Spanish Meadows

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 4 residents (Resident #1) reviewed for PASRR. The facility failed to initiate Resident #1's Nursing Facility Specialized Services (NFSS) within 20 business days following the Interdisciplinary Team (IDT) meeting held on 04/21/2026, during which the need for a customized manual wheelchair was identified and agreed upon by the IDT. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise a comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for 1 of 3 (Resident #2) residents reviewed for care plan revisions. The facility failed to revise Resident #2's care plan to discontinue the use of floor mats to the bilateral side of the bed. This deficient practice could affect Resident #2, by placing him at risk of not receiving appropriate interventions to meet his specific needs. Record review of Resident #2's face sheet dated 7/23/2026, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. His relevant diagnoses included Unspecified Dementia (decline in memory and thinking skills), Muscle Weakness (generalized), other abnormalities of gait and mobility, and other lack of coordination. [...]

Inspectors wroteBased on interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 3 residents (Resident #1 and Resident #2) reviewed for comprehensive person-centered care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 and Resident #2 to address transfers. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 5 residents (Resident #1) reviewed for abuse and neglect, in that: The facility did not implement their abuse policy related to reporting a major injury when Resident #1 had an unwitnessed fall that resulted in multiple rib fractures, T5 vertebral fracture and lumbar transverse fracture. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but no later than 2 hours after the allegation was made, if the alleged violation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for reporting injuries of unknown origin. The facility failed to report when Resident #1 was readmitted to the facility from the hospital after having sustained a fall at the facility, of multiple fractures to the ribs, T5 vertebral fracture, and lumbar transverse process fracture. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation.2. The facility failed to label and date 4 cans of evaporated milk stored in the dry storage area.3. The facility failed to ensure that 4 oz. cups of sherbert stored in the freezer were labeled and dated. These failures could place residents who store food items in resident refrigerators and who receive meal and/or snacks from the kitchen at risk for cross contamination if consumed and food-borne illnesses if consumed.

Inspectors wroteBased on interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for 1 (Resident #54) of 2 residents reviewed for parenteral fluids. The facility failed to ensure that Resident #54's intravenous medication bag was labeled with the resident's name. The facility failed to ensure the dressing on Resident #70's peripheral intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was dated and initialed. This failure could place residents at risk for medication errors and delay in medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #23) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident # 23's oxygen was administered at the correct setting of 2 liters per minute on 1/27/2026 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #78) of 2 residents reviewed for pharmacy services. The facility failed to ensure discontinued medication prescribed for Resident # 78 were removed from medication storage room [ROOM NUMBER]. This failure could place residents at risk of receiving wrong medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure biologicals were stored in locked compartments and accessed by authorized personnel for 2 (Resident #54 and Resident #61) of 6 residents were reviewed for medication storage. The facility failed to ensure Resident #54's and Resident #61's did not have Normal Saline (a sterile mixture of water and 0.9% salt that closely matches the natural fluid balance in human blood) Prefilled syringe on top of the residents' bedside tables on 1/27/2026. This failure could place the residents at risk of having unauthorized access to prescription medications and biologicals and place residents at risk of access to hazards.

