Spanish Hills Wellness Suites

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the facility failed to ensure the hand sink in the kitchen food preparation area dispensed hot water; kitchen equipment was free of greasy buildup and food debris; floors were maintained free of heavy food debris and spillage; the ventilation hood filter was free of visible dust and grease buildup; and food items were properly stored in the freezer. The deficient practices had the potential to compromise food safety, increase the risk of foodborne illness, and create conditions conducive to pest infestation and physical hazards, placing residents, staff, and visitors at risk.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a copy of the discharge notice was sent to the Office of the State Long-Term Care (LTC) Ombudsman for 1 of 42 sampled residents (Resident 150). This failure had the potential to lead to resident rights not being advocated for improper discharges.

Inspectors wroteBased on observation, medical record review, interview, and document review, the facility failed to ensure a care plan was developed for the care of extensive skin dryness in the lower extremities for 1 of 42 sampled residents (Resident 119). This deficient practice had the potential to worsen skin dryness and compromise skin integrity.

Inspectors wroteBased on observation, medical record review, interview, and document review, the facility failed to ensure 1) prescribed splints were applied as ordered for 1 of 42 residents (Resident 17), and 2) a staff member did not document an antifungal ointment as administered when it was not available in the medication cart and not applied to the resident for 1 of 42 sampled residents (Resident 119). This deficient practice had the potential to result in worsening contractures due to the lack of consistent joint positioning, and to result in untreated skin dryness, worsening skin breakdown, and missed medication doses.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure dietary orders were followed for a resident receiving a chopped diet for 1 of 42 sampled residents (Resident 16). The deficient practice created potential for choking, aspiration and/or compromised nutritional status of the resident.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure expired food items were discarded from two resident refrigerators. The deficient practice had the potential for expired foods to be consumed, which could lead to foodborne illness.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain proper waste management practices by allowing 3 of 3 outdoor waste dumpsters to remain uncovered. This deficient practice had the potential to attract pests and create unsanitary conditions in the waste handling area.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a report submitted to the state agency (SA) regarding an allegation of sexual abuse was thoroughly completed for 1 of 6 sampled residents (Resident 2). The deficient practice had the potential to compromise the safety of residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dented cans and expired food products were discarded, and the kitchen floor and essential cooking equipment were cleaned and maintained in sanitary conditions. The deficient practice had the potential to expose residents to foodborne illnesses.

Inspectors wroteBased on observation, document review, record review, and interview, the facility failed to provide a working over the bed light for 1 of 24 residents (Resident 125). The failed practice had the potential to deprive the resident of using a urinal bottle independently overnight.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a clean and sanitary homelike environment by ensuring proper floor cleaning procedures were performed in 16 of 90 residents' rooms (rooms 406 to 422). The deficient practice had the potential to increase infection risk and denied the residents the right to a safe and clean homelike environment.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 24 sampled residents (Resident 69). The deficient practice had the potential to deprive the residents of concern and other residents of necessary behavioral health services.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a baseline care plan was formulated to manage the resident's care with a nephrostomy tube for 1 of 24 sampled residents (Resident 98). This deficient practice could have led to an increased risk of complications related to improper management and a lack of continuity in care.

Inspectors wroteBased on observation, record review, interviews and document review, the facility failed to: 1) implement a care plan for restorative hand splinting services to prevent contractures for 1 of 24 sampled residents (Resident 44), and 2) develop care plans for side rails, weight loss and pressure ulcer for 3 of 24 sampled residents (Residents 62, 87, and 129). The deficient practice placed the residents at risk for worsening health conditions related to contractures, injuries, malnutrition and pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to provide an ongoing program of activities designed to meet the interests of the residents for 2 of 24 sampled residents (Residents 26 and 117) and 7 unsampled residents. The deficient practice had the potential risk to cause psychosocial distress to the residents.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure an expired medication was not administered to 1 of 7 unsampled residents (Unsampled Resident 02). The deficient practice had a potential for a non-viable medication to be administered to the resident.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to place hand splint for contracture management for 1 of 24 sampled residents (Resident 44). The deficient practice placed the resident at risk to develop contractures, decrease hand functionality, and cause pain and discomfort.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a physician's order had been obtained for the presence of the nephrostomy tube, the insertion site had been monitored, and dressing changes had been scheduled for 1 of 24 sampled residents (Resident 98). This deficient practice increased the risk of infection, complications from improper management, and a lack of continuity in care.

