Spanish Trails Wellness & Rehabilitation

Inspectors wroteBased on record review and interview, the facility failed to complete a Significant Change (a major decline or improvement in a resident's physical or mental condition that is not self limiting, affects more than one area of health status, and requires review and potential care plan revision) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for 1 (R #3) of 1 (R #3) resident, when: R #3 began receiving hospice services while in the facility as ordered by a physician. This deficient practice could likely result in the residents not receiving the appropriate care and services they need.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards for 2 (R #1, and R #5) of 2 (R #1, and R #5) resident reviewed medication errors when staff failed to:1. Ensure that an order was obtained before administering routine blood sugars checks for R #5.2. Ensure medications were available for administration for R #1 and R #5.3. Ensure Medication Administration Record is updated/corrected when medications are not administered for R #5. If the facility fails to administer medications as prescribed by the physician, then residents are not likely to receive the therapeutic value of medications prescribed, and if lab results are not relayed to the physician, then the physician is unable to properly monitor and assess the physical condition of the resident.

Inspectors wroteBased on record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #2) of 3 (R #1, R #2, and R #3) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.

Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 (R #2) of 1 (R #2) resident reviewed for care plans. This deficient practice is likely to result in staff being unaware of the current and actual needs of the residents. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents.

Inspectors wroteBased on interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (R #4) of 1 (R #4) resident reviewed for accidents and supervision when: The facility failed to ensure that a resident that need supervision/assistance was accompanied to a doctor's appointment and not left unattended for an extended period of time. This deficient practice is likely to make residents feel helpless and ignored, and possible experiencing avoidable accidents and/or injuries. A. On 02/06/26 at 1:20 PM during an interview with R #4's brother he stated. I got a phone call from the doctor's office asking who was supposed to pick my brother up, and they were concerned about his safety. He (R #4) had a stroke (medical emergency that occurs when blood flow to part of the brain is blocked or sudden bleeding in the brain) this was a follow-up appointment. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents are free of a significant medication error for 1 (R #1) of 1 (R #1) resident reviewed. The facility failed to administer a prescribed anticoagulant, Warfarin, (medication used to control blood sugar levels) for three consecutive doses. This failure occurred despite the resident's high-risk clinical status for stroke and systemic embolism.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure 1 (R #1) of 1 (R #1) resident reviewed received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by not ensuring that staff received the appropriate training to mitigate resident aggressive behaviors. This deficient practice likely resulted in R #1 attacking an Certified Nurse Assistant (CNA), resulting in R #1 falling.

Inspectors wroteBased on record review, and interview, the facility failed to provide quality care that meets professional standards for 1 (R #2) of 2 (R #'s 1 and 2) residents when the staff failed to:Follow physician orders for weekly skin assessments. Obtain a physician's order and complete a swallow study (a test that evaluates how well your throat and esophagus function while swallowing) without delay after recommendations by the Speech Language Pathologist (SLP). These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on record review and interview, the facility failed to provide daily care needs including brief changes for 2 (R #'s 1 and 2) of 3 (R #'s 1, 2, and 3) residents reviewed for care needs. Failure to provide for residents' daily care needs can result in residents feeling dirty, unclean and ashamed.

Inspectors wroteBased on record review and interviews, the facility failed to protect 1 (R #1) of 1 (R #1) resident reviewed from neglect. The facility failed to ensure that a resident was provided care and assistance by staff during the night of 08/29/25. Failure to prevent neglect of residents can result in residents' frustration and fear of being left alone and not assisted with care needs.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly document the investigation of neglect of for 1 (R #1) of (R #1) resident reviewed for abuse or neglect. The facility was notified of an instance of neglect and investigated the allegation of neglect but failed to document the completed investigation. Failure to document reported investigations could result in confusion and misunderstanding of investigation results.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan for 1 (R #1) of 3 (R #1, #2, and #3) residents. Failure to develop a comprehensive care plan could result in residents not receiving optimal care that meets their daily needs and preferences.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow physician orders for 1 (R #1) of 1 (R #1) resident. This deficient practice is likely to result in residents receiving care that is not medically appropriate.

Inspectors wroteBased on record review and interview, the facility failed to accurately document the changing conditions of 1 (R #3) of 3 (R #2, 3, 4) residents. The facility documented conflicting resident daily assessments for R #3's conditions. This deficient practice is likely to result in resident care and care plans being confusing and inadequate.

