Inspection Reports for Spanish Hills Wellness Suites

Two complaints and three Facility Reported Incidents (FRIs) were investigated. Complaint #NV00073580 was substantiated without deficient practice. FRIs #NV00073243, #NV00073277, and #NV00073216 and Complaint #NV00073261 were not substantiated and no regulatory deficiencies were identified. The deficient practice identified was related to incomplete reporting of an allegation of sexual abuse involving Resident 2.

The investigation found that one complaint (#NV00073580) was substantiated without deficient practice, while other complaints and FRIs were unsubstantiated or lacked regulatory deficiencies. A deficient practice was identified related to failure to report an allegation of sexual abuse thoroughly, which had the potential to compromise resident safety.

Three complaints (#NV00070833, #NV00070948, #NV00070937) were investigated and all were unsubstantiated with no regulatory deficiencies related to the allegations. The investigation included observations, interviews with residents and staff including the Director of Nursing, and clinical record reviews.

The investigation found regulatory deficiencies related to baseline care planning and mobility care, specifically failure to develop and implement a baseline care plan for a resident with an Aspen collar and failure to ensure appropriate treatment and orders for a resident with limited range of motion. No complaints were substantiated.

Three complaints were investigated: Complaint #NV00068610 was verified; Complaints #NV00068838 and #NV00069266 could not be verified. No regulatory deficiencies were identified for the unverified complaints.

The investigation identified regulatory deficiencies unrelated to the complaints, including failure to ensure medications were administered per physician orders and improper storage and labeling of drugs and biologicals. Corrective actions and monitoring plans were outlined.

Two complaints and four Facility Reported Incidents (FRIs) were investigated. Complaint #NV00068738 was verified with no deficient practice. Complaints #NV00068554 and FRIs #NV00068214, #NV00067989, #NV00068363, and #NV00068515 could not be verified and no regulatory deficiencies were identified.

The investigation found no verified deficiencies related to the complaints and FRIs. However, deficient practices unrelated to the complaints were identified, including issues with resident rights, communication barriers, consent for psychoactive medications, privacy breaches, abuse investigation procedures, activities programming, hearing impairment treatment, and medication storage and security.

Two complaints and four Facility Reported Incidents (FRIs) were investigated. One complaint was verified with no deficient practice; the others could not be verified and no regulatory deficiencies were identified.

The facility was investigated for multiple complaints and incidents with no deficient practices verified for most. However, several deficiencies unrelated to the complaints were identified, including failure to provide interpretation services to a Spanish-speaking resident, failure to obtain proper consent in the resident's language, failure to protect resident privacy on medication carts, failure to suspend staff during abuse investigations, failure to provide person-centered activities, failure to address hearing impairment, and failure to properly secure medication carts.

The complaint investigation included 24 complaints with multiple allegations. Some allegations were substantiated without regulatory deficiencies, while others resulted in identified deficiencies. Specific complaints involved allegations of staff threatening family members, rude treatment by staff, medication errors, weight loss, lack of notification to family, resident neglect, call light response delays, and inadequate care. Substantiation status varied by allegation.

The investigation included 24 complaints with multiple allegations related to resident care, medication administration, staff behavior, and facility policies. Many allegations were not substantiated, but several regulatory deficiencies were identified including issues with notification of changes, baseline care plans, activities of daily living, pain management, medication storage, wound care, and quality of care.

Six complaints were investigated. Complaint #NV00061285 was substantiated with regulatory deficiencies related to oxygen provision. Other complaints had allegations that were either substantiated without regulatory deficiencies or not substantiated after review and interviews.

The investigation substantiated some allegations including a resident discharged without oxygen and a delay in physical therapy evaluation, while many other allegations such as medication errors, staffing sufficiency, and resident care issues were not substantiated. Two regulatory deficiencies were cited related to failure to ensure home oxygen delivery and failure to evaluate a resident for physical therapy within the required timeframe.

