Inspection Reports for
La Estancia Nursing and Rehabilitation Center

The complaint investigation found that the facility did not send discharge notices to the Ombudsman for seven months, including for residents discharged against medical advice. The facility had multiple case management staff turnovers, and the lack of notification could lead to unsafe discharges and lack of resident advocacy.

The facility failed to send discharge or transfer notices to the Ombudsman for 3 sampled residents, potentially preventing residents from accessing advocacy services. Multiple interviews and record reviews confirmed a lapse in sending these notices for several months, attributed to case management turnover and lack of communication.

The complaint investigation focused on the failure to implement abuse policies, failure to report a major injury to the State Agency, and failure to investigate the injury thoroughly. The resident (#5) sustained a left periprosthetic femur fracture and a right hip fracture after a fall. Staff interviews revealed the injury was unwitnessed and not reported to the state. The facility's investigation was limited to speaking with the nurse who found the resident. The resident was on palliative care and had been denied therapy at multiple facilities.

The facility failed to ensure implementation of abuse policies related to a major injury sustained by resident #5, failed to report the injury to the State Agency, and did not thoroughly investigate the incident. The resident sustained fractures after a fall, and staff concluded the fall was unwitnessed and did not report it as required.

The complaint investigation included allegations of failure to notify resident representatives of condition changes, resident-to-resident abuse incidents, failure to investigate abuse and narcotic misappropriation allegations, inadequate ADL care, improper pressure ulcer care, and failure to implement infection control precautions for C-diff infection. Substantiation status is not explicitly stated.

The facility failed to notify a resident's medical power of attorney of a significant change in condition, protect residents from abuse by other residents, thoroughly investigate allegations of abuse and narcotic misappropriation, provide adequate activities of daily living care, ensure proper pressure ulcer treatment, and implement infection control precautions for a resident with C-diff infection.

The facility failed to ensure that resident #72's needs and preferences regarding his wheelchair were adequately addressed. The resident arrived without his electric wheelchair, experienced delays in receiving it, and refused to eat until it was delivered and repaired. The facility provided a regular wheelchair but lacked documentation on the receipt and handling of the electric wheelchair. Staff interviews revealed inconsistent knowledge and documentation about the wheelchair issue.

The facility was found deficient in multiple areas including failure to reasonably accommodate resident needs (wheelchair issue), medication administration errors, inadequate ADL care, insufficient activity offerings, inconsistent wound care, hydration monitoring deficiencies, pharmaceutical service lapses, medication labeling issues, expired glucometer controls, unsafe food storage and sanitation, and infection prevention and control program deficiencies.

The complaint investigation focused on resident #2's multiple elopements and the facility's failure to provide adequate supervision and monitoring. The resident was found outside the facility multiple times, with the wander guard failing to alarm. The investigation included staff interviews and review of clinical records, revealing lack of physician order for the wander guard and incomplete documentation.

The facility failed to provide adequate supervision and monitoring for resident #2, who was an elopement risk and eloped multiple times. The wander guard device did not alarm during elopements, and there was no physician order for the wander guard, resulting in lack of proper documentation and monitoring. Despite interventions, increased supervision was not evidenced in the clinical record.

The facility failed to ensure adequate staffing was maintained, with documented instances of registered nurse (RN), licensed practical nurse (LPN), and certified nursing assistant (CNA) staffing below required levels on multiple dates in December 2022 and February 2023. Interviews confirmed occasional understaffing, which could impact resident care and quality of life.

The complaint involved an allegation of sexual abuse made by resident #30 on February 22, 2023. The facility was aware of the allegation on that date but did not report it to the State Agency until March 3, 2023, approximately 8 days later. The allegation was substantiated as the facility acknowledged the late reporting.

The facility failed to report an allegation of sexual abuse to the State Agency within the required timeframe, reporting it approximately 8 days after the allegation was made, which could result in residents not being protected from further abuse.

The facility was found deficient in multiple areas including informed consent for psychotropic medications, housekeeping and cleanliness, timely reporting of abuse allegations, accuracy of Minimum Data Set (MDS) assessments, PASRR screening, assistance with activities of daily living, wound care and skin assessments, range of motion care, catheter care, staffing levels, and accuracy of advance directives documentation.

The facility was found deficient in ensuring accurate Minimum Data Set (MDS) assessments, timely wound treatment per physician orders, safe smoking assessments and supervision, proper wheelchair positioning, and safe food handling practices including avoiding bare hand contact and maintaining clean kitchen air vents and ceiling tiles.