likely to result in resident care and care plans being confusing and inadequate. The findings are: A. Record review of R #3's face sheet dated 07/10/25 revealed she was admitted to the facility on [DATE] and discharged from the facility on 05/09/25 to return home with home health services. B. Record review of R #3's Admitting History and Physical dated 03/29/25 revealed she was admitted to the facility with the following diagnosis:-Left Intertrochanteric Femur Fracture (Broken Hip)C. Record review of R #3 Minimum Data Set (a set of assessments that describes a person's needs and abilities: MDS) dated [DATE] revealed the following:-MDS Section C (section that assesses cognitive patterns) Brief Interview for Mental Status (BIMS) (a simple test that assesses a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Repeat Deficiency from 03/10/25 Based on record review and interview, the facility failed to notify the resident's provider or Emergency Contact (EC) of the resident's change in condition for 1 (R #30) of 2 (R #15 and #30) residents reviewed for changes of condition (new or worsening symptoms). If the facility is not notifying the provider and EC when the resident experiences a change of condition, then both would be unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of R #30's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: -Acute Respiratory (breathing) Failure with Hypoxia (low blood oxygen). -Heart Failure. -Unspecified Kidney Disease. -Malignant (cancer) Neoplasm (tumor) of upper third of Esophagus (throat). The face sheet further revealed the name and phone number of an EC for R #30. B. Record review of R #30's daily care notes revealed the following: -02/06/25 R #30 was sent to the hospital by R…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff revised the care plan for 6 (R #'s 1, 54, 55, 70, 73, and 79) of 6 (R #'s 1, 54, 55, 70, 73, and 79) residents reviewed when staff failed to: 1. Conduct a quarterly care plan meeting as required for R #'s 1, 54, 55, 70, and 73 in accordance with their admission date and Minimum Data Set (MDS) assessments. 2. Update R #79's plan of care to include resident and resident's family assistance with colostomy (surgery to create an opening for the colon (large intestine) through the abdomen). These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: Care Plan Meetings: R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's MDS resident assessment page located in R #1's Electronic Health Record (EHR) revealed R #1's last two quarterly MDS assessments occurred on 09/09/24 (quarterly review)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Food was stored appropriately and not left open to air in the kitchen freezer. 3. Food items were not expired in the kitchen and dry storage. These deficient practices are likely to affect all 117 residents listed on the resident census list provided by the Administrator on 04/21/25 and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 04/21/25 at 11:43 am, observation of the kitchen revealed the following: 1. Three large cheese pizzas were not labeled or dated and stored in the kitchen freezer. 2. One large cardboard box of green beans were left open to air and stored in the kitchen freezer. 3. Thirteen 24 count plastic containers of chocolate chip cookies was not labeled or dated and stored in the kitchen dry storage. 4. One 5 pound (lb) and 5 ounce (oz)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote care with dignity and respect for 1 (R #1) of 1 (R #1) resident reviewed for residents' rights by walking into the room to speak to a staff member who's performing personal care on a resident. This deficient practice is likely to result in residents feeling as if they were unimportant and not having privacy. The findings are: A. On 04/22/25 at 12:30 PM during an interview with R #1, she stated that she felt a nurse did not treat her with respect when she went into the bathroom without announcing herself when she was showering. The nurse needed to talk to the Certified Nurse Aide (CNA) who was assisting me with my shower. R #1 further stated, Just because she's a nurse doesn't mean it's okay to just go into someone's bathroom to talk to another staff. I felt like she didn't respect my privacy. B. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE]. C. Record review of R #1's Minimum Data Set (MDS; a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a timely assessment for 1 (R #15) of 2 (R #15 and #30) residents reviewed for hospitalizations and had a sufficient change (a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions) within 14 days of the significant event. This deficient practice could likely result in residents not receiving the care and assistance needed. The findings are: A. Record review of R #15 face sheet dated 04/29/25 revealed he was admitted to the facility on [DATE] with the following diagnoses: -Paranoid (unreasonable suspicious thoughts) Schizophrenia (a psychiatric condition characterized by a disconnect from reality). -Psychotic (a psychiatric condition characterized by disorganized speech and behavior) Disorder with Delusions (unreal thoughts). -Chronic Kidney Disease -Diabetes (a condition that the body is unable to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Past non-compliance Based on interview and record review, the facility failed to prevent misappropriation of resident money when debit card was used by unauthorized parties for 1 (R #47) of 2 (R #47, and 156) residents reviewed for exploitation (the fact of making use of a situation to gain unfair advantage for oneself). This deficient practice is likely to cause residents to feel unsafe, experience anger and frustration along with dealing with debit card theft, and fraud. The findings are: A. Record review of the facility's investigative narrative report dated 09/12/23 revealed that R #156 had been admitted to the hospital on [DATE] and $1300.00 was withdrawn from her account on 08/02/23. R #156 expired in the hospital on [DATE]. The facility was unable to substantiate abuse or neglect or misappropriation. The facility is unable to determine who, make purchases or withdrew money from her account. All pertinent information has been turned over to law enforcement for further investigation. Staff have been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure that 1 (R #47) of 1 (R # 47) resident reviewed for skin issues received care and treatment that met the resident's needs by not documenting, assessing or treating residents skin issue. If the facility fails to provide the highest level of care to it's residents, then residents are likely to experience a decline in their wellbeing. The findings are: A. On 04/22/25 at 10:30 am during an interview with R #47 and observation of R #47's right eye, R #47 had redness and a sore on the right side of his face next to his right eye. R #47 stated he had a wound next to his right eye and he did not know what was wrong with it. R #47 further stated that it bothered him (pain) and he had asked someone to look at it. R #47 was unsure as to who he had let know about the wound . R #47 feels that he scratched himself because at times he does not have control of his hands. R #47 stated nursing had not examined it as of this day. R #47 was unsure of when he had scratched himself or when he had notified staff. B. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the facility providers (Nurse Practitioner, Physician) and the resident's Emergency Contact (EC), when a resident experienced an unwitnessed fall while also prescribed a blood thinner for 1 (R #2) of 1 (R #2) resident reviewed for a change of condition. This deficient practice is likely to result in a delay in treatment or inadequate treatment. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted on [DATE] and was discharged to the hospital on [DATE]. B. Record review of R #2's physician orders dated 01/03/25, revealed R #2 was prescribed and taking Warfarin (blood thinner) 2 milligrams (mg), once a day. C. Record review of R #2's SBAR (Situation, Background, Assessment, and Recommendation- form used to help healthcare professionals communicate quickly) Communication form dated 01/09/25, revealed the Medical Doctor (MD) #1 was contacted at 4:40 am, and R #2's daughter was contacted at 5:40 am after R #2's fall. Note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a quality care that meets professional standards for 1 (R # 2) of 1 (R #2) resident when the facility failed to obtain physician orders prior to providing oxygen (O2). If the facility is providing O2 without physician orders, then residents are likely to not receive the therapeutic benefits and care needed. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted on [DATE] and was discharged to the hospital on [DATE]. B. Record review of R #2's O2 saturations (a measure of how much oxygen is in your blood) page located in R #2's electronic health record (EHR) dated 01/03/25 through 01/13/25 revealed R #2 was provided O2 on the following dates: 1. 01/13/25 at 8:42 am: R #2 was administered 3 liters per minute (LPM) of O2. 2. 01/11/25 at 8:02 am: R #2 was administered 2 LPM of O2. 3. 01/10/25 at 7:07 pm: R #2 was administered 3 LPM of O2. 4. 01/10/25 at 4:54 pm: R #2 was administered 3 LPM of O2. 5. 01/08/25 at 6:55 am:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure food preference was followed for 1(R #1) of 1 (R #1) resident observed for dining. This deficient practice could result in R #1 not eating his meals and losing weight. A. On 03/06/25 at 10:46 am, during interview with R #1, she stated I can't eat any vegetables, gravy, chocolate, mashed potatoes, corn dog, chicken salad, and mushrooms and they keep giving me vegetables, gravy, chocolate, mashed potatoes, corn dog, chicken salad, and mushrooms. B. On 03/06/25 at 12:45 pm, during an observation of R #1's lunch plate, mashed potatoes were on R #1's plate which she had not eaten. C. Record review of R#1's meal ticket revealed red bold writing, can't eat all vegetables, gravy, chocolate, mashed