A list of the most recent deficiencies for The Estates of Spanish Lake. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-25 | 2024-03-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-25 | 2024-03-08 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-01-25 | 2024-03-08 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-01-25 | 2024-03-08 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2024-01-25 | 2024-03-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-25 | 2024-03-08 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-01-25 | 2024-03-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-25 | 2024-03-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-25 | 2024-03-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-25 | 2024-03-08 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-25 | 2024-03-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-25 | 2024-03-08 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-01-25 | 2024-03-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-01-25 | 2024-03-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-01-25 | 2024-03-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 2024-03-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-25 | 2024-03-08 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-25 | 2024-03-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-01-25 | 2024-03-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-25 | 2024-03-08 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-01-25 | 2024-03-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-01-25 | 2024-03-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-22 | 2024-03-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-22 | 2024-03-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-22 | 2024-03-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-22 | 2024-03-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-24 | 2023-11-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-24 | 2023-11-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-24 | 2023-09-22 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-24 | 2023-09-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-01 | 2023-05-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-09 | 2023-03-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-09 | 2023-03-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-05 | 2022-06-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-05 | 2022-06-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-05 | 2022-06-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-05 | 2022-06-08 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-05-05 | 2022-06-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-14 | 2022-06-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-14 | 2022-06-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-14 | 2022-06-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-14 | 2022-06-08 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-01-14 | 2022-06-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-14 | 2022-03-21 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-01-14 | 2022-03-21 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-01-14 | 2022-02-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-14 | 2022-02-28 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-01-14 | 2022-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-14 | 2022-02-28 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-01-14 | 2022-02-28 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-08 | 2021-10-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-08 | 2021-10-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-08 | 2021-10-08 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-04-08 | 2021-05-22 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-04-08 | 2021-05-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-04-08 | 2021-05-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-08 | 2021-05-22 | N |
| Provide activities to meet all resident's needs. | Health | 2021-04-08 | 2021-05-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-08 | 2021-05-22 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-04-08 | 2021-05-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-08 | 2021-05-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-08 | 2021-05-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-04-08 | 2021-05-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-08 | 2021-05-22 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-04-08 | 2021-05-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-08 | 2021-05-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-08 | 2021-05-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-08 | 2021-05-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-08 | 2021-05-22 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-04-08 | 2021-05-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-08 | 2021-05-22 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2021-04-08 | 2021-05-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-08 | 2021-05-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-04-08 | 2021-05-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-08 | 2021-05-22 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-04-08 | 2021-05-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-08 | 2021-05-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-08 | 2021-05-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-08 | 2021-05-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-04-08 | 2021-05-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-21 | 2019-08-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-21 | 2019-08-02 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-06-21 | 2019-08-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-21 | 2019-08-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-21 | 2019-08-02 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-21 | 2019-08-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-21 | 2019-08-02 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-06-21 | 2019-08-02 | N |
| Maintain 15 months of resident assessments in the resident's active clinical record. | Health | 2019-06-21 | 2019-08-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-21 | 2019-08-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-21 | 2019-08-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-21 | 2019-08-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-21 | 2019-08-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-21 | 2019-08-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-21 | 2019-08-02 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-06-21 | 2019-08-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-21 | 2019-08-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-21 | 2019-08-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-06-21 | 2019-08-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-21 | 2019-08-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-21 | 2019-08-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-21 | 2019-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-21 | 2019-08-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-21 | 2019-08-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-21 | 2019-08-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-21 | 2019-08-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-21 | 2019-08-02 | N |
