Inspection Reports for Spanish Trails Rehabilitation Suites
1610 N RENAISSANCE BLVD NE, NM, 87107
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Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 14, 2022
Visit Reason
The inspection was conducted as an on-site complaint survey for substantiated complaints #55893, 57889, 57805, 57741, 57056, and 57863 related to compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found deficient in multiple areas including failure to update care plans to reflect oxygen use, administering medications without physician orders, delayed medication administration, inadequate oxygen therapy, failure to provide timely and adequate care to residents including Activities of Daily Living (ADL) assistance, and insufficient nursing staff to meet resident needs. These deficiencies posed risks to resident health and safety, including an Immediate Jeopardy related to oxygen and medication management.
Complaint Details
The inspection was complaint-driven based on substantiated complaints #55893, 57889, 57805, 57741, 57056, and 57863.
Severity Breakdown
SS=D: 1
SS=E: 2
SS=J: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to revise care plan to include oxygen use for resident #11. | SS=D |
| Failed to administer medications in accordance with physician's orders for resident #9 and provided medications without orders for resident #11. | SS=E |
| Failed to provide treatment and care in accordance with professional standards for resident #7, including not administering oxygen as ordered and not providing medications to treat anxiety. | SS=J |
| Insufficient nursing staff to meet resident needs for residents #1, #2, and #10, resulting in inadequate assistance with ADLs and residents urinating in water bottles due to lack of timely care. | SS=E |
Report Facts
Complaints substantiated: 6
Residents reviewed: 3
Residents reviewed: 3
Score: 14
Score: 10
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 17, 2022
Visit Reason
The inspection was conducted as an unannounced on-site complaint survey and COVID-19 Focused Infection Control survey triggered by Complaint #57055.
Findings
The facility was found in compliance with COVID-19 emergency preparedness requirements, but failed to timely report and properly investigate an abuse allegation involving a Certified Nursing Assistant (CNA) and Resident #1. The complaint was unsubstantiated, but the facility did not provide required incident or follow-up reports to the State Survey Agency and delayed investigation of the abuse allegation.
Complaint Details
Complaint #57055 was unsubstantiated. The facility failed to report an abuse allegation involving Resident #1 to the State Survey Agency and delayed investigation by 18 days. The CNA was terminated. The Director of Nursing and Social Services Director confirmed the investigation was incomplete and delayed. The Administrator acknowledged the failure and implemented corrective actions including re-education and audits.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report alleged abuse incidents immediately and failure to complete timely investigations of abuse allegations involving Resident #1 and a CNA. | SS=D |
Report Facts
Days delay in abuse investigation: 18
Completion date for re-education to Administrator: Mar 18, 2022
Completion date for re-education to facility staff: Mar 25, 2022
Completion date for resident grievance audit: Mar 21, 2022
Completion date for resident council review: Mar 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse allegation investigation and confirmed delays |
| Social Services Director | Social Services Director (SSD) | Interviewed and confirmed abuse grievance investigation was incomplete |
| Administrator | Administrator (ADM) | Interviewed and acknowledged failure to timely report and investigate abuse allegations; responsible for abuse and neglect coordination |
Inspection Report
Abbreviated Survey
Census: 91
Deficiencies: 2
Jan 26, 2022
Visit Reason
An unannounced onsite COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with infection control and resident care requirements.
Findings
The facility was found to have deficiencies related to failure to provide adequate Activities of Daily Living (ADL) care to residents in isolation, including failure to change adult briefs and provide denture care, and failure to maintain proper infection prevention measures, specifically improper reuse of disposable PPE gowns by staff.
Severity Breakdown
SS=D: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide ADL assistance including changing adult briefs and inserting dentures for residents in isolation. | SS=D |
| Failure to maintain proper infection prevention measures by reusing disposable PPE gowns, contrary to facility policy. | SS=F |
Report Facts
Resident census: 91
Deficiency completion date: Feb 21, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named as responsible for ADL care of residents #1 and #2 and observed reusing PPE gowns |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding resident care and staffing |
| Director of Nursing | Director of Nursing | Provided statements about staff responsibilities and corrective actions |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided information about isolation precautions and staff assignments |
| Ward Clerk #1 | Ward Clerk | Interviewed about resident care and timing of brief changes |
| Administrator | Facility Administrator | Provided statements about PPE policy and corrective actions |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 12
Aug 25, 2021
Visit Reason
An unannounced on-site complaint survey was conducted to investigate multiple complaints regarding compliance with federal regulations for Long Term Care Facilities.