potatoes, corn dog, chicken salad, and mushrooms. D. On 03/06/25 at 12:52 pm during an interview with Certified Nursing Assistant #1 (CNA), she confirmed R #1 had mashed potatoes on her plate. E. On 03/10/25 at 3:48 pm, during interview with Dietary Manager (DM), he stated R #1 has dietary restrictions and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to conduct an in-depth investigation and correct the grievance allegation for 1 (R #34) of 1 (R #34) residents reviewed for the outcomes and resolutions of their grievances. This deficient practice could likely result in the facility not considering the needs of the residents or adequately resolving their grievances and lead to a decrease in resident quality of life. The findings are: A. Record review of R #34's grievance report, dated 12/12/24, revealed the following: - Grievance Details: R #34 stated he deserved a hot meal, and he was tired of eating cold food that was also stiff. R #34 had to pull hair out of his food multiple times and stated the amount of hair in his food sometimes feels like spaghetti. R #34 also stated that he was legally blind, and the CNAs were not available to assist him with a brief change for one to two hours. - Investigation: Social Services Director (SSD) checked on R #34's food for breakfast. The food was warm but not to R #34's liking. No other investigation notes present. - Summary of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff revised the care plan for 2 (R #35 and #90) of 2 (R #35 and #90) residents reviewed when staff failed to conduct a quarterly care plan meeting as required. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #35: A. Record review of R #35's face sheet revealed R #35 was admitted into the facility on [DATE]. B. Record review of R #35's care conference (care plan meeting) report revealed R #35's last care plan meeting occurred on 07/24/24. Staff did not document any other care plan meetings as completed after 07/24/24. C. On 12/18/24 at 2:43 pm during an interview with R #35, he stated he did not remember having a care plan meeting for a while. D. On 12/18/24 at 3:50 pm during an interview with the Social Services Director (SSD), he stated R #35 should have had a care plan meeting since 07/24/24. The SSD stated R #35 did not have a quarterly care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to meet professional standards for 2 (R #7 and #122) of 2 (R #7 and #122) residents reviewed when staff failed to: 1. Ensure labs were reviewed and critical results conveyed to the medical provider in a timely manner. 2. Ensure medications were available for administration. If the facility fails to administer medications as prescribed by the physician, then residents are not likely to receive the therapeutic value of medications prescribed. If the facility fails to relay lab results, then the physician is unable to properly monitor and assess the physical condition of the resident. The findings are: R #7 A. Record review of R #7's face sheet, dated 12/23/24, revealed she was admitted to the facility on [DATE] with multiple diagnoses including the following: Add punctuation to the end of each entry in the list below. - Diabetes (failure of the body to properly process and balance blood sugar), - Chronic kidney disease (a chronic failure of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5 percent (%) when staff performed six medication errors out of 26 opportunities for 2 (R #118 and 122) of 6 (R #66, 89, 90, 118, 122) residents reviewed during medication administration. This resulted in a medication error rate of 23.08%. If residents are not informed of the medications they are receiving, then residents do not have the ability to accept or reject the medications being administered. The findings are: A. On 12/19/24 at 8:14 am during observation of Registered Nurse (RN) #2 administering medications, he poured and administered the following medications to R #118: - Amlodipine (medication to manage blood pressure) 10 milligrams (mg), - Aspirin (medication prescribed to reduce blood clotting factors) 81 mg, - Atorvastatin (medication prescribed to reduce blood fats and cholesterols) 20 mg. B. Record review of R #118's physician orders revealed the following: - Dated 12/12/24, amlodipine 10 mg once a day at 7:00 am, - Dated 12/12/24, aspirin 81 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure meals were served at a safe and appetizing temperature for 4 (R #34, #43, #72, and #84) of 4 (R #34, #43, #72, and #84) residents reviewed for meal quality. This deficient practice is likely to lead to foodborne illnesses if staff do not maintain food temperatures outside of the danger zone [between the temperatures of 45 degrees (°) Fahrenheit (F) and 135° F; the temperature range in which food-borne bacteria can grow.) The findings are: A. On 12/17/24 at 9:55 am during an interview with R #84, she stated her food was usually cold when she received it in her room. R #84 stated she would like her food to be warmer. She stated she has the nursing staff the food was served cold, but staff continued to serve her food cold. B. On 12/17/24 at 1:28 pm during an interview with R #43, he stated his food was often cold, and he did not like that. R #43 stated his food was cold when he ate in his room and in the dining room. R #43 stated he told staff about his food being cold, but it did not change anything. C.