The survey identified multiple deficiencies related to life safety code compliance including means of egress obstructions, exit signage issues, kitchen hood fire suppression system maintenance, fire alarm system testing, portable fire extinguisher obstructions, HVAC smoke damper repairs, combustible decorations, fire door inspections, generator testing, electrical equipment and power cord usage, and electrical receptacle testing.

The facility failed to develop and maintain a comprehensive emergency preparedness program including policies for emerging infectious diseases, communication failures, subsistence needs for staff and patients, and arrangements with other facilities for resident transfer during emergencies. Several deficiencies were identified related to lack of specific policies and documentation.

The facility was found to have no regulatory deficiencies related to multiple reported incidents of neglect and abuse. However, deficiencies were cited related to failure to follow self-administration medication policies, failure to submit final investigation reports timely, failure to provide restorative nursing services as ordered, failure to maintain resident room temperatures, failure to provide adequate personal care such as nail care and shaving, medication errors including incorrect dosage and holding medications outside physician parameters, and medication storage issues including expired and unlabeled medications.

Complaint #NV00057767 was investigated with six allegations including verbal mistreatment by an LPN, improper charting practices, LPNs with drug addictions, neglect of residents left dirty and soaked in urine, harassment and discharge of a CNA for reporting, and inappropriate resident care. None of these allegations were substantiated.

The investigation found that none of the complaint allegations could be substantiated. However, a regulatory deficiency was identified related to the facility's failure to investigate and report an allegation of neglect within five working days as required by regulations.

Two complaints were investigated. Complaint #NV00057476 was substantiated regarding a resident not being showered for multiple days. Complaint #NV00057232 was not substantiated. The investigation included observations, interviews with staff and residents, and review of medical records and policies.

The investigation substantiated one complaint regarding a resident not being showered for multiple days and identified a regulatory deficiency related to quality of care, specifically failure to ensure showers were given twice a week for one of nine residents. Multiple other allegations were not substantiated.

Two complaints were investigated. Complaint #NV00057476 was substantiated regarding a resident not being showered for multiple days. Complaint #NV00057232 was not substantiated. Multiple allegations under each complaint were reviewed through observations, interviews, and record reviews.

The investigation substantiated one complaint regarding a resident not being showered for multiple days. Multiple other allegations were not substantiated. A regulatory deficiency related to quality of care was identified due to failure to ensure showers were given twice a week for one resident.

The facility failed to provide a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials, failed to maintain an emergency preparedness communication plan including names and contact information for patients' physicians, failed to conduct and maintain evidence of annual emergency preparedness training, and failed to conduct a full-scale community-based emergency preparedness exercise.

Two complaints were investigated. Complaint #NV00055894 with allegations of chest x-ray mix-up, financial mismanagement, and missing items was not substantiated. Complaint #NV00055996 with allegations of wrist band errors, HIPAA violations, and residents left in soiled diapers was not substantiated.

The survey identified multiple deficiencies related to safe environment, baseline care planning, quality of care, parenteral fluids, pain management, drug regimen review, labeling and storage of drugs, infection control, food safety, and hospice services. Several allegations in the complaints were not substantiated. Corrective actions and audits were planned or implemented for all deficiencies.

The facility was found deficient in maintaining fire safety systems including kitchen cooking facility extinguishment systems, automatic fire sprinkler systems, smoke dampers, fire drills, smoking regulations, portable space heaters, electrical systems, and gas equipment storage. Corrective actions and re-education plans were outlined for each deficiency.

Two complaints were investigated: Complaint #NV00055259 regarding ants crawling in resident's bedroom was substantiated; Complaint #NV00055144 regarding failure to administer intravenous antibiotic medications was substantiated. Allegations about failure to administer Ativan medication and install bed rails were not substantiated.

The investigation identified multiple deficiencies including failure to ensure a physician's order for bed position was followed, inadequate coordination of intravenous antibiotic treatment with dialysis, failure to maintain an effective pest control program, and deficiencies in pharmacy services related to medication administration and drug regimen review.

