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Deficiency Records for Spanish Trails Rehabilitation Suites
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.
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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-22 | 2024-08-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-22 | 2024-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-22 | 2024-08-23 | 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 | 2024-07-22 | 2024-08-23 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-07-22 | 2024-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-22 | 2024-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-22 | 2024-08-23 | 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 | 2024-07-22 | 2024-08-23 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-18 | 2024-08-23 | 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 | 2024-07-18 | 2024-08-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-07-18 | 2024-08-23 | 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 | 2024-07-18 | 2024-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-07-18 | 2024-08-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-01 | 2024-05-17 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-01 | 2024-05-17 | 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 | 2024-03-22 | 2024-04-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-22 | 2024-04-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-22 | 2024-04-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-03-22 | 2024-04-11 | 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 | 2024-03-22 | 2024-04-11 | 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 | 2024-03-22 | 2024-04-11 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-03-22 | 2024-04-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-19 | 2024-04-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-19 | 2024-04-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-19 | 2024-04-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-19 | 2024-04-09 | N |
| 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 treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-02 | 2022-07-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
| 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 |
| 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 | 2022-03-17 | 2022-03-25 | Y |
| 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 |
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