Deficiency Records for Spanish Trails Rehabilitation Suites
Updated as of March 01, 2024
A list of the most recent deficiencies for Spanish Trails Rehabilitation 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-26 | 2023-10-27 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-09-26 | 2023-10-27 | 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 | 2023-09-26 | 2023-10-27 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-09-26 | 2023-10-27 | 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 | 2023-09-26 | 2023-10-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-26 | 2023-10-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-26 | 2023-10-27 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-26 | 2023-10-27 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-09-26 | 2023-10-27 | 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 | 2023-09-26 | 2023-10-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-26 | 2023-10-27 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-09-26 | 2023-10-27 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-09-26 | 2023-10-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-26 | 2023-10-27 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-21 | 2023-10-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-21 | 2023-10-27 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-06-09 | 2023-07-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-09 | 2023-07-07 | Y |
| 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 | 2023-06-09 | 2023-07-07 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-06-09 | 2023-07-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-10 | 2023-06-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-10 | 2023-06-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-24 | 2022-11-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-24 | 2022-11-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-24 | 2022-11-23 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-10-24 | 2022-11-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-24 | 2022-11-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-02 | 2022-07-08 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-02 | 2022-07-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-02 | 2022-07-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-02 | 2022-07-08 | 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 | 2022-06-02 | 2022-07-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-02 | 2022-07-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-02 | 2022-07-08 | N |
| Provide activities to meet all resident's needs. | Health | 2022-06-02 | 2022-07-08 | 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 | 2022-06-02 | 2022-07-08 | 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 | 2022-06-02 | 2022-07-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-02 | 2022-07-08 | 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 | 2022-06-02 | 2022-07-08 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-06-02 | 2022-07-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-02 | 2022-07-08 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-02 | 2022-07-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-02 | 2022-07-08 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-24 | 2022-07-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-24 | 2022-07-08 | 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 | 2022-04-14 | 2022-05-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-14 | 2022-05-03 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-14 | 2022-05-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-05-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-17 | 2022-03-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-26 | 2022-03-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-26 | 2022-03-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-15 | 2022-01-22 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-12-15 | 2022-01-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-15 | 2022-01-22 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-12-15 | 2022-01-22 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-15 | 2022-01-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-25 | 2021-09-24 | 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 | 2021-08-25 | 2021-09-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-25 | 2021-09-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-25 | 2021-09-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-25 | 2021-09-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-25 | 2021-09-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-25 | 2021-09-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-25 | 2021-09-24 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-08-25 | 2021-09-24 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-25 | 2021-09-24 | Y |
| Post nurse staffing information every day. | Health | 2021-08-25 | 2021-09-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-25 | 2021-09-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-25 | 2021-09-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-25 | 2021-04-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-03-25 | 2021-04-23 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-03-25 | 2021-04-23 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-03-25 | 2021-04-23 | 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 | 2021-03-25 | 2021-04-23 | 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 | 2021-03-25 | 2021-04-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-25 | 2021-04-23 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-03-25 | 2021-04-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-25 | 2021-04-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-25 | 2021-04-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-25 | 2021-04-23 | 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 | 2021-03-25 | 2021-04-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-25 | 2021-04-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-25 | 2021-04-23 | N |
| Provide activities to meet all resident's needs. | Health | 2021-03-25 | 2021-04-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-25 | 2021-04-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-25 | 2021-04-23 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-03-25 | 2021-04-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-25 | 2021-04-23 | 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 | 2021-03-25 | 2021-04-23 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-03-25 | 2021-04-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-03-25 | 2021-04-23 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-03-25 | 2021-04-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-25 | 2021-04-23 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-03-25 | 2021-04-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-03-25 | 2021-04-23 | Y |
| Post nurse staffing information every day. | Health | 2021-03-25 | 2021-04-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-25 | 2021-04-23 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-23 | 2021-04-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-03-23 | 2021-04-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-03-23 | 2021-04-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-23 | 2021-04-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-03-23 | 2021-04-23 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-03-23 | 2021-04-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-23 | 2021-04-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-23 | 2021-04-23 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2021-03-23 | 2021-04-23 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-03-23 | 2021-04-23 | N |
