Casa Mora Rehabilitation and Extended Care

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program to mitigate and prevent the spread of infection related to: failing to provide an anti-parasitic medication to one (#2) of three residents being treated for scabies, failed to ensure staff were accurately educated on the implementation of transmission-based precautions, and ensure personal protective equipment (PPE) was readily available for one (#380) of three sampled rooms posted with transmission-based precautions.

Inspectors wroteBased on record review, interviews and review of the facility policy, the facility failed to thoroughly investigate allegations of abuse, neglect and misappropriation of property for one resident (#1) of two residents reviewed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure Advance Directives were properly documented in the medical record for three residents (#2, #12, and #13) out of three residents reviewed for code status. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury or death to Residents #2, #12, and #13 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure Advance Directives were honored and properly documented in the medical record for three residents (#2, #12, and #13) out of three residents reviewed for code status. Resident #2 received cardiopulmonary resuscitation (CPR), despite his preference to be a Do Not Resuscitate (DNR) code status, after he was found unresponsive by staff on [DATE]. Staff failed to inform the Emergency Response Team (EMT) of the DNR code status and CPR was begun at the facility and conducted during transport and care in the emergency room (ER). This failure created a situation that resulted in a worsened condition and the likelihood for serious injury or death to Residents #2 and resulted in the determination of Immediate Jeopardy on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide supervision to prevent elopement for one resident (#1) out of four residents reviewed for elopement risk. On 7/26/25 Resident #1 exited the facility at 6:30 p.m., unnoticed by staff. Resident #1 was mildly impaired, confused, and had an electronic monitoring device in place. Resident #1 followed another resident out the door which was remotely opened by staff. The door alarm was disabled by a resident who was aware of the code after Resident #1 triggered the alarm upon exit. Resident #1 walked approximately 0.2 miles to a hospital near the facility and was returned with assistance of law enforcement to the facility at 9:00 p.m. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow the established facility grievance policies and procedures related to investigation and follow-up for resident grievances for five residents (#16, #17, #18, #19, and #20) out of six residents sampled.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed 1) to properly store and secure medications for two residents (#8 and #9) out of twenty resident sampled, and 2) to properly secure medications out of reach of residents in one nursing station (200) out of four nursing stations.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to report an incident of elopement related to lack of supervision for one Resident (#1) out of four residents reviewed for elopement.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure consistent podiatry services were provided to one (#3) of ten sampled residents.

Inspectors wroteBased on record review, review of facility's policies and procedures, resident and staff interviews, the facility failed to protect the residents' rights to be free from neglect. The facility failed to ensure timely evaluation of resident's condition, and immediate physician notification in the presence of an acute change in condition to avoid physical harm for 1 (Resident #98) of 4 residents reviewed for coordination of care. Resident #98 had a diagnosis of Atrial Fibrillation (Type of irregular heartbeat) with long term use of anticoagulant (blood thinner) medication with a potential side effect of bleeding. On 8/28/23 Resident #98 underwent multiple dental extractions, arranged by the facility. [...]

Inspectors wroteBased on record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement processes to ensure effective coordination between staff, physicians, and outside medical providers in accordance to professional standards of care to meet the needs of 4 (Residents #98, #9, #99, and #110) of 4 residents reviewed. Resident #98 had a diagnosis of Atrial Fibrillation (Type of irregular heartbeat) with long term use of anticoagulant (blood thinner) medication with a potential side effect of bleeding. The facility arranged an appointment for multiple dental extractions for Resident #98. The facility did not ensure coordination between facility staff, the dentist, or the attending physician related to the use of anticoagulant (Eliquis) before and after the dental extractions. [...]

Inspectors wroteBased on record review, resident and staff interview the facility administration failed to use its resources effectively to protect residents' rights to be free from neglect, in that they failed to show effective coordination of care to ensure 1 (Resident #98) of 4 sampled residents received care and services in accordance with professional standards of care. Resident #98 had a diagnosis of Atrial Fibrillation (abnormal heart rhythm) with long term use of anticoagulant (blood thinner) medication. On 8/28/23 Resident #98 underwent multiple dental extractions, arranged by the facility. There was no documentation of coordination with the dentist and the physician related to the use of the blood thinner before and after the dental extractions. [...]

Inspectors wroteBased on record review, resident and staff interview, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program that recognize quality deficiencies in the areas of neglect and effective coordination of care related to the use of anticoagulant (blood thinner). Resident #98's medication regimen included long term use of Eliquis (anticoagulant). On 8/28/23 the facility arranged for multiple dental extractions for Resident #98 without documentation of coordination with the dentist or the attending physician related to the use of anticoagulant before and after the extractions. Resident #98 experienced uncontrollable bleeding from the extractions resulting in a transfer to an acute care hospital. Resident #98 was critically ill, required a blood transfusion and was admitted to the Intensive Care Unit. [...]

Inspectors wroteBased on observation, record review, review of policies and procedures, and staff interviews, the facility failed to implement an activity program to meet the needs of 3 (Resident #112, #114, and #136) of 3 sampled residents dependent on staff for physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a functioning call light system on 2 (room [ROOM NUMBER] and #277) of 32 rooms observed.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to provide necessary maintenance and repairs to maintain a safe, clean, and homelike environment for residents on 3 (300 wing, South, and North wing) of 4 wings observed.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Resident #31 and #184) of 5 dependent residents reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on observation, clinical record review and staff and resident interview, the facility failed to provide the appropriate monitoring and application of splints for 1(Resident #24) of 1 resident reviewed with a limitation in range of motion (ROM). This had the potential to cause pain and worsening of the contracture.

Inspectors wroteBased on observation, review of facility policy and procedure, and staff interview, the facility failed to store respiratory equipment in a sanitary manner for 1(Resident #489) of 2 residents reviewed for respiratory care. This had the potential to cause respiratory infections in compromised residents.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure the environment was free from odors in two units (Hall 300 and Hall 200) of four units related to sewer gas smells in Hall 300 and cigarette smoke smell in the Hall 200, for four days (3/21/22, 3/22/22, 3/23/22 and 3/24/22) of a four day survey.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for one resident (#78) of three residents sampled for Transmission Based Precautions.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide needed care and services for treatment of a wound for one resident (#140) of three residents sampled for skin conditions.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide respiratory care in accordance with professional standards of practice for two residents (#140 and #161) of four residents sampled for respiratory care.

Inspectors wroteBased on observation, staff interviews and kitchen records, the facility did not ensure it maintained a High Wash temperature dish machine according to specifications during one of five days observed (1/4/2021) and thirty of thirty-four days reviewed regarding not reaching the required temperature of 160 degrees F for the wash cycle.

Inspectors wroteBased on observation, record review, and interview the facility did not ensure that the medication error rate was less than 5%. The facility medication error rate was 36.36% related to medications being passed to 2 (Resident #151 and Resident #159) out of 5 residents sampled more than 2 hours after the time ordered.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain drugs and biologicals used in the facility in a safe and secure manner in one of eight medication carts.