Mi Casa Nursing Center

Inspectors wroteBased on observations, interviews, clinical record review, weather data review, and review of facility policy and procedure, the facility failed to provide adequate supervision for one resident (#109) who was assessed to have poor safety awareness and required assistance with mobility, while in the courtyard during extreme summer temperatures. Sampled residents for accidents were 3. As a result, Resident #109 remained outdoors for an undetermined period of time in temperatures reaching 103 F and sustained second-degree burns to both thighs requiring emergency medical treatment at the hospital.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the abuse policy was implemented following an incident involving staff-to-resident abuse and neglect for one resident (#70). The deficient practice could result in continued abuse, neglect, and physical or emotional harm to residents.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an incident involving staff-to-resident abuse and neglect for one resident (#70) was reported to the required state agencies. The deficient practice could result in continued abuse, neglect, and physical or emotional harm to residents.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that 1 of 2 sampled residents (Resident #1) was free from abuse by staff members (Staff #182, Staff #111, and Staff #174). The deficient practice could result in other residents being abused.

Inspectors wroteBased on record review and staff interview, the facility failed to accurately document wound treatment for one resident, which could cause a delay in required wound treatment, prolonging healing time, a possible infection, and needless pain to the resident.

Inspectors wroteBased on observation, resident and staff interviews, clinical record review, and facility policy and procedures, the facility failed to provide care and services related to constipation for one resident (#12); and failed to ensure catheter care was provided to one resident (#46) as ordered by the physician. The deficient practice could result in complications and as well as pain and discomfort.

Inspectors wroteBased on observations, staff interviews, and facility policy and procedure, the facility failed to follow proper food handling practices while distributing beverages. This deficient practice can result in contamination of resident beverages, and an increased risk of food-borne related illness. An observation was conducted on a hall with six residents on Enhanced Barrier Precautions (EBP), on April 1, 2025 at approximately 11:39 a.m. A staff member retrieved an uncovered beverage from the bedside table, and delivered the glass and meal to a resident room. Simultaneously, a second staff member returned from a resident room on the far end of the hallway, and retrieved a meal tray which contained a cup of coffee, glass of water and juice, which were all uncovered. [...]

Inspectors wroteBased on clinical records, observation, interviews, and policy review, the facility failed to ensure infection control measures were in place for one resident (#2). This deficient practice can result in transmission of preventable illness to residents and staff.

Inspectors wroteBased on clinical record review, interviews, and facility policy; the facility failed to ensure a resident (#65 ) had the right to make choices regarding the continuation of specialized rehabilitative services. This deficient practice could result in loss in autonomy for residents, regarding their care and goals. Findings Include, Resident # 65 was admitted to the facility on [DATE] for orthopedic aftercare following a fracture of the right fibula ( calf bone), with additional diagnoses of severe osteoporosis, depression, chronic pain, muscle weakness, and difficulty in walking. Orders for Physical Therapy and Occupational Therapy evaluations and treatment were written on March 7, 2025. The Physical Therapy Evaluation and Plan of Treatment signed March 9, 2025 revealed a certification period of March 9, 2025 through April 19, 2025. [...]

Inspectors wroteBased on clinical record review, staff interviews and review of policy and procedures, the facility failed to ensure a resident ' s (# 98) code status was ordered and care planned for in the clinical record. This deficient practice can result in residents receiving emergent services which are not in accordance with their wishes.

Inspectors wroteBased on clinical record review, interviews, and facility policy; the facility failed to ensure one resident (# 65) received specialized rehabilitative services according to provider orders and professional standards. This deficient practice could result in residents not reaching their highest level of well-being.

Inspectors wroteBased on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that adequate staffing was available to provide for the residents needs and care timely. The deficient practice could result in residents not receiving the care needed.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and review of facility policy and facility assessment, the facility failed to ensure it had adequate staffing to meet the needs of the residents. Review of Resident Council meeting minutes revealed the following staffing related concerns: -March 02, 2023: The Director of Nursing (DON / Staff #122) spoke to residents about staffing and the efforts to hire more staff. -October 05, 2023: concerns with Saturday and Sunday staffing -January 04, 2024: concerns with call lights being turned off only after the Residents' needs/wants are met. -February 08, 2024: Discussion of business with executive director (ED / Staff #505): regarding call lights, staff could forget. Put the call light back on, and Doing the best we can to keep up with shower schedule. -March 14, 2024: [...]

Inspectors wroteBased on review of records and staff interviews, it was revealed that the facility failed to ensure that dignity was maintained for one resident (#33). The deficient practice could result in residents not being treated in a dignified manner.

Inspectors wroteBased on clinical record review, facility documentation, and staff interviews, the facility failed to ensure that one resident (resident #47) was free from verbal abuse from an employee. The deficient practice could result in further instances of verbal abuse from an employee, creating an unsafe resident environment.

Inspectors wroteBased on clinical record reviews, interviews, facility documentation and policies, the facility failed to ensure that three residents (# 3, # 8, # 11) received consistent showers. The sample size was four residents. The deficient practice can result in resident grooming and hygiene needs not being met.

Inspectors wroteBased on clinical record reviews, resident and staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of two residents (#30 and #20) to be free from abuse by a staff and another resident. The deficient practice could result in further abuse and injury of residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation and policies, the facility failed to ensure care and treatment were provided for one resident (#10) according to professional standards of practice. The deficient practice resulted in the hospitalization of the resident.

Inspectors wroteBased on observations, staff interviews and a review of the facility policies, the facility failed to ensure that two medication carts were secured while left unattended. The deficient practice could result in unauthorized personnel having access to the medications.

Inspectors wrote-Resident #76 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included chronic systolic congestive heart failure, difficult walking, muscle weakness, chronic obstructive pulmonary disease, Type 2 Diabetes Mellitus, and morbid obesity, A Care Plan dated January 7, 2021 revealed the resident had an Activity of Daily Living (ADL) self-care deficit related to limited mobility and required extensive assistance of one staff with showering two times per week and as necessary. A quarterly MDS assessment dated [DATE] included a BIMS score of 13, which indicated the resident was cognitively intact. Review of the shower schedule revealed the resident was to receive showers on Tuesdays and Fridays. Review of the facility shower sheets for March 2022 revealed documentation that the resident received showers on three out of nine scheduled days during the month. [...]

Inspectors wroteBased on clinical record review, staff interviews, and review of the facility's policy and procedure, the facility failed to ensure timely consistent treatments were provided to one resident (#78) with pressure ulcers. The sample size was 2. The deficient practice could result in worsening of residents' pressure ulcers.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure opioid pain medication was administered as ordered for one sampled resident (#4). The deficient practice could result in residents receiving unnecessary medications.

Inspectors wroteBased on clinical record review, staff interviews, and policy reviews, the facility failed to ensure that physician orders regarding Advance Directives were obtained for one resident (#67). The sample size was 18. The deficient practice could result in residents not having physician orders regarding code status.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one of two sampled residents (#46), who remained in the facility longer than 30 days, Level I Preadmission Screening and Resident Review (PASRR) was updated. The deficient practice could result in specialized services not being provided for residents who need it.

Inspectors wroteBased on clinical record review, staff interviews and policy review, the facility failed to ensure one resident (#71) and/or their representative were provided a written summary of the baseline care plan. The deficient practice could result in residents and their representatives not being provided a copy of the baseline care plan.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#23) who was receiving a psychotropic medication was monitored for possible side effects, effectiveness, and adverse reactions. The sample size was 5. The deficient practice could result in residents receiving antipsychotic medications that may not be necessary.