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodations for residents, failure to maintain a safe and homelike environment, failure to prevent abuse and neglect, failure to report and investigate alleged violations timely, inaccurate assessments, incomplete care plans, failure to meet professional standards in medication administration and skin checks, failure to document discharge summaries, inadequate pain management, incomplete nurse staffing postings, unsanitary food handling practices, and inadequate infection prevention and control measures.
Complaint Details
The complaint investigation included multiple complaints, some substantiated with citations and others not substantiated. The investigation focused on resident rights, abuse and neglect, care planning, medication administration, infection control, and other regulatory requirements.
Severity Breakdown
SS=E: 8
SS=D: 3
SS=C: 1
SS=F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure residents had adequate privacy via shower curtains and rooms were prepared prior to admission. | SS=E |
| Failure to provide a homelike environment by not maintaining clean and clutter-free resident rooms. | SS=D |
| Failure to ensure residents were free from abuse and neglect, including failure to properly investigate and report incidents. | SS=D |
| Failure to report alleged violations within required timeframes and failure to thoroughly investigate abuse allegations. | SS=E |
| Failure to provide accurate and complete assessments including mental status, skin assessments, and post-medication error assessments. | SS=E |
| Failure to revise care plans timely and failure to complete care plans. | SS=E |
| Failure to meet professional standards by not administering medications as ordered and not completing weekly skin checks. | SS=E |
| Failure to ensure proper discharge documentation and discharge summaries. | SS=D |
| Failure to provide pain management medication timely and adequately. | SS=E |
| Failure to maintain posted nurse staffing information for a minimum of 18 months. | SS=C |
| Failure to store and serve food under sanitary conditions by not ensuring staff wore hair restraints and face coverings in the kitchen. | SS=F |
| Failure to maintain proper infection prevention and control measures including PPE use and signage in quarantine units. | SS=E |
Report Facts
Residents reviewed for pain management: 3
Residents on census: 93
Residents reviewed for assessments: 7
Residents reviewed for care plans: 2
Residents reviewed for discharge: 2
Residents reviewed for abuse/neglect: 3
Residents reviewed for medication administration: 2
Dates missing nurse staffing postings: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding room readiness, discharge summary, and infection control practices. | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including assessments, care plans, medication errors, discharge summaries, infection control, and staff education. |
| Certified Nursing Assistant #1 | Certified Nurses Aide | Involved in abuse incident with Resident #4. |
| Certified Nursing Assistant #2 | Certified Nurses Aide | Observed not using PPE in quarantine unit. |
| Certified Nursing Assistant #3 | Certified Nurses Aide | Interviewed about shower curtain deficiencies. |
| Dietary Manager | Dietary Manager | Interviewed regarding hair restraint use in kitchen. |
| Cook #1 | Cook | Observed not wearing hair restraint while serving food. |
| Registered Nurse #1 | Registered Nurse | Observed not administering pain medication timely. |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding quarantine unit and PPE use. |
| Social Services Director | Social Services Director | Interviewed regarding care plan meetings and behavioral health referrals. |
| Medical Doctor | Medical Doctor | Interviewed regarding behavioral health orders for Resident #13. |
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 21
Mar 25, 2021
Visit Reason
Annual recertification, on-site COVID-19 Focused Infection Control and complaint survey completed on 03/25/21 for the requirements of 42 CFR Part 483, Subpart B, requirements for Long Term Care Facilities.
Findings
The facility was found in compliance with COVID-19 emergency preparedness but cited for multiple deficiencies including resident rights violations, care planning issues, infection control failures, insufficient staffing, medication management errors, food service problems, and environmental safety concerns.
Complaint Details
Complaints #50118 and #50947 were substantiated with no deficiencies cited.
