A list of the most recent deficiencies for Spanish Hills Wellness Suites. 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? |
|---|---|---|---|---|
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-01-11 | 2024-02-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-01-11 | 2024-02-09 | 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 | 2024-01-11 | 2024-02-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-11 | 2024-02-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-11 | 2024-02-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-11 | 2024-02-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-11 | 2024-02-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-12 | 2024-02-02 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-01-12 | 2024-02-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-12 | 2024-02-02 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-12 | 2024-02-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-12 | 2024-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-12 | 2024-02-02 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2024-01-12 | 2024-02-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-12 | 2024-02-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-12 | 2024-02-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-24 | 2023-09-08 | Y |
| 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 | 2023-08-24 | 2023-09-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-14 | 2023-07-01 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-14 | 2023-07-01 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-14 | 2023-07-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-14 | 2023-07-01 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-06-14 | 2023-07-01 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-06-14 | 2023-07-01 | Y |
| 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 | 2023-06-14 | 2023-07-01 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-01-12 | 2023-02-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-12 | 2023-02-15 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-01-12 | 2023-02-15 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-01-12 | 2023-02-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-01-12 | 2023-02-15 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-01-12 | 2023-02-15 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2023-01-12 | 2023-02-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-12 | 2023-02-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-01-12 | 2023-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-13 | 2023-02-06 | N |
| 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 | 2023-01-13 | 2023-02-06 | 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 | 2023-01-13 | 2023-02-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-13 | 2023-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-13 | 2023-02-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-12 | 2023-01-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-12 | 2023-01-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-12 | 2023-01-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-12 | 2023-01-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-26 | 2022-11-23 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-10-26 | 2022-11-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-26 | 2022-11-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-26 | 2022-11-23 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-26 | 2022-11-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-26 | 2022-11-23 | Y |
| 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 | 2022-10-26 | 2022-11-23 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-10-26 | 2022-11-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-26 | 2022-10-26 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2020-01-17 | 2020-02-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-17 | 2020-02-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-01-10 | 2020-02-07 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2020-01-10 | 2020-02-07 | 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 | 2020-01-10 | 2020-02-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-10 | 2020-02-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-10 | 2020-02-07 | N |
| 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 | 2020-01-10 | 2020-02-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-10 | 2020-02-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-10 | 2020-02-07 | 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 | 2020-01-10 | 2020-02-07 | N |
