Inspection Reports for
Spanish Trails Rehabilitation Suites

The complaint investigation substantiated that the facility failed to provide appropriate training to staff to manage aggressive behaviors, resulting in a resident attacking a CNA and falling. The CNA involved was terminated after investigation. Abuse re-training and de-escalation training were conducted post-incident. No similar incidents were found in interviews with other residents.

The facility failed to provide appropriate behavioral health care and staff training to manage aggressive behaviors, resulting in a resident attacking a Certified Nurse Assistant and subsequently falling. The investigation found inadequate staff training on de-escalation prior to the incident, and corrective training was implemented after the event.

The complaint investigation was substantiated. CNA #1 neglected resident #1 by failing to provide care during the night shift of 08/29/25 to 08/30/25, leaving the resident in a urine-soaked brief and not responding to call lights. The facility administrator substantiated the complaint after investigation.

The facility failed to protect resident #1 from neglect when CNA #1 did not provide care or assistance during the night shift, leaving the resident in a urine-soaked brief. The complaint was substantiated. Additionally, the facility failed to document the investigation properly, did not complete a comprehensive care plan for resident #1, and failed to provide professional quality care for resident #2, including missed weekly skin assessments and delayed swallow study. Both residents #1 and #2 experienced inadequate daily care, including insufficient brief changes leading to skin breakdown.

The complaint investigation found substantiated deficiencies related to medication administration and documentation of resident care and discharge planning.

The facility failed to follow physician orders for one resident regarding medication administration with meals, and failed to accurately document the changing conditions of another resident, including multiple refusals of medications and care, and inadequate documentation of discharge against medical advice.

The complaint investigation involved allegations of financial exploitation of residents via unauthorized use of debit cards by former Certified Nurse Aides and related staff. The investigation found that one resident lost approximately $23,000 due to unauthorized withdrawals. Staff involved were terminated. The facility reimbursed the affected resident and conducted staff in-services. Additionally, a failure to treat and document a resident's skin issue was identified.

The facility failed to prevent misappropriation of resident funds involving unauthorized use of debit cards by former staff, resulting in significant financial loss to a resident. Additionally, the facility failed to document, assess, or treat a resident's skin issue, leading to potential decline in resident wellbeing.

The facility was found deficient in multiple areas including failure to promote residents' dignity and privacy, failure to notify providers and emergency contacts of changes in condition, failure to complete timely assessments, failure to conduct quarterly care plan meetings and update care plans, and failure to store and serve food under sanitary conditions. All deficiencies were assessed as minimal harm or potential for actual harm.

The complaint investigation focused on the failure to notify providers and emergency contact after a fall on 01/09/25 involving resident #2 who was on blood thinners, failure to obtain physician orders for oxygen use, and failure to follow dietary restrictions for resident #1. The investigation found substantiated deficiencies in all areas.

The facility failed to notify the appropriate healthcare providers and the resident's emergency contact after a resident experienced an unwitnessed fall while on blood thinners, resulting in delayed treatment. Additionally, the facility provided oxygen to the resident without physician orders and failed to honor a resident's dietary restrictions, serving prohibited foods.

The visit was complaint-related involving multiple grievances including failure to assist with purchases, unresolved grievances about food temperature and quality, missed care plan meetings, medication errors, and infection control lapses. The grievance for cold food was not fully investigated or resolved to the resident's satisfaction.

The facility was found deficient in several areas including failure to assist a resident with purchases reflecting their preferences, inadequate grievance investigations, failure to conduct required quarterly care plan meetings, delayed reporting of critical lab results, medication administration errors including missed medications and hand hygiene lapses, failure to provide resident-preferred diets, serving food at unsafe temperatures, and failure to provide therapeutic diets as ordered.

The complaint was substantiated based on video evidence and interviews. The CNA assigned to the resident did not provide care or check on the resident during a 12-hour shift on 05/28/24. The CNA was immediately relieved of duties and barred from returning. The facility confirmed other residents received appropriate care and initiated staff education.

The facility failed to provide adequate care to one resident on 05/28/24, as staff did not enter the resident's room or assist with toileting and brief changes during the entire day. The CNA responsible was relieved of duties, and the facility educated staff to ensure all residents receive timely care.

The investigation was complaint-driven, focusing on allegations that the facility failed to update care plans for residents, failed to notify family members of changes, and failed to provide adequate wound care leading to worsening pressure ulcers and poor health outcomes. The complaint was substantiated with findings of deficiencies.

The facility failed to update care plans for three residents regarding ADL care and activity preferences, failed to notify the Power of Attorney of changes in care plans for one resident, and failed to provide timely and appropriate wound care for a resident with a worsening pressure ulcer that led to actual harm and hospice placement.

The facility was found deficient in multiple areas including failure to update and follow care plans for residents, inadequate assistance with activities of daily living, improper medication handling, failure to follow dietary recipes and food safety protocols, poor infection control practices including improper storage and sanitation of CPAP and nebulizer equipment, and unsanitary kitchen conditions.

The complaint investigation was triggered by an incident on 03/17/24 where resident #1 was found engaged in sexual activity with another male resident in an open doorway. Concerns were raised about resident #1's capacity to consent and the use of medication to dampen libido. The Nurse Practitioner and Medical Director had differing opinions on the resident's capacity and medication management. The resident was his own decision maker without a guardian appointed.

The facility failed to ensure the rights of one resident by administering medication to reduce sexual desires without adequate consent or indication, and provided an anti-depressant at an excessive dose without adequate indications. The resident engaged in sexual activity with another resident, raising concerns about capacity to consent. Interviews with staff and medical professionals revealed differing opinions on the resident's capacity and the appropriateness of medication adjustments.

The facility failed to ensure staff completed accurate medical records for 9 residents, including incomplete activity participation logs and missing medication administration and admission notes for one resident. This deficient practice could result in staff not knowing resident daily activities, preferences, or medication requirements.

The complaint investigation substantiated that the facility failed to notify the POA of treatment changes and condition decline for resident #1, failed to respond to a grievance filed by resident #2's husband, and that a CNA stole $300 from resident #3 but returned it after being confronted. The CNA was terminated and the incident reported to the State Agency.

The facility failed to notify the POA of changes in treatment and condition for resident #1, failed to respond to a grievance filed by resident #2's husband, and failed to prevent misappropriation of money by a Certified Nurse Aide from resident #3. The theft was substantiated, the money was returned, and the CNA was terminated.

The complaint investigation found substantiated deficiencies related to failure to provide adequate ADL care and failure to properly assess, monitor, and treat injuries after resident #1's falls, resulting in actual harm.

The facility failed to provide adequate ADL assistance with baths/showers to resident #1, and failed to assess, monitor, and notify the physician timely after resident #1 sustained falls resulting in an open fracture of the right lower leg, causing significant pain and delayed treatment.

The inspection was complaint-driven based on substantiated complaints #55893, 57889, 57805, 57741, 57056, and 57863.

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 #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.

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.

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.

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.

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.

Complaints #50118 and #50947 were substantiated with no deficiencies cited.

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 # 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.

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.

Five complaints were investigated: substantiated complaints related to staffing, neglect, death/abuse, and quality of care; one complaint was unsubstantiated with no deficiencies.

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.