Inspectors wroteBased on observation, record review, document review, and interview, the facility failed to assess a resident's nutritional status during a period of substantial weight loss for 1 of 24 residents (Resident 87). The deficient practice had the potential to place the resident at risk of malnutrition and dehydration, compromising the residents' health and increasing susceptibility to further medical complications.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the Dialysis Communication Record were completed, shunt or dialysis access assessments were conducted, and vital signs were obtained pre- and post-dialysis for 1 of 24 sampled residents (Resident 16). The deficient practice increased the risk of complications, including delayed detection of shunt malfunction, inadequate dialysis, hemodynamic instability, bleeding, and potential infection.

Inspectors wroteBased on observation, record review, document review, and interview, the facility failed to obtain a physician order for the use of bed side rails for 1 of 24 residents (Resident 62). The failed practice had the potential to place the resident at risk of injury such as falls, entrapment, and broken bones.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure an expired punch card of medications was discarded. The deficient practice had a potential for a non-viable medication to be administered to the resident.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure: 1. hand hygiene was performed for 1 of 24 residents (Resident 16) and enhanced barrier precautions (EBP) were implemented for 2 of 24 residents (Residents 16 and 98) and 2. hand sanitizer was available in the resident care areas. These deficient practices could have led to potential cross-contamination and transmission of infectious diseases among residents and staff.

Inspectors wroteBased on interviews, record review, and document review, the facility failed to establish and implement a baseline care plan for the care and management of an Aspen collar (neck support device to manage spinal fractures while healing) for 1 of 6 residents (Resident 3). The deficient practice had the potential to result in skin impairments for resident.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a cervical (Aspen) collar was ordered as recommended for 1 of 6 sampled residents (Resident 3). The deficient practice had a potential for resident to heal incorrectly after a cervical fracture.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1) clean and sanitary kitchen floors, walls, kitchen equipment, and ice machine in 1 of 2 nourishment rooms, and 2) temperatures were within appropriate range for a food item and reach-in freezer in 1 of 2 nourishment rooms. The deficient practice had the potential to compromise food safety, lead to cross contamination of harmful substances to food, or cause foodborne illnesses to resident.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the staff provided privacy and dignity to the residents by knocking on the door and introducing themselves prior to entering the residents' rooms for 3 of 24 sampled residents (Resident 91, 86, and 44) and 6 unsampled residents (Resident 54, 56, 76, 31, 62, and 289). The deficient practice had the potential for the residents' rights to be violated.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure there was a process in place to identify and refer residents for pre-admission screening and resident review (PASARR) level two for 3 of 24 residents (Residents 20, 80, and 85) with psychiatric diagnosis. The deficient practice had the potential to deprive residents of necessary behavioral health services.

Inspectors wroteBased on observation, interviews, record review, and document review, the facility failed to establish and implement a baseline care plan for the care and management of an ostomy (surgical opening) site for 2 of 24 residents (Resident 49 and Resident 232). The deficient practice had the potential to result in poor outcomes for residents.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure care and management of a resident's ileostomy device was included in the resident's comprehensive care plan for 1 of 24 sampled residents (Resident 232). The deficient practice placed the resident at risk for complications related to the ileostomy device.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure showers were provided as scheduled for a resident who required assistance with showers for 1 of 24 sampled residents (Resident 234). The deficient practice resulted in the resident expressing feelings of discomfort and embarrassment.

Inspectors wroteBased on observation, interviews, and document review, the facility failed to ensure medications were administered in accordance with physician orders for 1 of 24 sampled residents (Resident 44). The deficient practice had the potential to have ineffective results with medication administration.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure skin checks and skin assessments were completed and the rashes, redness, bruising, and open area on the resident's leg were reported and treated in a timely manner for 1 of 24 sampled residents (Resident 61). The deficient practice had the potential for the worsening of the resident's skin condition.

Inspectors wroteBased on observation, interviews, record review, and document review the facility failed to ensure physician orders for care and management of a 1) colostomy and 2) ileostomy were obtained for 2 of 24 sampled residents (Resident 49 and Resident 232). The deficient practice had the potential for inappropriate care and negative outcomes of ostomy sites. Resident 49 (R49) R49 was admitted on [DATE] and readmitted on [DATE] with diagnoses including non-pressure chronic ulcer of skin of other sites with fat layer exposed, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A discharge assessment dated [DATE] documented acknowledgment of colostomy site. An admission assessment dated [DATE] documented R49 had colostomy. The medical record lacked documented evidence of a care plan for colostomy. [...]