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to assure staff followed infection control practices for 2 (R #118 and #122) of 2 (R #118 and #122) residents when Registered Nurse (RN) #2 did not wash his hands before and after he administered medications to residents. This deficient practice has the potential to spread infectious diseases between residents. The findings are: A. On 12/19/24 at 8:14 am during observation of medication administration, RN #2 drew and poured medications for R #118 into a medication cup. He took the medications to the resident, administered the medications, and returned to the medication cart. RN #2 then began to draw and pour medications for R #122 into a medication cup. RN #2 took the medications to the resident, administered the medications and returned to the cart. RN #2 did not wash his hands before, during, or after pouring and passing medications to the residents. B. On 12/19/24 at 8:20 am during an interview with RN #2, he stated he usually used the hand wash stations in the resident rooms. He stated he did not wash his hands during the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to consider and provide the preferences of (R #81) of 1 (R #81) residents reviewed when the facility failed to assist R #81 with purchases that reflected R #81's interests after R #81 asked the facility staff for assistance. These deficient practices are likely to result in the resident's personal choices not being honored. The findings are: R #81: A. Record review of R #81's face sheet revealed R #81 was admitted into the facility on [DATE]. B. Record review of R #81's care plan, dated 01/23/24, revealed R #81 liked to watch TV, paint, read, and use his computer. Staff to ensure R #81 had materials for individual activities as desired and materials for painting. C. On 12/17/24 at 9:34 am during an interview with R #81, he stated he was unable to purchase his painting materials and additional winter clothes. R #81 also stated the previous Social Services Director (SSD) would assist him with purchasing those items, but nobody offered to help…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide food to accommodate resident preferences for 1 (R #225) of 1 (R #225) residents observed for food preferences. This deficient practice is likely to result in resident frustration and weight loss due to the resident not receiving and eating their preferred diet. The findings are: R #225: A. Record review of R #225's face sheet, dated 12/23/24, revealed she was admitted to the facility on [DATE]. B. Record review of R #225's physician dietary order, dated 12/13/24, revealed she was to receive the house (regular) diet. C. Record review of R #225's Diet Order and Communication, dated 12/13/24, revealed R #225 was to receive a regular diet with no pudding or sweet desserts. The admitting nurse signed the order. D. On 12/16/24 at 2:30 pm during observation of R #225's room, she had multiple food items stacked on her room shelf. The foods were all labeled as vegan compliant. E. On 12/19/24 at 1:30 pm during observation of R #225's meal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to provide a therapeutic diet as ordered by a Physician for 1 (R #64) of 1 (R #64) residents reviewed during random dining observations. If the facility fails to provide a diet as ordered, then residents are likely to experience weight loss due to not receiving their prescribed nutritional caloric intake. The findings are: A. Record review of Dietary Census List, dated 12/23/24, revealed R #64 was on a regular pureed diet (a texture modified diet that requires no chewing.) B. Record review of R#64's care plan, dated 12/19/2024, revealed R #64 was on a regular pureed diet, start date 04/05/24. C. Record review of R#64's Dietary Meal ticket, dated 12/23/24, revealed staff to provide a therapeutic diet (a meal plan prescribed by a doctor or dietician that controls the intake of foods or nutrients as part of a treatment.) D. On 12/16/24 at 12:40 pm during a lunch observation, staff served R #64 pureed mashed potatoes, pureed carrots, and mechanical soft (a texture modified diet that requires some chewing but less…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

