Spanish Peaks Veterans Community Living Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use and maintenance of medical gas equipment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

Construction Deficiencies

Install a two-hour-resistant firewall separation.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nursing and Physician Services Deficiencies

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.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

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.

Pharmacy Service Deficiencies

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Emergency Preparedness Deficiencies

Establish policies and procedures for medical documentation.

Pharmacy Service Deficiencies

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.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

A survey for Incident #40003 and Incident #40315 was conducted on 6/18/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for abuse out of six sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #1 from physical abuse by Resident #2.Findings include:I. Facility policy and procedureThe Abuse Prohibition policy, revised January 2025, was provided by the nursing home administrator (NHA) on 6/18/25 at 3:24 p.m. The policy read in pertinent part,"The policy of this facility is to make all efforts to protect its residents from abuse."The facility will educate staff and residents on how to avoid situations that may result in an abuse incident."The facility has implemented proactive rounding to identify any potential triggers that may lead residents to respond negatively to each other and to identify stimuli such as wandering residents."This proactive approach will promote a safe environment that is free of abuse and identify triggers that will help avoid abuse."II. Incident of physical abuse on 5/19/25 by Resident #2 towards Resident #1A. Facility investigation The 5/19/25 facility investigation was received from the NHA on 6/18/25 at 11:22 a.m. The investigation documented that Resident #2 walked to Resident #1' s doorway. Resident #1 told Resident #2 she could not enter his room. Resident #2 threw hot coffee on Resident #1. The investigation documented facility staff responded to the altercation and separated the residents. The nurse completed an assessment on both residents and documented that Resident #1 had a four centimeter (cm) by four cm red area on his right elbow from the hot coffee. Resident #2 had no injuries.The facility investigation indicated physical abuse was substantiated.B. Resident #2 (assailant)1. Resident statusResident #2, age greater than 65, was admitted on 12/22/23. According to the June 2025 computerized physician' s orders (CPO), diagnoses included Alzeheimer' s disease and dementia.The 6/11/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental ..

Based on observation and staff interviews during the survey, it was determined that the facility needed to maintain one of one trans-filling of oxygen storage room ventilation per NFPA 99 - Health Care Facilities, 9.3.7.2 and NFPA 55 Compressed Gases and Cryogenic Fluids Code. This deficient practice could affect all residents and staff within the facility should a emergency occur. The following evidenced this:The oxygen trans-filling room is not mechanically ventilated correctly to maintain a negative pressure per NFPA 99 and NFPA 55. Venting the oxygen transfill room into the facility exhaust fan system ducts affects all smoke compartments within the facility.2012 NFPA 99 9.3.7.4 Trans-filling area shall be provided with ventilation in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code.9.3.7.5.3.1 Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction.9.3.7.5.3.2 Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm).9.3.7.5.3.3 Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) off the floor and adjacent to the cylinder or conta.. Based on observation, staff interview, and record review, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standards 13 and 25. This deficient practice could affect all residents, staff, and visitors should the automatic sprinkler system fail to operate promptly and effectively due to non-code-compliant maintenance. A coaxial cable not part of the sprinkler system was attached to the main sprinkler piping in the maintenance shop, which is not permitted. Failure of or damage to the main sprinkler pipe could affect water pressure for all sprinklers within all smoke compartments in the facility.NFPA 25, 2018 section 5.2.2.2 Sprinkler piping shall not be used to support components. During the facility tour, the maintenance director acknowledged the coaxial attachment to the sprinkler piping. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is one story, Type II (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1991 and is license for 120 beds. This re-certification survey was conducted on December 26, 2024. was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey.

A recertification survey was conducted from 12/2/24 to 12/5/24. Six deficiencies were cited. An Emergency Preparedness survey was conducted from 12/2/24 to 12/5/24. No deficiencies were cited. Based on observations and interviews, 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.Specifically, the facility failed to ensure appropriate hand hygiene was conducted while performing wound care.Findings include:I. Professional referenceAccording to the Cent.. Based on observations, record review and interviews, the facility failed to ensure food was prepared, stored, and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of food-borne illness in one of two dining rooms.Specifically, the facility failed to:-Ensure hand hygiene was performed appropriately while assisting residents with meals; and,-Ensure staff did not handle ready to eat food with bare hands.I. Profession.. Based on record review and interviews, the facility failed to ensure one (#4) of five residents out of 28 sample residents was free from significant medication errors.Specifically, the facility failed to:-Ensure insulin was not given when Resident #4' s blood glucose (sugar) level was below the parameter for administration;-Ensure insulin was consistently administered for Resident #4; and,-Ensure Resident #4 had physician orders for what to do if the residen.. Based on record review and interviews, the facility failed to ensure three (#65, #56 and #12) of three residents reviewed out of 28 sample residents were kept free from abuse.Specifically, the facility failed to:-Prevent a resident-to-resident altercation between Resident #65 and Resident #56; and, -Protect Resident #12 from physical abuse by Resident #65.Findings include:I. Facility policy and procedureThe Abuse Prohibition policy and procedure, d.. Based on record review and interviews, the facility failed to provide adequate supervision and an environment as free from accidents hazards as possible for two (#4 and #24) of 18 residents reviewed for accident hazards out of 28 sample residents. Specifically, the facility failed to:-Ensure scissors were not available for Resident #4 to use and prevent injury to Resident #4 when he attempted to cut his fingernails with the scissors; -Ensure essential oils were not left u.. Based on record review, observations and interviews, the facility failed to ensure a through safety assessment was completed and documented before the installation of side/bed rails for four (#70, #57, #63 and #38) of 10 residents out of 28 sample residents.Specifically, for Residents #70, #57, #63 and #38, the facility failed to:-Ensure the residents were thoroughly assessed prior to the installation of bed rails, to include the residents' medical diagnoses, conditions..