Severity Breakdown
Level E: 9
Level D: 7
Level F: 4
Deficiencies (21)
| Description | Severity |
|---|---|
| Facility failed to promote care with dignity and respect by referring to residents needing assistance as 'feeders'. | Level E |
| Facility failed to promote resident choice by not accommodating a resident's choice to have coffee in the morning after waking. | Level D |
| Facility failed to give resident council feedback on grievances for multiple residents. | Level E |
| Facility failed to ensure residents had access to personal funds after hours and on weekends. | Level E |
| Facility failed to provide a homelike environment by not maintaining clean resident rooms free of debris and used glucometer strips. | Level D |
| Facility failed to make prompt efforts to resolve resident grievances timely and provide written decisions. | Level E |
| Facility failed to prevent verbal abuse by not removing a verbally abusive roommate. | Level E |
| Facility failed to properly prepare and inform a resident prior to discharge to another facility. | Level D |
| Facility failed to conduct accurate comprehensive assessments including Activities of Daily Living (ADL) needs. | Level E |
| Facility failed to ensure Minimum Data Set (MDS) assessments were accurate, including incorrect documentation of indwelling catheter and speech clarity. | Level D |
| Facility failed to develop and implement baseline care plans and comprehensive care plans reflecting resident needs and treatments. | Level D |
| Facility failed to ensure sufficient nursing staff to provide care and supervision to all residents. | Level F |
| Facility failed to post daily census and nurse staffing data in a prominent place accessible to residents and visitors. | Level F |
| Facility failed to provide routine and emergency drugs and biologicals with accurate documentation and proper storage. | Level E |
| Facility failed to store and serve food under sanitary conditions, including unlabeled, undated, and improperly stored food items and lack of dish sanitizer. | Level F |
| Facility failed to maintain an infection prevention and control program including failure to don and doff PPE properly and failure to screen staff for COVID-19 symptoms. | Level F |
| Facility failed to meet nutritional needs and preferences by not providing alternative meals or accommodating food preferences. | Level E |
| Facility failed to serve food that was appetizing and at the correct temperature, including re-warming food without proper temperature checks. | Level D |
| Facility failed to provide Activities of Daily Living assistance including showers and nail care. | Level E |
| Facility failed to prevent development of avoidable pressure ulcers and failed to provide adequate supervision and fix broken bed rails. | Level D |
| Facility failed to properly manage enteral feeding including labeling and dating of feeding tubes and formula. | Level E |
Report Facts
Residents: 90
Deficiency counts: 20
Care plan meeting delay: 180
Temperature: 55.5
Medication counts: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | CNA | Named in dignity and respect deficiency for referring to residents as 'feeders' |
| Dietary Manager | Dietary Manager | Named in food service deficiencies and resident rights re-education |
| Social Services Assistant/Director | SSA/SSD | Named in grievance and resident rights deficiencies |
| Director of Nursing | DON | Named in multiple deficiencies including infection control, staffing, care planning |
| Registered Nurse #1 | RN | Named in MDS and wound care deficiencies |
| Licensed Practical Nurse #1 | LPN | Named in wound care deficiency |
| Certified Medication Aide #2 | CMA | Named in medication administration deficiency |
| Assistant Director of Nursing #1 | ADON | Named in verbal abuse and shower deficiencies |
| Activities Director | Activities Director | Named in activities deficiency |
| Registered Nurse #4 | RN | Named in oxygen therapy deficiency |
| Certified Nurse Aide #6 | CNA | Named in environmental safety deficiency |
| Maintenance Director | Maintenance Director | Named in environmental safety deficiency |
| Registered Nurse #5 | RN | Named in infection control deficiency |
| Receptionist | Receptionist | Named in infection control deficiency |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 21, 2020
Visit Reason
An unannounced on-site COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Targeted Survey were conducted.
Findings
The facility was found to be in compliance with 42 CFR 483.83 related to emergency preparedness and in substantial compliance with 42 CFR 483 subpart B related to infection control. No deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 18, 2020
Visit Reason
The inspection was conducted as a complaint survey related to Complaint #42070.
Findings
No deficiencies were cited as a result of the complaint survey, and the complaint was found to be unsubstantiated.
Complaint Details
Complaint #42070 was unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 19, 2019
Visit Reason
The inspection was conducted as a complaint survey related to allegations of abuse and neglect at the facility, specifically regarding resident rights and quality of care.
Findings
The facility failed to support a resident's right to make decisions about their care and did not provide timely, consistent, and documented assessments for a resident with an acute change in condition. This resulted in a resident feeling shamed for calling 911 and a delay in hospital transfer for a resident who was very sick.
Complaint Details
Complaint # NM41503 was substantiated. The complaint involved a resident and a friend feeling shamed and belittled after calling 911 due to concerns about the resident's condition. The facility staff discouraged calling 911 and failed to provide timely care and monitoring.