PAST NON-COMPLIANCE Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance with toileting and brief changes for 1 (R #1) of 1 (R #1) resident reviewed. These deficient practices have the potential to affect the dignity and health of the residents. The findings are A. Record review of Facility Reported Incident (FRI), dated 06/06/24, revealed R #1's daughter contacted the Assistant Director of Nursing (ADON) to inform ADON that she reviewed an in-room video camera recording of R #1's care during the day of 05/28/24. The daughter stated the recording showed staff did not enter R #1's room to provide care, to assist with toileting, or to check the resident's brief on 05/28/24. The FRI further documented the ADON interviewed the Certified Nurses Aide (CNA) assigned to provide care to R #1 on 05/28/24. The CNA stated R #1 did not use her call light during the day, and the CNA did not check on R #1 during her 12 hour shift. B.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Maintain the ice machine in a manner to prevent contamination and foodborne illness, - Perform hand hygiene and to change gloves as often as necessary to avoid cross contamination, - Protect clean dishes and plastic ware to prevent contamination, - [NAME] and serve pureed food at the appropriate temperatures to prevent the growth of foodborne pathogens and illnesses, - Allow dishes to air dry completely before use or storage, - Keep staff food separated from resident food, - Utilize hair restraints and beard guards in a manner which restrained all hair while in the kitchen, - Properly store open food with labels and dates to prevent cross contamination and outdated usage, - Store scoops for bulk bins in a manner to prevent cross contamination, - Use the sanitizing solution according to manufacturer's instructions, - Wash, rinse, and sanitize the food preparation sink…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff revised the care plan for 3 (R #45, #60 and #320) of 2 (R #45, #60 and #320) residents reviewed when staff failed to: 1. Update the care plan to include Activities of Daily Living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) care for R #45 and #60. 2. Update the care plan to include activity preferences for R #60. 3. Inform the Power of Attorney (POA) of changes in care plan to include new behaviors for R #320 These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #45: A. Record review of R #45's face sheet revealed R #45 was admitted into the facility on [DATE]. B. Record review of R #45's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/17/24, revealed R #45 required partial to moderate assistance, in which the helper did less…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers for 2 (R #'s 45 and 60) of 2 (R #'s 45 and 60) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: R #45: A. Record review of R #45's face sheet revealed R #45 was admitted into the facility on [DATE]. B. Record review of R #45's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/17/24, revealed R #45 required partial/ moderate assistance, in which the helper did less than half the effort. Helper lifted, held, or supported the resident's trunk or limbs, but provided less than half the effort for most ADL tasks. C. Record review of R #45's physician orders, dated 05/13/24, revealed R #45 was to be offered/receive a bath or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure staff did not leave medications on the resident's bedside table. These deficient practices had the potential to impact the health of all residents on the 400 hall, and could likely result in residents taking a medication that is not intended for them or taking more than the dose prescribed. The findings are: A. On 07/18/24 at 12:03 PM, during an observation of R #28's room, there were a total of 12 pills. Six pills were oblong shaped pills engraved with LS703 (Ranolazine; used to treat chest pain), four yellow oval pills engraved with AN038 (Mucus Relief DM dextromethorphan 30 mg / guaifenesin 600 mg)], two beige oval pills engraved with MP9 [Pantoprazole Sodium Delayed Release 40 mg (used to treat acid reflux)] on R #28's bedside table. H. On 07/18/24 at 12:03 PM during an interview with R #28, he stated he did not know what the pills were or how long they were on bedside table. B. Record review of R #28's Physician order, dated 07/01/24, revealed the following: - An order for ranolazine ER, 500…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review, the facility failed to ensure staff followed nutritionally calculated recipes for pureed diets. Failure to follow recipes that have been approved by the Registered Dietician (RD) has the potential for food not to meet the nutritional requirements of the residents. This failure had the potential to affect all six residents who ate pureed meals. The findings are: A. Observation on 07/15/24 at 10:52 am revealed the [NAME] placed one premeasured bag of vegetables into the food processor bowl. She added an unmeasured amount of a chicken flavored powder. The [NAME] pureed the mixture until smooth and placed it in the warmer for lunch service. B. On 7/15/24 at 10:54 am, during an interview, the [NAME] stated she prepared pureed meals for six residents. She stated she did not know the measurement of the vegetables, because they came in a pre-measured bag. She stated she added one bag of vegetables. The [NAME] stated she did not have a recipe for the pureed vegetables, and she did not know how much chicken flavored powder she added to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow proper infection control practices for 4 (R #'28, #45, #60, and #79) of 4 (R #28, #45, #60, and #79) residents identified during random observation when the facility failed to: 1. Ensure nasal cannulas [a device that delivers extra oxygen (O2) through a tube and into your nose] were labeled with the date when they were changed for R #28 and #79. 