Inspectors wroteRepeat Deficiency from 03/10/25 Based on record review and interview, the facility failed to notify the resident's provider or Emergency Contact (EC) of the resident's change in condition for 1 (R #30) of 2 (R #15 and #30) residents reviewed for changes of condition (new or worsening symptoms). If the facility is not notifying the provider and EC when the resident experiences a change of condition, then both would be unable to make decisions related to treatment and advocate for the resident's care.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 6 (R #'s 1, 54, 55, 70, 73, and 79) of 6 (R #'s 1, 54, 55, 70, 73, and 79) residents reviewed when staff failed to: 1. Conduct a quarterly care plan meeting as required for R #'s 1, 54, 55, 70, and 73 in accordance with their admission date and Minimum Data Set (MDS) assessments. 2. Update R #79's plan of care to include resident and resident's family assistance with colostomy (surgery to create an opening for the colon (large intestine) through the abdomen). These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Food was stored appropriately and not left open to air in the kitchen freezer. 3. Food items were not expired in the kitchen and dry storage. These deficient practices are likely to affect all 117 residents listed on the resident census list provided by the Administrator on 04/21/25 and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on interview and record review, the facility failed to promote care with dignity and respect for 1 (R #1) of 1 (R #1) resident reviewed for residents' rights by walking into the room to speak to a staff member who's performing personal care on a resident. This deficient practice is likely to result in residents feeling as if they were unimportant and not having privacy.

Inspectors wroteBased on record review and interview, the facility failed to complete a timely assessment for 1 (R #15) of 2 (R #15 and #30) residents reviewed for hospitalizations and had a sufficient change (a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions) within 14 days of the significant event. This deficient practice could likely result in residents not receiving the care and assistance needed.

Inspectors wrotePast non-compliance Based on interview and record review, the facility failed to prevent misappropriation of resident money when debit card was used by unauthorized parties for 1 (R #47) of 2 (R #47, and 156) residents reviewed for exploitation (the fact of making use of a situation to gain unfair advantage for oneself). This deficient practice is likely to cause residents to feel unsafe, experience anger and frustration along with dealing with debit card theft, and fraud.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure that 1 (R #47) of 1 (R # 47) resident reviewed for skin issues received care and treatment that met the resident's needs by not documenting, assessing or treating residents skin issue. If the facility fails to provide the highest level of care to it's residents, then residents are likely to experience a decline in their wellbeing.

Inspectors wroteBased on record review and interview, the facility failed to notify the facility providers (Nurse Practitioner, Physician) and the resident's Emergency Contact (EC), when a resident experienced an unwitnessed fall while also prescribed a blood thinner for 1 (R #2) of 1 (R #2) resident reviewed for a change of condition. This deficient practice is likely to result in a delay in treatment or inadequate treatment.

Inspectors wroteBased on record review and interview, the facility failed to provide a quality care that meets professional standards for 1 (R # 2) of 1 (R #2) resident when the facility failed to obtain physician orders prior to providing oxygen (O2). If the facility is providing O2 without physician orders, then residents are likely to not receive the therapeutic benefits and care needed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food preference was followed for 1(R #1) of 1 (R #1) resident observed for dining. This deficient practice could result in R #1 not eating his meals and losing weight. A. On 03/06/25 at 10:46 am, during interview with R #1, she stated I can't eat any vegetables, gravy, chocolate, mashed potatoes, corn dog, chicken salad, and mushrooms and they keep giving me vegetables, gravy, chocolate, mashed potatoes, corn dog, chicken salad, and mushrooms. B. On 03/06/25 at 12:45 pm, during an observation of R #1's lunch plate, mashed potatoes were on R #1's plate which she had not eaten. C. Record review of R#1's meal ticket revealed red bold writing, can't eat all vegetables, gravy, chocolate, mashed potatoes, corn dog, chicken salad, and mushrooms. D. [...]

Inspectors wroteBased on record review and interview, the facility failed to conduct an in-depth investigation and correct the grievance allegation for 1 (R #34) of 1 (R #34) residents reviewed for the outcomes and resolutions of their grievances. This deficient practice could likely result in the facility not considering the needs of the residents or adequately resolving their grievances and lead to a decrease in resident quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 2 (R #35 and #90) of 2 (R #35 and #90) residents reviewed when staff failed to conduct a quarterly care plan meeting as required. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, record review and interview, the facility failed to meet professional standards for 2 (R #7 and #122) of 2 (R #7 and #122) residents reviewed when staff failed to: 1. Ensure labs were reviewed and critical results conveyed to the medical provider in a timely manner. 2. Ensure medications were available for administration. If the facility fails to administer medications as prescribed by the physician, then residents are not likely to receive the therapeutic value of medications prescribed. If the facility fails to relay lab results, then the physician is unable to properly monitor and assess the physical condition of the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5 percent (%) when staff performed six medication errors out of 26 opportunities for 2 (R #118 and 122) of 6 (R #66, 89, 90, 118, 122) residents reviewed during medication administration. This resulted in a medication error rate of 23.08%. If residents are not informed of the medications they are receiving, then residents do not have the ability to accept or reject the medications being administered.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure meals were served at a safe and appetizing temperature for 4 (R #34, #43, #72, and #84) of 4 (R #34, #43, #72, and #84) residents reviewed for meal quality. This deficient practice is likely to lead to foodborne illnesses if staff do not maintain food temperatures outside of the danger zone [between the temperatures of 45 degrees (°) Fahrenheit (F) and 135° F; the temperature range in which food-borne bacteria can grow.)