Two complaints were investigated. Complaint #NV00054283 regarding the facility not providing Percocet from 08/18/18 12:00 PM until 08/19/18 after 12:00 AM was substantiated. Complaint #NV00054420 regarding the facility losing a resident's prosthesis and locating it after several weeks was substantiated. Other allegations, including verbal and physical abuse and development of a stage 2 sacral ulcer, were not substantiated.

Two complaints were substantiated: one regarding the facility's inability to provide Percocet for a specified period, and another concerning the loss and delayed return of a resident's prosthetic limb. The facility failed to ensure a grievance related to the missing prosthetic limb was properly resolved and failed to maintain an adequate supply of prescribed medications for one resident.

Two complaints were investigated. Complaint #NV00054150 with multiple allegations was not substantiated. Complaint #NV00053931 was substantiated involving missing resident clothing and failure to respond to multiple complaints. The facility failed to label residents' personal clothing properly and did not promptly resolve grievances related to missing clothing.

One complaint (#NV00053931) was substantiated involving missing resident clothing and failure to respond to multiple complaints, while the other complaint (#NV00054150) with multiple allegations was not substantiated. Deficiencies were identified related to the facility's failure to ensure reasonable care for residents' personal belongings and grievance handling.

Four complaints were investigated. Complaint #NV00051532 and #NV00053184 were substantiated. Complaint #NV00052931 and #NV00053751 were partially substantiated or not substantiated. Allegations included removal of Foley catheter without diaper change, pain medication unavailability, resident placement in too small bed, staff rudeness, and others.

The investigation substantiated multiple complaints including removal of Foley catheter without changing resident's diapers, pain medication availability, resident placement in a bed too small, and other care deficiencies. Several allegations were not substantiated. Deficient practices unrelated to complaints were also identified.

Three complaints were investigated. Complaint #NV00051985 was substantiated regarding failure to provide showers twice weekly, untreated wounds, and missing personal belongings. Complaint #NV00052705 was substantiated regarding denial of pain medication, failure to follow wound care orders, and discharge without prescriptions. One complaint was not substantiated.

The investigation substantiated several allegations including failure to provide showers at least twice weekly, untreated wounds, missing personal belongings upon discharge, denial of pain medication, failure to follow physician orders for wound care, and discharge without prescriptions. The facility also failed to ensure residents received necessary assistance with activities of daily living and proper medication administration.

Complaint #NV00052396 was substantiated. Substantiated allegations included incorrect resident legal name usage on door name plate and identification bracelet, failure to assist a resident with impaired mobility to bathe and dress, and a resident changing their own bandage. Other allegations such as failure to treat a resident with dignity and respect and staff not giving assistance during a fall were not substantiated.

The investigation substantiated several allegations including incorrect resident legal name usage on identification, failure to assist a resident with impaired mobility, and a resident changing their own bandage. Other allegations were not substantiated. Deficiencies were identified in developing individualized care plans, activities of daily living assistance, and quality of care related to wound management and fall assessments.

Complaint #NV00052134 was substantiated. The allegation that the facility failed to prevent the drowning of a cognitively impaired resident in a spa room containing a whirlpool bath was confirmed.

The facility failed to initiate baseline care plans addressing elopement risks for six sampled residents and failed to prevent a cognitively impaired resident from drowning in an unsecured spa room. The spa room was not properly secured, and staff failed to monitor residents adequately. Several residents were at risk for elopement without appropriate care plans or interventions.

Complaint #NV00052134 was substantiated. The allegation that the facility failed to prevent the drowning of a cognitively impaired resident in a spa room whirlpool bath was confirmed. The resident was found unresponsive face down in the tub and later expired. The spa room door was unlocked and residents frequently wandered into the room unsupervised.

The facility failed to initiate baseline care plans addressing elopement risks for 6 sampled residents and failed to prevent a cognitively impaired resident from drowning in an unsecured spa room whirlpool tub. The spa room door was unlocked and accessible, and staff failed to monitor and document wandering incidents or reassess elopement risks appropriately.

The facility failed to obtain physician orders and provide documented wound care treatments for one resident with new wounds for four days after identification. The care plan was not updated to address the wounds, and wound care treatments were not properly documented.

