Estates of Spanish Lake, The

In the surveyor’s words

From the most serious findings on record at Estates of Spanish Lake, The, in the surveyor’s own words.

• Immediate jeopardy, widespreadF888Jan 14, 2022

  Based on observation, interview and record review, the facility failed to meet the requirement of staff vaccination for 100% of their 82 facility-employed staff to either have one dose of a COVID-19 vaccine, or a pending exemption or approved exemption within 30 days of CMS' vaccination rule being in effect. As of the first date onsite at the facility, on [DATE], 23 of 82 facility-employed staff had not received their first dose of the COVID-19 vaccination and/or requested an exemption or temporary medical delay. This equals 28.048% of facility-employed staff who have not met the requirement for staff COVID-19 vaccinations. […]

• Immediate jeopardy, patternF584Aug 24, 2023

  Based on observation, interview and record review, the facility failed to maintain temperatures in resident accessible areas at or below 81 degrees and/or meet the comfort needs of residents for one of two resident floors. On [DATE], temperatures in the facility on the second floor exceeded 81 degrees Fahrenheit (F) up to 92.3 degrees F in resident use areas and resident rooms. Resident #1, whose diagnosis includes seizure disorder, sat by the air conditioning unit and reported he/she was hot and uncomfortable. His/Her room temperature registered 91.2 degrees F. Resident #2, whose diagnoses included asthma/chronic obstructive pulmonary disease (COPD)/chronic lung disease and seizure disorder, was in his/her room where the air blew out and the code flashed E8. […]

• Immediate jeopardy, patternF600Jan 14, 2022

  Based on observation, interview and record review, the facility failed to ensure residents were free from abuse, when the facility failed to follow their policy, state and federal regulations by failing to develop an appropriate care plan upon admission to closely monitor Resident #23's behaviors that included a history of violent outbursts, being physically aggressive, threatening staff and residents over cigarettes, using racial slurs, and punching holes in the walls. On 1/2/22, the facility failed to ensure staff were present on the behavioral unit when a verbal and physical confrontation occurred involving Resident #23, Resident #26 and Resident #1, failed to immediately intervene once they were aware of the physical altercation, and failed to ensure staff knew how to use the intercom… […]

• Immediate jeopardy, isolatedF689Jan 25, 2024

  Based on observation, interview, and record review, the facility failed to ensure a safe environment for one resident (Resident (R) 203), who resided on a secured unit, out of a total of 14 residents reviewed for accidents. The facility failed to ensure R203, who had a known history of drinking hand sanitizer and making statements indicating he/she wanted to kill himself/herself, did not have access to hand sanitizer and antimicrobial wipes. R203 reported he/she obtained and drank hand sanitizer on the night of 01/17/24 and that he/she obtained the hand sanitizer from the unit. Direct care staff were unaware of R203's previous behaviors or how to interact with R203 related to his/her behaviors. […]

• Actual harm, isolatedF600Jan 25, 2024

  40902 Based on record review, staff interview, and facility policy review, the facility failed to ensure residents were free from abuse, for seven of nine sampled residents (Resident (R) 4, R77, R84, R30, R62, R350, and R83) reviewed. Examples include: R4 struck R77 in the mouth, resulting in a cut to the inner right lip where the resident's tooth hit it, a contusion to the upper lip and a transfer to the hospital for assessment. In a second incident, R4 pulled up the shirt of one resident with impaired decision making and cognition related to intellectual disability (R84), reaching underneath R84's shirt and touching his/her chest. In a third incident, staff entered the hallway and observed R4 being punched in the face by R30 after R4 spit on R30 and threw a cup of juice on him/her. […]