Spanish Trails Rehabilitation Suites

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.The findings are:A. Record review of R #1's face sheet revealed

she was admitted to the facility on [DATE REDACTED] with multiple diagnoses including:Parkinsonism (a chronic, progressive disease of the nervous system).Acute Respiratory Failure (failure of the lungs to inflate and deflate properly) with hypoxia (low blood oxygen level).R #1 was discharged from the facility on 09/22/25 to return home.B. Record review of R #1's 5-day Minimum Data Set assessment (a collection of assessments that determines a person's abilities and needs dated 08/25/25 revealed the following:Brief Interview for Mental Status (a test that measures a person's memory and mental abilities) resulted in a score of 15 out of 15 indicated clear memory and mental abilities.Functional Abilities rated R #1 was in need of some assistance with self-care and mobility, that she used a wheelchair to move about, she was dependent on staff to assist with toileting (moving to and from the toilet) and dressing.R #1 was noted to be incontinent (unable to control) of bowel and bladder.C. Record review of R #1's initial care plan dated 08/25/25 revealed

a plan to encourage the use of her call light, monitor for pain and provide medication as needed. R #1 is incontinent of bowel and bladder.D. Record review of R #1's daily Point of Care (a portion of each resident's Electronic Medical Record that documents Certified Nurse's Aides (CNA) interaction and care provided) revealed there was no documentation by CNA #1 or any other CNA from the evening of 08/29/25 until the morning of 08/30/25 (indicating staff did not assist R #1 with toilet or brief changing needs throughout the entire pm shift). E. Record review of the facility's incident report dated 09/05/25 revealed an investigation that CNA #1 failed to provide care to R #1 from the evening of 08/29/25 until the morning of 08/30/25. The investigation stated that CNA #1 had left R #1 in a urine-soaked brief through the night, failed to respond to R #1's call light to provide assistance and neglected her throughout the shift. The report stated the neglect of CNA #1 towards R #1 was substantiated. F. On 11/13/25 at 2:36 pm during interview with the facility administrator, she stated she had been notified of an incident of possible neglect on 08/30/25 during the early morning hours. Administrator further stated she was informed by telephone of CNA #1 neglecting care for R #1 for the entire night from 08/29/25 at about 7:00 pm until 08/30/25 at 6:00 am. Administrator stated

she interviewed staff and determined the allegation of neglect was true.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spanish Trails Rehabilitation Suites

1610 N Renaissance Blvd NE Albuquerque, NM 87107

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.The findings are:A. Record review of R #1 face sheet revealed she was admitted to the facility on [DATE REDACTED] with the following diagnoses:Heart Failure (Failure of the heart to properly move blood through the body).Parkinson's Disease (a chronic medical condition that affects motor and non-motor systems of the body).Respiratory Failure (difficulty breathing).R #1's face sheet also revealed she was discharged from the facility on 09/22/25.B. Record review of New Mexico Health Care Authority Complaint and Incident records revealed incident #2604414 dated 08/30/25 stated R #1 was neglected by a Certified Nurse's Aide (CNA) #1 on 08/30/25. C. Record review of the facility's follow-up report for incident #2604414 dated 09/05/25 revealed that CNA #1 was reported to have provided no care to R #1 on the night of 08/29/25 to 08/30/25.

The report stated R #1 was left in her room for most of the 12 hours from 08/29/25 at 6:00 pm until 08/30/25 6:00 am. The administrator began an immediate investigation on the morning of 08/30/25 by calling the facility and interviewing staff by phone. She provided her report of the incident which included only the follow up report. Administrator did not provide documentation of any interviews, of any training and of any follow-up documentation.D. On 11/13/25 at 2:45 pm during an interview, the Administrator stated she was notified early morning on 08/30/25 of an incident involving R #1 and CNA #1. Administrator stated she began an immediate investigation by telephone. Administrator stated she called and spoke with the weekend nurse supervisor and with CNA #1. Administrator determined the incident report was accurate and constituted neglect. Administrator substantiated the complaint and directed all staff to be retrained on abuse and neglect. Administrator stated she did not have any written documentation to support her investigation report or follow up training.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spanish Trails Rehabilitation Suites

1610 N Renaissance Blvd NE Albuquerque, NM 87107

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.The findings are: A. Record review of R #1 face sheet revealed she was admitted to the facility on [DATE REDACTED] with the following diagnoses:Heart Failure (Failure of the heart to properly move blood through the body).Parkinson's Disease (a chronic medical condition that affects motor and non-motor systems of the body).Respiratory Failure (difficulty breathing).R #1's face sheet also revealed she was discharged from the facility on 09/22/25.B. Record review of R #1's Minimum Data Set (MDS-a collection of assessments that describes a person's abilities and needs) 5-day admission dated 08/25/25 revealed that the MDS assessment was completed and signed by the MDS Registered Nurse on 09/04/25. C. Record review of R #1's Electronic Medical Record (EMR) between the dates of 08/22/25 to 09/22/25 failed to find a comprehensive care plan.D. Record review of R #1's care plan dated 11/12/25 revealed an initial care plan was completed on 08/22/25 with additions dated 08/25/25. E. On 11/13/25 at 1:48 pm, during an interview, the interim Director of Nursing (iDON) stated she reviewed R #1's care plan as well as R #1's EMR. iDON was unable to locate a complete comprehensive care plan. iDON confirmed that an initial care plan had been completed but the comprehensive care plan had not been completed. iDON confirmed that the facility should have completed the comprehensive care plan for R #1.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spanish Trails Rehabilitation Suites