2. Ensure Continuous Positive Airway Pressure (CPAP; used to treat sleep apnea) equipment was stored appropriately for R#45 and #60. 3. Ensure R #60's nebulizer (device for producing a fine spray of liquid, used for example for inhaling a medicinal drug) was stored appropriately. This deficient practice could likely result in the spread of contagious and resistant illnesses to other residents. The findings are: Nasal Cannula Findings: R #28 A. Record review of R #28's physicians order, dated 06/02/23, revealed keep O2 cannula/mask/tubing and/or nebulizer mask/tubing bagged when not in use.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to provide assistance devices for 1 (R #13) of 1 (R #13) residents reviewed during random observation. This deficient practice are likely to result in residents being unable to perform activities of daily living which could likely result in consuming less food. The findings are: A. Record review of R #13's Annual Nutritional Assessment, dated 04/23/2024 and completed by the Registered Dietitian, revealed a recommendation for sippy cup (a plastic cup with two handles). B. Record review of R #13's physician orders, dated 04/01/24, revealed an order for a sippy cup with all meals. C. Record review of R #13's meal ticket, dated 07/18/24, revealed a note for a sippy cup. D. On 07/18/24 at 12:00 PM am during lunch observation, staff served R #13 his lunch meal plate without a sippy cup. Further observation revealed R #13 ate lunch and did not have a sippy cup. E. On 07/18/24 at 12:03 PM during an interview, Licensed Practical Nurse (LPN) #1 stated she never saw a sippy cup. She confirmed there was not a sippy cup with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the rights of 1 (R #1) of 2 (R #1 and #2) residents when the facility administered medication to reduce the resident's sexual feelings and desires. This deficient practice could cause residents to feel repressed and unable to interact in intimate relations. The findings are: A. On 04/29/24 at 11:00 am through 3:00 pm, during observation, R #1 left his room, walked the hallway, interacted with other residents and staff, and participated in activities. B. Record review of R #1's face sheet, dated 04/29/24, revealed he was admitted to the facility on [DATE] with multiple diagnoses including: - Vascular (related to blood vessels and blood flow) dementia (a chronic progressive decline in mental abilities), - Psychotic disturbance (a psychiatric condition that affects thought and behavior), - Mood disturbance (alteration of feelings), - Cognitive communication deficit (a breakdown in the link between thought and speech). - R#1's face…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility provided an anti-depressant (a medication that treats the symptoms of depression and sadness) medication for 1 (R #1) of 2 (R #1 and #2) at an excessive dose and without adequate indications for its use. This deficient practice is likely to result in resident being overmedicated leading to greater risk of developing side effects such as drowsiness, weight gain, nausea, fatigue. The findings are: A. Record review of R #1's face sheet, dated 04/29/24, revealed he was admitted to the facility on [DATE] with multiple diagnoses including: - Vascular (related to blood vessels and blood flow) dementia (a chronic progressive decline in mental abilities), - Psychotic disturbance (a psychiatric condition that affects thought and behavior), - Mood disturbance (alteration of feelings), - Cognitive communication deficit (a breakdown in the link between thought and speech). B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff completed accurate medical records for 9 (R #s 19, 31, 73, 91, 92, 200, 202, 203, and 247) of 9 (R #s 19, 31, 73, 91, 92, 200, 202, 203, and 247) residents reviewed for the following: 1. Activity participation logs were not completed for R #'s 19, 31, 73, 91, 92, 200, 202, and 203. 2. Medication administration notes and pertinent admission notes were not documented for R #247. This deficient practice is likely to result in staff not knowing of resident daily activities and preferences, or why a resident requires medications and pertinent admission information. The findings are: Activity Log Findings: A. On 09/21/23 at 2:41 pm during observation of resident rooms, each room contained a calendar labeled September 2023 Spanish Trails Rehabilitation and Suites. The calendar listed a variety of activities that were available to residents on a daily basis. The calendar was posted on the wall of each occupied room. B. Record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.