Casas Adobes Post Acute Rehab Center

Inspectors wroteBased on clinical record review, interviews, and review of the facility's policies and procedures, the facility failed to ensure the Ombudsman's office was notified of the discharge of four residents (#150, #211, #215, and #217). The sample size was four. The deficient practice could lead to lack of post-discharge care coordination for residents. Findings Include: - Regarding Resident #217: Resident #217 was admitted on [DATE] with diagnoses that included fracture of the right lower leg, difficulty in walking, and polyneuropathy. Resident #217 was discharged on February 20, 2026. A care plan, initiated on February 8, 2026, revealed a focus for discharge to home with interventions that included coordination with the resident and the resident's family for plan of care and discharge planning. [...]

Inspectors wroteBased on clinical record review, observations, interviews, and review of the facility's policies, the facility failed to ensure 1 of 35 residents (Resident #1) received oxygen therapy in accordance with a current physician's order. The deficient practice placed Resident #1 at risk for unmonitored and potentially unnecessary medical treatment.

Inspectors wroteBased on clinical record reviews, staff and resident interviews, review of facility documentation, and review of facility's policy and procedures, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of the four sampled residents (#2 and #3). The deficient practice could result in placing residents at risk for physical harm, injury and psychological distress. Findings Include: Regarding Resident #2: Resident #2 was admitted on [DATE], with a diagnosis that included metabolic encephalopathy, vascular dementia, major depressive disorder, anxiety disorder, cerebral infarction, hearing loss, and respiratory failure. A quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating he was severely cognitively impaired. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that two residents did not abuse other residents. The deficient practice could result in residents being physically harmed. Findings Include: Past non-compliance was identified for this citation:In November 27, 2023 the facility conducted an in-service regarding behavioral care and charting that included implementation of a 24-hour report to monitor new behaviors, daily clinical meetings with discussion regarding new behaviors. In January 2024, the facility implemented new training in January 2024 training for all nursing staff and certified nursing assistants, using the Crisis Prevention Institute program training for all nursing staff and certified nursing assistants. On March 18, 2025, a nursing meeting was conducted on managing difficult behaviors and de-escalation. [...]

Inspectors wroteBased on clinical record reviews, facility documentation, interviews, and facility policies, the facility failed to ensure that medications were administered as ordered by the physician for one resident (#10). The deficient practice could result medication errors and uncontrolled pain for the residentsFindings include:On March 28, 2024 the facility implemented a Quality Improvement Plan (QIP) regarding medications administered outside of parameters. The plan included inservice/education with the nursing team on medication administration, and weekly random review of the medication administration record to verify pain medications are administered per physician orders. The QIP was reviewed by the CQI committee on June 20, 2024, August 23, 2024, November 5, 2024, January 20, 2025, and May 25, 2025. [...]

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility policy, the facility failed to failed to prevent resident to resident abuse with resident #55 being the aggressor and #44 being the victim. The deficient practice could result in further abuse of residents at the facility.

Inspectors wroteBased on clinical record review, staff and resident interviews, and a review of the facility's policy and procedures, the facility failed to protect the rights of five residents (#1, #4, #2, #5, and #3) to be free from abuse from other residents. The deficient practice could lead to further abuse and residents being placed in an unsafe environment.

Inspectors wroteBased on clinical record review, staff interviews, observation of current facility practice and review of the facility's policies, the facility failed to ensure controlled medications were provided and accounted for in accordance with professional standards for 4 residents (#52, #358, #27) The deficient practice could result in diversion of resident medication.

Inspectors wroteRegarding Resident # 1 and # 460: -Resident # 1 was admitted on [DATE] with diagnoses of Alzheimer's Disease, cognitive communication deficit, major depressive disorder, and unspecified psychosis. The care-plan initiated July 25, 2022 revealed interventions that included staff will assign seating away from other residents when agitated during meal times. A review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 2, indicating resident had severe cognitive impairment. A review of the electronic medical records revealed that on August 11, 2023 at 10:50 a.m., resident # 1 entered the dining room and saw resident #460 sitting in her favorite spot. Per the documentation, resident #1 asked resident #460 to move and as resident #460 was getting up, both residents started having a verbal altercation. [...]

Inspectors wroteBased on clinical record reviews, staff interviews, the Resident Assessment Instrument (RAI) manual, and facility policies, the facility failed to develop and complete a quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident (#47). The deficient practice could result in delayed identification of potential risks and care needs of the resident.

Inspectors wroteBased on observation, staff and resident interviews, and facility policy, the facility failed to ensure that one resident (#124) was free from accident hazards. The deficient practice could result in resident not taking their needed medications as prescribed and other residents gaining access to and taking the medications.

Inspectors wroteBased on clinical record review, interviews, and facility policy, the facility failed to ensure one resident (#84) received safe monitoring of vital signs, to include weights. The deficient practice could result in the potential for complications and the resident not receiving appropriate care and treatment.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that five residents (#1, #3, #4, #5, #6) were free from abuse from other residents. The deficient practice could result in other residents being abused.

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#99) was free from physical abuse by other residents. The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on clinical record review, staff interviews and review of facility policy and procedures, the facility failed to ensure weekly weights for one resident (#12) were completed as ordered by the physician. The deficient practice could result in resident not receiving the appropriate care and treatment they need.

Inspectors wroteBased on clinical record review, staff interviews and facility documentation, the facility failed to ensure that ongoing assessment and monitoring for complications before and after dialysis was provided to one resident (#12). The deficient practice could result in resident not provided with treatment and care according to their assessed needs.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy and procedure review, the facility failed to ensure the clinical record was accurate and complete for regarding an advanced directive one resident (#105). The sample size was 24. The deficient practice could result in residents' clinical record not being accurate and complete.

Inspectors wroteBased on clinical record review, resident and staff interviews, and review of policy and procedure, the facility failed to ensure one of 5 sampled residents (#110) was informed of the risks and benefits of a psychotropic medication prior to its administration. The deficient practice could result in resident not fully informed of the risk and benefits of the use of a psychotropic drug.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide one resident (#84) consistent restorative nursing services according to the physician order. The deficient practice could decrease resident's ability to carry out the activities of daily living.