1610 N Renaissance Blvd NE Albuquerque, NM 87107

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.The findings are:A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE REDACTED] with the following diagnoses: Metabolic Encephalopathy (a change in brain function caused by systemic metabolic disturbances, such as electrolyte imbalances, liver failure, or infections).Dysphagia (Difficulty swallowing).Moderate Malnutrition.Weakness.Dementia. Weekly Skin Assessments: B. Record review of R #2's physician orders dated 09/05/25 revealed R #2 is to have weekly skin assessments completed on Sunday by a facility licensed nurse. C. Record review of R #2's skin assessments dated 09/05/25 through 11/11/25 revealed the following: 09/05/25: No skin alterations noted.09/19/25: Skin assessment was not completed and left blank.10/06/25: Stage 2 pressure ulcer (characterized by a shallow, open wound that has broken through

the top layer of skin but not the fatty tissue beneath) with a length of 2 centimeters (cm), width of 2 cm, and

a depth of 0.5 cm was present on coccyx (lower back).10/13/25: Stage 2 pressure ulcer present to coccyx and redness to groin area.10/19/25: Stage 2 pressure ulcer present to coccyx and redness to groin area.10/27/25: Stage 2 pressure ulcer to buttocks.11/10/25: Redness in groin area.Skin assessments were not completed for each week as ordered. D. On 11/13/25 at 10:51 am during an interview with Registered Nurse (RN) #1, she stated skin assessments are supposed to be completed for residents weekly as ordered by a physician. E. On 11/13/25 at 1:40 pm during an interview with the Interim Director of Nursing (IDON), she confirmed R #2 was not receiving weekly skin assessments as ordered and should have. The IDON stated R #2 not receiving weekly skin assessments as ordered did not meet her expectations.

Swallow Study: F. Record review of R #2's Speech Therapy Notes revealed the following: 10/02/25: R #2 was seen by SLP for skilled swallow evaluation and R #2's swallow initiation was severely impaired.10/08/25: SLP has recommended R #2 complete a swallow study and informed R #2's family of recommendation.10/09/25: SLP continues to recommend swallow study for R #2.10/10/25: SLP continues to recommend swallow study for R #2.G. Record review of R #2's physician orders dated 10/20/25 revealed speech therapy swallow study for evaluation and treat for aspiration risks (as the potential for foreign materials, such as liquids, solids, or secretions, to be inhaled into the lungs, leading to serious respiratory complications) and concerns. Study was completed on 10/23/25. H. Record review of R #2's Speech Therapy progress notes dated 11/03/25 indicated the swallow study was completed on 10/23/25 with the study results verbally delivered to R #2's family by the Speech Therapist on 11/03/25. I. On 11/12/25 at 2:07 pm during an interview with R #2's son, he stated R #2 needed a swallow study completed and it took a long time for R #2 to get that done. R #2's son stated he wanted his mom to be able to eat pureed food. J.

On 11/13/25 at 1:25 pm during an interview with the SLP, she stated she requested R #2 have a swallow evaluation completed for several weeks, but it was not done until 10/23/25. The SLP stated that better communication between the facility nursing staff and therapy would have been beneficial so R #2's swallow study could have been completed sooner than it was. K. On 11/13/25 at 1:42 pm during an interview with IDON, she confirmed R #2's swallow study orders should have been placed sooner than 10/20/25 due to

the SLP requesting a swallow study being completed several weeks earlier.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Spanish Trails Rehabilitation Suites

1610 N Renaissance Blvd NE Albuquerque, NM 87107

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

and diarrhea and should be checked and/or changed often during a shift. RN #1 also stated she is aware that R #2's brief is not checked or changed as frequently as it should be because R #2 began to develop redness in her groin area which is indicative of being in a soiled brief for extended periods of time.

N. On 11/13/25 at 1:39 pm during an interview with the Interim Director of Nursing (IDON), she stated usually MASD (Moisture-Associated Skin Damage) in the groin area is caused by incontinence and she would expect R #2's brief to be checked/changed every two hours and as needed. The IDON confirmed R #2 should have been changed more than one to two times per 24 hours, and that did not happen.

Event ID:

Facility ID:

If continuation sheet