Severity Breakdown
SS=D: 1
SS=G: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to support a resident's right to make decisions about their care, including the right to call 911. | SS=D |
| Failed to ensure quality of care by not providing timely assessments and consistent, ongoing, documented monitoring of a resident's acute change in condition. | SS=G |
| Failed to ensure nursing staff possessed competencies and skills necessary to identify and provide timely nursing care and related services to meet resident needs. | SS=G |
Report Facts
Deficiencies cited: 3
Date of Substantial Compliance: 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to discouraging calling 911 and failure to timely send resident to hospital. |
| Director of Nursing | Director of Nursing | Responsible for re-educating nursing staff and monitoring compliance. |
| Administrator | Administrator | Interviewed regarding staff conduct and complaint handling. |
| Physician | Physician | Examined resident and noted significant change in condition. |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 22, 2019
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a facility survey conducted on 10/22/2019.
Findings
No specific deficiencies or findings are detailed in the provided document; it primarily serves as a cover sheet for the plan of correction.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 22, 2019
Visit Reason
The inspection was conducted as a complaint survey to investigate three complaints received regarding the facility.
Findings
No deficiencies were cited as a result of the complaint survey. Of the three complaints investigated, one was substantiated with no deficiencies, and two were unsubstantiated with no deficiencies.
Complaint Details
Three complaints were investigated: NM #39387 was substantiated with no deficiencies, NM #39636 was unsubstantiated with no deficiencies, and NM #39651 was unsubstantiated with no deficiencies.
Report Facts
Complaints investigated: 3
Inspection Report
Annual Inspection
Census: 111
Deficiencies: 20
Sep 10, 2019
Visit Reason
The survey was a recertification survey which became an extended survey to assess compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities, including investigation of 5 complaints.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, reasonable accommodations, self-determination, care planning, medication administration, staffing sufficiency and competency, infection control, and quality assurance processes. Several repeat deficiencies were noted. Residents reported delayed call light responses, lack of showers, inadequate hydration, and disrespectful treatment. The facility failed to timely complete assessments, care conferences, and plans of correction. Medication errors and failure to monitor residents post-fall were also identified.
Complaint Details
Five complaints were investigated: substantiated complaints related to staffing, neglect, death/abuse, and quality of care; one complaint was unsubstantiated with no deficiencies.
Severity Breakdown
SS=E: 9
SS=H: 1
SS=J: 2
SS=D: 5
SS=F: 3
Deficiencies (20)
| Description | Severity |
|---|---|
| Failure to treat residents with dignity and respect, including timely response to call lights and appropriate incontinence care. | SS=E |
| Failure to provide reasonable accommodations for residents requiring shower chairs and assistance. | SS=E |
| Failure to promote resident self-determination through support of resident choice in activities, bathing, and meals. | SS=E |
| Failure to maintain accurate and complete advanced directives documentation and physician orders. | SS=E |
| Failure to make prompt efforts to resolve resident grievances, including failure to investigate and document roommate abuse. | SS=H |
| Failure to ensure residents are free from abuse and neglect, including failure to follow proper care procedures and notify providers of changes in condition. | SS=J |
| Failure to complete comprehensive assessments timely and failure to revise care plans and conduct care conferences as required. | SS=D |
| Failure to provide services that meet professional standards including medication administration errors and failure to provide restorative nursing services. | SS=E |
| Failure to increase or prevent decrease in range of motion and mobility as indicated by resident needs. | SS=D |
| Failure to provide appropriate care and monitoring for residents receiving enteral nutrition via feeding tubes. | SS=E |
| Failure to maintain sufficient nursing staff to meet resident needs and timely respond to call lights. | SS=J |
| Failure to ensure nursing staff competency in care provision, including post-fall assessments and medication administration. | SS=D |
| Failure to maintain proper labeling, storage, and security of drugs and biologicals, including refrigerator temperature monitoring and medication cart security. | SS=E |
| Failure to provide sufficient fluids and hydration to residents consistent with their needs and preferences. | SS=F |
| Failure of the medical director to implement and coordinate appropriate plans of action to correct identified quality issues affecting resident care. | SS=D |
| Failure to maintain an effective infection prevention and control program including surveillance, hygienic practices, and equipment management. | SS=F |
| Failure to implement an antibiotic stewardship program including protocols and monitoring of antibiotic use. | SS=D |
