Deficiency Records for Spanish Trails Rehabilitation Suites
Updated as of June 01, 2020
This is not the most recent data for Spanish Trails Rehabilitation Suites. For the most recent information, click here.
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 and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-12-19 | 2020-01-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-19 | 2020-01-17 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-12-19 | 2020-01-17 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2019-09-10 | 2019-10-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-10 | 2019-10-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-09-10 | 2019-10-14 | 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 | 2019-09-10 | 2019-10-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-10 | 2019-10-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-10 | 2019-10-14 | 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 | 2019-09-10 | 2019-10-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-10 | 2019-10-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-09-10 | 2019-10-14 | 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 | 2019-09-10 | 2019-10-14 | 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 | 2019-09-10 | 2019-10-14 | 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 | 2019-09-10 | 2019-10-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-10 | 2019-10-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-10 | 2019-10-14 | 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 | 2019-09-10 | 2019-10-14 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2019-09-10 | 2019-10-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-09-10 | 2019-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-10 | 2019-10-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-10 | 2019-10-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-10 | 2019-10-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-10 | 2019-10-14 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-09-10 | 2019-10-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-10 | 2019-10-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-09-10 | 2019-10-14 | 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 | 2019-09-10 | 2019-10-14 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-09-10 | 2019-10-14 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-02 | 2018-11-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-10-02 | 2018-11-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-02 | 2018-11-01 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2018-10-02 | 2018-11-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-03 | 2018-11-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-10-03 | 2018-11-01 | 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 | 2018-10-03 | 2018-11-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-10-03 | 2018-11-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-03 | 2018-11-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-03 | 2018-11-01 | N |
| 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 | 2018-10-03 | 2018-11-01 | 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 | 2018-10-03 | 2018-11-01 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-10-03 | 2018-11-01 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2018-10-03 | 2018-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-03 | 2018-11-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-10-03 | 2018-11-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-10-03 | 2018-11-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-10-03 | 2018-11-01 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-10-03 | 2018-11-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-03 | 2018-11-01 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-10-03 | 2018-11-01 | Y |
