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 Ombudsman confirmed not receiving notices except for December and November 2024. Multiple staff interviews revealed case manager turnover and lack of notification, posing risks of 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. Interviews and record reviews confirmed multiple case manager turnovers and lapses in sending required notifications over several months.

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 investigation was complaint-driven, triggered by allegations of failure to notify representatives, abuse incidents, failure to investigate abuse and narcotic misappropriation, inadequate ADL care, pressure ulcer care deficiencies, and infection control lapses. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to notify resident representatives of significant condition changes, failure to protect residents from physical and verbal abuse by other residents, failure to thoroughly investigate abuse and narcotic misappropriation allegations, inadequate assistance with activities of daily living for some residents, failure to provide ordered wound care treatments, and failure to implement proper 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 found that resident #72 did not have his electric wheelchair upon admission, leading to delays in obtaining it. The resident refused to eat until the wheelchair was delivered and repaired. The facility was aware but documentation and follow-up were inadequate. Staff interviews indicated delays and lack of clear communication regarding the wheelchair status.

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

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 provide adequate supervision and monitoring for a resident at risk of elopement, including lack of physician order for wander guard use, incomplete documentation of wander guard checks, and insufficient increased supervision despite multiple elopements. Testing of wander guards was limited to only two doors, and the resident's wander guard did not alarm during elopement incidents.

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 facility failed to maintain adequate staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants on multiple dates in December 2022 and February 2023, which could result in necessary services not being provided to residents. Interviews with staff confirmed staffing shortages on some shifts.

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 mandated timeframe, resulting in a delay of approximately 8 days. The investigation included review of records, staff interviews, and facility policies, confirming the late reporting and potential risk to resident safety.

The facility was found deficient in multiple areas including failure to fully inform residents about psychotropic medications, inadequate housekeeping services, delayed abuse reporting, inaccurate resident assessments, failure to coordinate PASRR screenings, inadequate assistance with activities of daily living, insufficient wound care and skin assessments, failure to provide appropriate range of motion care, failure to conduct bladder training for a resident with an indwelling catheter, and insufficient nursing staff to meet resident needs.

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.