| Failure to ensure monthly drug regimen reviews are timely and pharmacist recommendations are acted upon promptly. | SS=D |
| Failure to ensure residents are free from significant medication errors including missed or late doses of medications. | SS=E |
| Failure to provide pneumococcal vaccination education and documentation consistent with CDC and ACIP guidelines. | SS=D |
Report Facts
Residents reviewed: 111
Complaints investigated: 5
Missed medication documentation: 26
Missed refrigerator temperature logs: 11
Missed refrigerator temperature logs: 42
Residents with call light delays: 111
Residents needing assistance with bathing: 97
Residents needing assistance with dressing: 98
Residents needing assistance with transferring: 101
Residents needing assistance with toileting: 103
Residents needing assistance with eating: 102
Residents incontinent of urine: 65
Residents incontinent of bowel: 65
Residents in wheelchairs: 89
Residents walking with assistance: 44
Residents receiving preventative skin care: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Involved in failure to notify provider of resident condition and improper care leading to resident death |
| CNA #4 | Certified Nursing Assistant | Involved in improper care of resident during bed bath leading to resident injury |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing, medication monitoring, infection control, and quality assurance |
| Administrator | Administrator | Interviewed regarding staffing, grievances, infection control, and quality assurance |
| Medical Director | Medical Director | Interviewed regarding quality assurance and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding restorative services, medication administration, and infection control |
| Nurse Manager | Nurse Manager | Re-educated staff on medication administration, staffing, and quality assurance monitoring |
| Social Service Assistant | Social Service Assistant | Involved in grievance follow-up and resident interviews |
| Certified Medication Aide | Certified Medication Aide | Observed leaving medication unattended and improper medication administration |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding neurological checks and Glasgow Coma Scale |
| Registered Nurse #3 | Registered Nurse | Interviewed regarding post-fall care and neurological checks |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed improper medication administration via feeding tube |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding post-fall neurological checks and Glasgow Coma Scale |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding hydration delivery and staffing |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed improper medication administration and leaving medication unattended |
| Director of Regulatory Compliance | Director of Regulatory Compliance | Interviewed regarding infection control and quality assurance |
| Nurse Educator | Nurse Educator | Provided competency check-offs for nursing staff |
| Kitchen Manager | Kitchen Manager | Interviewed regarding hydration supplies |
| Clinical Consultant | Clinical Consultant | Re-educated staff on quality assurance processes |
Inspection Report
Life Safety
Census: 115
Capacity: 134
Deficiencies: 0
Aug 20, 2019
Visit Reason
A life safety code recertification survey was conducted in accordance with Title 42 Code of Federal Regulations, Part 483, Subpart B: Requirements for Long Term Care Facilities.
Findings
The facility was found in substantial compliance with Title 42 Code of Federal Regulations, 483.90(a) (Life Safety from Fire). No deficiencies were cited.
Inspection Report
Original Licensing
Deficiencies: 0
Jul 21, 2017
Visit Reason
The inspection visit was conducted as an initial survey for licensing to assess compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities.
Findings
No deficiencies were cited as a result of the initial survey completed on 07/21/2017.
Inspection Report
Life Safety
Deficiencies: 0
May 24, 2017
Visit Reason
An Initial Life Safety Code Survey was conducted at the facility as per the provider's request.
Findings
The facility was found not in substantial compliance with the Life Safety Code Portion of the NFPA 101 (2012 Edition) on May 24, 2017. A follow-up onsite revisit on June 13, 2017 confirmed all issues had been corrected, and a Certificate of Occupancy was received on June 19, 2017.
Inspection Report
Life Safety
Deficiencies: 0
May 24, 2017
Visit Reason
An Initial Life Safety Code Survey was conducted at the facility as per provider's request.
Findings
The facility was found not in substantial compliance with the Life Safety Code Portion of the NFPA 101 (2012 Edition) on May 24, 2017. A follow-up onsite revisit on June 13, 2017 confirmed all issues had been corrected, and a Certificate of Occupancy was received on June 19, 2017.
Report Facts
Survey completion date: Jun 19, 2017
Inspection Report
Life Safety
Deficiencies: 0
May 24, 2017
Visit Reason
An Initial Life Safety Code Survey was conducted at the facility on May 24, 2017, at the provider's request.
Findings
The facility was found not in substantial compliance with the Life Safety Code portion of New Mexico State regulations during the initial survey. A follow-up onsite revisit on June 13, 2017, confirmed all issues had been corrected, and a Certificate of Occupancy was received on June 19, 2017. Temporary licensure was recommended.
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