Three complaints were investigated during the survey. Complaint #NV00050688, #NV00050625, and #NV00050665 were not substantiated. Allegations included pain and sleep medications not working, overmedication by night shift, inappropriate care, resident falls, journal pages being ripped, infrequent bathing, and pressure sore treatment.

The facility had multiple deficiencies including failure to timely answer call lights, improper medication self-administration assessment, lack of podiatry services, unclean resident rooms and common areas, incomplete resident-centered care plans, failure to assist residents with eating as per care plans, failure to follow physician orders for orthostatic blood pressures and weights, failure to provide vision services, failure to provide podiatry services, inadequate accident prevention related to smoking assessments, failure to justify indwelling catheter use and follow bladder training orders, failure to maintain PICC line dressings, failure to follow oxygen therapy orders and care plans, failure to assess dialysis access sites, medication errors, unsafe medication storage, and infection control lapses including improper isolation signage and PPE use.

Three complaints were investigated during the survey. Complaint #NV00050688 regarding residents' pain and sleep medications was not substantiated. Complaint #NV00050625 alleging night shift overmedication, inappropriate care, and resident falls resulting in death was not substantiated. Complaint #NV00050665 alleging inadequate bathing and pressure sore treatment was not substantiated.

The facility was found deficient in timely response to call lights for residents, and failure to provide adequate assistance with eating for dependent residents. Three complaints investigated were not substantiated. Specific deficiencies included delayed call light response causing distress to residents and inadequate feeding assistance for residents requiring help.

The facility was found deficient in multiple areas including fire safety systems (cooking facility extinguishment, fire alarm, sprinkler system), corridor door smoke resistance, smoke barrier construction and doors, electrical system maintenance, fire drills, smoking regulations enforcement, and oxygen cylinder storage.

The facility was found to be in substantial compliance with Emergency Preparedness regulations but had multiple deficiencies related to fire safety, cooking facilities, sprinkler systems, fire alarms, smoke barriers, corridor doors, electrical equipment, and smoking regulations. Deficiencies were acknowledged by the Regional Plant Operations Director and other facility representatives during the exit interview.

Three complaints were investigated during the survey. Complaint #NV00050688 and #NV00050625 could not be substantiated. Complaint #NV00050665 was also not substantiated. Allegations included residents' pain and sleep medications not working, overmedication, lack of appropriate care, falls, bathing frequency, and pressure sore treatment.

The facility was found to have multiple deficiencies related to resident rights, self-administration of medications, podiatry services, safe environment, comprehensive care planning, quality of care, medication errors, infection control, and other areas. Several complaints were investigated but not substantiated. Deficiencies were identified with corrective actions planned and implemented.

Five complaints were investigated. Several allegations such as residents left in dirty diapers, lack of staff response, medication errors, and neglect were not substantiated. Complaint #NV00050226 regarding improper disposal of medications and used gloves was substantiated.

The investigation included observations, interviews with staff and residents, and review of clinical records. Several allegations were not substantiated, but one complaint regarding improper disposal of intravenous medications and used gloves was substantiated, resulting in a deficiency related to infection control and prevention.

Five complaints were investigated. Four complaints (#NV00050404, #NV00050409, #NV00050026, #NV00050327) were not substantiated. Complaint #NV00050226 was substantiated regarding improper disposal of medication bags in the storeroom.

The investigation included observations, interviews, and record reviews related to multiple complaints. Most allegations were not substantiated except for one complaint regarding improper disposal of medications. A regulatory deficiency was identified for infection control failures related to improper disposal of used intravenous medications and gloves.

Six complaints were investigated. Complaint #NV00048675 and #NV00048919 were substantiated. Allegations included failure to perform appropriate weight assessment, failure to provide regular showers and clean linens, and housekeeping deficiencies. Some allegations such as staff not answering call lights timely and rough nursing care were not substantiated.

Six complaints were investigated with some substantiated, including failure to perform appropriate weight assessment, failure to provide regular showers and clean linens, and housekeeping deficiencies. Several allegations were not substantiated. The facility failed to maintain a sanitary environment and ensure clean linens for residents.