Inspectors wroteBased on observation and interview, the facility failed to assure staff followed infection control practices for 2 (R #118 and #122) of 2 (R #118 and #122) residents when Registered Nurse (RN) #2 did not wash his hands before and after he administered medications to residents. This deficient practice has the potential to spread infectious diseases between residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to consider and provide the preferences of (R #81) of 1 (R #81) residents reviewed when the facility failed to assist R #81 with purchases that reflected R #81's interests after R #81 asked the facility staff for assistance. These deficient practices are likely to result in the resident's personal choices not being honored.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide food to accommodate resident preferences for 1 (R #225) of 1 (R #225) residents observed for food preferences. This deficient practice is likely to result in resident frustration and weight loss due to the resident not receiving and eating their preferred diet.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a therapeutic diet as ordered by a Physician for 1 (R #64) of 1 (R #64) residents reviewed during random dining observations. If the facility fails to provide a diet as ordered, then residents are likely to experience weight loss due to not receiving their prescribed nutritional caloric intake.

Inspectors wrotePAST NON-COMPLIANCE Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance with toileting and brief changes for 1 (R #1) of 1 (R #1) resident reviewed. These deficient practices have the potential to affect the dignity and health of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury; skin damage which results from unrelieved pressure on the body) for 1 (R #128) of 1 (R #128) residents reviewed when staff failed to: 1. Timely identify the community acquired wound, monitor for changes in the wound, and notify the physician the wound was worsening for R #128. 2. Updating wound care treatment orders in relation to R #128's pressure ulcer becoming worse. This deficient practice likely resulted in R #128's pressure ulcer worsening and developing poor health outcomes. This deficient practice is also likely to lead to residents developing pressure ulcers and wounds worsening.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Maintain the ice machine in a manner to prevent contamination and foodborne illness, - Perform hand hygiene and to change gloves as often as necessary to avoid cross contamination, - Protect clean dishes and plastic ware to prevent contamination, - [NAME] and serve pureed food at the appropriate temperatures to prevent the growth of foodborne pathogens and illnesses, - Allow dishes to air dry completely before use or storage, - Keep staff food separated from resident food, - Utilize hair restraints and beard guards in a manner which restrained all hair while in the kitchen, - Properly store open food with labels and dates to prevent cross contamination and outdated usage, - Store scoops for bulk bins in a manner to prevent cross contamination, - [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 3 (R #45, #60 and #320) of 2 (R #45, #60 and #320) residents reviewed when staff failed to: 1. Update the care plan to include Activities of Daily Living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) care for R #45 and #60. 2. Update the care plan to include activity preferences for R #60. 3. Inform the Power of Attorney (POA) of changes in care plan to include new behaviors for R #320 These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers for 2 (R #'s 45 and 60) of 2 (R #'s 45 and 60) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff did not leave medications on the resident's bedside table. These deficient practices had the potential to impact the health of all residents on the 400 hall, and could likely result in residents taking a medication that is not intended for them or taking more than the dose prescribed.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff followed nutritionally calculated recipes for pureed diets. Failure to follow recipes that have been approved by the Registered Dietician (RD) has the potential for food not to meet the nutritional requirements of the residents. This failure had the potential to affect all six residents who ate pureed meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control practices for 4 (R #'28, #45, #60, and #79) of 4 (R #28, #45, #60, and #79) residents identified during random observation when the facility failed to: 1. Ensure nasal cannulas [a device that delivers extra oxygen (O2) through a tube and into your nose] were labeled with the date when they were changed for R #28 and #79. 2. Ensure Continuous Positive Airway Pressure (CPAP; used to treat sleep apnea) equipment was stored appropriately for R#45 and #60. 3. Ensure R #60's nebulizer (device for producing a fine spray of liquid, used for example for inhaling a medicinal drug) was stored appropriately. This deficient practice could likely result in the spread of contagious and resistant illnesses to other residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide assistance devices for 1 (R #13) of 1 (R #13) residents reviewed during random observation. This deficient practice are likely to result in residents being unable to perform activities of daily living which could likely result in consuming less food.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the rights of 1 (R #1) of 2 (R #1 and #2) residents when the facility administered medication to reduce the resident's sexual feelings and desires. This deficient practice could cause residents to feel repressed and unable to interact in intimate relations.

Inspectors wroteBased on record review and interview, the facility provided an anti-depressant (a medication that treats the symptoms of depression and sadness) medication for 1 (R #1) of 2 (R #1 and #2) at an excessive dose and without adequate indications for its use. This deficient practice is likely to result in resident being overmedicated leading to greater risk of developing side effects such as drowsiness, weight gain, nausea, fatigue.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff completed accurate medical records for 9 (R #s 19, 31, 73, 91, 92, 200, 202, 203, and 247) of 9 (R #s 19, 31, 73, 91, 92, 200, 202, 203, and 247) residents reviewed for the following: 1. Activity participation logs were not completed for R #'s 19, 31, 73, 91, 92, 200, 202, and 203. 2. Medication administration notes and pertinent admission notes were not documented for R #247. This deficient practice is likely to result in staff not knowing of resident daily activities and preferences, or why a resident requires medications and pertinent admission information.