Inspectors wroteBased on observation, interview and record review the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for 1 of 2 resident refrigerators reviewed for refrigerator sanitation. The facility failed to ensure resident's personal refrigerators were maintained. Resident #90's refrigerator had 4 small individual cartons of orange juice and an individual container of gelatin that were all expired. This failure could place residents who store food items in resident refrigerators, at risk for cross-contamination and food-borne illnesses if consumed.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #68) of 8 residents observed for infection control. The facility failed to ensure CNA A changed gloves after touching the bed remote during perineal care for Resident#68 on 01/28/2026. The facility failed to implement the required contact precautions sign on the room entrance doors for Resident #54 and Resident # 70 for Transmission Based Precautions. These failures place residents at risk for healthcare associated with cross contamination and infections.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain effective pest control for 1 of 1 facility in that: The facility failed to have an effective pest control effectively treat the facility for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #2) reviewed for medical records accuracy, in that: The facility failed to document Resident #2's physician ordered weekly skin assessment from 12/26/24 through 02/27/25 for a total of 10 out of 10 skin assessments that were not documented. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 1 of 4 residents (Resident #1) reviewed for PASRR.The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to a safe, clean, comfortable, and homelike environment for 2 of 85 residents (Resident #1 and Resident #2) reviewed for safe, clean, and comfortable environment. The facility failed to recognize and repair water damage to the ceiling, in two rooms occupied by Resident #1, and Resident #2. This deficient practice failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 5 residents (R #1) reviewed for supervision. The facility failed to ensure R #1 received adequate supervision as R #1 eloped from the facility without anyone's knowledge on 11/21/24 between 2:30AM-3:00AM and was found by RT A when R #1 was reentering the facility. R #1 was out of the facility for approximately 8 minutes before RT A saw him reenter the facility. R#1 sustained an unwitnessed fall while out of the facility that resulted in a closed tripod fracture of left zygomaticomaxillary complex, a fracture of lateral orbital wall, left side, initial encounter for closed fracture, a fracture of left orbital floor, and a closed fracture of the left maxillary sinus. The non-compliance was identified as Past Non-Compliance. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 5 of 11 dietary staff (Dietary Staff M, N, P, Q, and R) reviewed for food and nutrition services. The facility did not ensure Dietary Staff M, N, P, Q, and R had a current food handlers' certificate while working in the facility's kitchen. This failure could place residents who consumed food prepared from the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to keep the kitchen and dish room walls and floors clean. 2 The facility failed to ensure the juice dispenser nozzles were clean. 3 The facility failed to ensure the ice machine was clean. These failures could place residents at risk of foodborne illnesses.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made to the State Survey Agency for 1 of 4 residents reviewed for abuse (Resident #1). The facility did not immediately report an incident involving alleged physical abuse to Resident #1 by an unknown staff member to the state agency. This failure placed resident at increased risk for delayed treatment and investigation for abuse and neglect. Findings Included: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to send a copy of the notice of transfer or discharge, and the reasons for the transfer or discharge, in writing to the resident, resident representative, or the Office of the State Long-Term Care Ombudsman at least 30 days before transfer or discharge (or as soon as practicable before transfer or discharge when the safety of the individual is endangered, the health of the individual would be endangered, the resident's health improves sufficiently to allow a more immediate transfer or discharge, an immediate transfer or discharge is required for urgent medical needs, or a resident has not resided in the facility for 30 days) for one of four residents (Resident #3) reviewed for transfer and discharge. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for 1 of 5 Residents (Resident #19) reviewed for nutritional status in that: The facility failed to initiate timely intervention to prevent weight loss when Resident #19 experienced severe weight loss of -8.2% (9 pounds) between the dates 09/27/2024 and 10/24/2024. This failure could place residents who are dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 residents (Resident #38) reviewed for respiratory care. The facility failed to ensure staff remained with Resident #38 while he received his nebulizer treatment. This failure could place residents at risk for respiratory distress.

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections, for 2 residents (Resident #14 and Resident # 69) of 30 residents that were reviewed for infection control and transmission-based precautions policies and practices, in that: The facility failed to ensure: 1. Med-Aide T did not grab Resident #69's barbeque sandwich with bare hands while being fed. 2. Med-Aide T did not feed Resident #14 a pureed diet without sanitizing her hands. These failures could place residents at risk for infection through cross contamination of pathogens.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 halls (Halls) reviewed for environment. The facility failed: 1. Failed to maintain Resident #37's room in good condition. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors with all required information for 4 (10/21/24, 10/22/24, 10/23/24, and 10/24/24) of 4 days reviewed for nurse staffing information. The facility failed to ensure the daily staffing information was posted on a form or spreadsheet, with all the required information on 10/21/24, 10/22/24, 10/23/24 and 10/24/24. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 4 of 6 halls (Hall 1-10, 11-20, 21-30, room [ROOM NUMBER], and room [ROOM NUMBER]) reviewed for environment. The facility did not address moisture damage and discoloration around vents, ceilings and walls. This failure could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to a safe, clean, comfortable, and homelike environment for 4 of 89 residents (Resident #1, and Resident #2, Resident #3, and Resident #4 reviewed for safe, clean, and comfortable environment. The facility failed to repair water damage to the wall and ceiling, in two rooms in which there were occupied by Residents #1, #2, #3 and #4. 2 residents in each room. This deficient practice failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility failed to remove narcotic medications from medication carts once the order was discontinued for Resident #1. This failure could place the residents at risk for inaccurate drug administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services in that: The facility failed to ensure foods were processed under sanitary conditions. This failure could place residents at risk of cross contamination and food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for one of one facility. The facility did not have a designated seven-day food supply for emergencies for their census of 72 residents who were served from the facility kitchen and 65 staff. The facility's failure could place the resident population at risk for not having resources identified and available to provide the necessary care and services the residents required.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program so that facility is free of pests and rodents for the facility's only kitchen and dry storage room. The facility did not maintain an effective pest control program to ensure the facility was free roaches in the dry storage room in the kitchen. These findings could place residents at risk for an unsanitary environment and a decreased quality of life.