Six complaints were investigated. Complaint #NV00048675 was substantiated regarding failure to perform appropriate weight assessment. Complaint #NV00048919 was substantiated. Other complaints included allegations about call light response, skin assessments, medication administration, staff conduct, and facility cleanliness, some of which were not substantiated.

The investigation substantiated several complaints including failure to perform appropriate weight assessments, failure to maintain a sanitary environment, failure to provide clean linens, and inadequate nutrition monitoring. Multiple allegations related to call light response, resident care, and staff conduct were not substantiated.

The survey identified multiple deficiencies including sprinkler heads covered with spray foam insulating material, corridor doors that did not resist the passage of smoke due to visible gaps, and unsecured oxygen cylinders with missing appropriate signage in storage areas. These deficiencies affected residents, staff, and visitors across multiple smoke compartments.

The facility was found deficient in several areas including sprinkler system installation, corridor doors not resisting smoke passage, and improper storage and labeling of oxygen cylinders. Deficiencies affected multiple smoke compartments and resident rooms, but no patients or staff were directly harmed.

Four complaints were investigated. Complaint #NV00047433 and several allegations related to resident care and staffing were not substantiated. Complaint #NV00047539 was substantiated, including issues related to resident falls and care. Complaint #NV00047537 and #NV00047576 were not substantiated. Investigations included observations, interviews with residents, family members, staff, and review of policies and clinical records.

The survey found multiple deficiencies including failure to follow policies on self-administration of medications, abuse/neglect investigations, medication errors, infection control, and fall management. Some complaints were substantiated while others were not. Corrective actions and re-education plans were outlined with completion dates.

Two complaints were investigated. Complaint #NV00046051 was not substantiated. Allegations included failure to prepare for admission with adequate staff and oxygen, failure to check on a resident at night, rough handling of residents by staff, failure to treat residents with dignity, residents left without fluids or call lights, contaminated rooms, insufficient food, failure to respond to worsening conditions, ignored family requests, and reports of resident falls. Complaint #NV00046880 was also not substantiated, with allegations including improper Foley catheter care, inadequate grooming, and denial of access to records.

The investigation found multiple allegations that could not be substantiated, but identified a regulatory deficiency related to improper Foley catheter care, which was not in compliance with federal regulations. The facility failed to ensure appropriate catheter care and documentation for several residents.

The facility failed to maintain automatic sprinkler systems in reliable operating condition, with sprinkler heads above the ceiling covered by foreign material, affecting four smoke compartments and potentially impacting residents, visitors, and staff.

The facility was found deficient in maintaining automatic sprinkler systems in reliable operating condition, specifically sprinkler heads above the ceiling were covered with foreign material such as plastic bags and insulating material, affecting all smoke compartments.

The facility failed to fully comply with the 2012 NFPA 101 Life Safety Code and 2006 AIA Guidelines for Design and Construction of Health Care Facilities. Deficiencies included inappropriate installation and use of heaters, insufficient and inconveniently located toilets relative to activity and dining areas, inaccurate and incomplete submitted building plans, and misidentified or missing office spaces.

The facility failed to obtain a State of Nevada laboratory license to perform waived testing as required for skilled nursing facilities with their own laboratory.

The facility was found deficient for failing to obtain a State of Nevada laboratory license to perform waived testing as required for skilled nursing facilities with their own laboratory.

The facility failed to meet certain requirements of the National Fire Protection Association (NFPA) 101 Life Safety Code and the American Institute of Architects (AIA) Guidelines for Design and Construction of Health Care Facilities. Specific deficiencies were noted related to heating, ventilation, air-conditioning, and toilet room requirements.

The facility failed to meet multiple Life Safety Code (NFPA 101) and American Institute of Architects (AIA) Guidelines requirements, including issues with corridor door hardware, smoke barrier doors lacking vision panels, emergency lighting testing, incomplete fire safety plan, lack of fire sprinkler coverage on exterior canopies, missing no smoking signage, HVAC and ventilation deficiencies, inadequate dining space, and incomplete functional program descriptions.