Mi Casa Nursing Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Emergency Preparedness Deficiencies

Create arrangements with other facilities to receive patients.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

Meet other general requirements that are deficient.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Based 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).Â

Based 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.Â

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Based 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: a resident discussed with the ED earlier in the day about concerns discussed in last month's resident council meeting, which she learned have not been addressed, by neither the ED nor the DON. -May 09, 2024: Old business discussed on March, 2024 still unresolved. New concerns included no showers, short staffed, no staff on weekends, staff idle at the nurse's station. Additionally, one resident reported he cannot get "a hold of anyone, when he has difficulty breathing". Another resident was revealed to state that night shift took too long to change and put back to bed. Review of the facility's Grievance Log and Concern and Comment Forms revealed: -January 09, 2023: a resident revealed that one time she waited over an hour to have someone help her off the bedside commode, and that she had to call the front desk. -February 08, 2023: a resident revealed that her call light was on from 8:00 PM to 10:30 PM, when she was given her night time medications that should have been given at 8:00 PM. The Investigation Findings on the form revealed that an In-Service was given for staff to monitor call lights closely. Direct Care Staffing was reviewed via the daily staff posting, staff schedule, and staff punch logs, for the date of March 16, 2023, and revealed the following staff for the whole facility. The census for that day was 116 residents. Day: -Registered Nurses (RN): 3 -Licensed Practical Nurses (LPN): 2 -Certified Nursing Assistants (CNA): 4 Evenings: -CNA: 6 Nights: -RN: 1 -LPN: 4 -CNA: 6 An observation was conducted on December 30, 2024, on the 300 hall unit. At 1:19 AM, a call light was observed to be on for room 327. A nurse was observed at the nurse's station, and was working at a computer. There were no care staff observed on the floor. The observation continued, and at 1:30 PM, a staff member entered the hall, and wheeled a different resident from another room out of the hallway in a wheelchair. The call light for room 327 was still unanswered. The observation continued. At 1:48 PM, the call light was still unanswered. The floor nurse was observed to tell a nurse from a different hallway that he is going on

Based on review of records and staff interviews, it was revealed that the facility failed to ensure that dignity was maintained for one resident (#33). Findings include: Resident #33 was readmitted to the facility on April 6, 2023 with diagnoses that included acute and chronic respiratory failure with hypoxia, Type 2 diabetes mellitus with diabetic neuropathy, and chronic obstructive pulmonary disease. Progress note dated August 9, 2023 indicated resident #33 neuro was alert and oriented x3 and psych was calm cooperative. Review of the Minimum Data Set (MDS) assessment dated October 3, 2023, revealed a Brief Interview of Mental Status (BIMS) of 15. The MDS also indicated the resident did not have any behavior or mood issues. The assessment also revealed that resident #33 needed substantial/maximal assistance with toileting. The facility 5-day investigation report dated August 11, 2023 revealed on August 11, 2023, resident #33 was upset and indicated a Certified Nursing Assistant (CNA) staff #313 was "very mean" to the resident. Resident #33 reported her call light was turned off by the CNA staff #313 and care had not been provided. Resident reported she was upset to the CNA staff #313. CNA informed resident that she was unable to wake resident. Resident and CNA started arguing per report and while resident #33 was speaking CNA staff #313 put her hand up to "shoosh" the resident. Resident #33 reported that the CNA did not respect her. CNA #313 stated to resident "you better watch your tone as I did nothing wrong" and further stated to the resident "you better respect me as your CNA because I am trying to help you." The report further indicated that CNA staff #313 got another CNA staff #507 to help her with the care of the resident but would not allow CNA #507 to take over the care of resident. In a handwritten statement by CNA staff #313, dated August 11, 2023 she reported she asked resident #33 to watch her tone because she did nothing wrong to resident. CNA staff #313 indicated she got another CNA staff #507 to be a witness while she changed the resident to avoid any allegations. Employee file contained a Corrective Action Form for CNA staff #313 dated August 16, 2023 regarding the incident on August 10, 2023. The form described the incident which indicated while producing care to a resident, CNA #313 rudely told the resident #33 to stop talking while the resident was expressing her concern for the delayed care. The form was signed by the DON and CNA staff #313. During a telephone interview with CNA staff #313 on December 31, 2023, she stated resident put call light on and when she went to the room, the resident was asleep and she was unable to wake the resident so she turned the call light off. CNA staff #313 stated a few hours later call light was back on and resident was angry and yelling. CNA informed resident she tried waking her but that resident not easy to wake due to loud CPAP machine. CNA also stated that resident had a history of beha

Based 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. Findings include: -Resident # 47 was admitted on December 21, 2022 with a diagnosis of encounter for orthopedic aftercare following surgical amputation, anxiety disorder, muscle weakness, cognitive communication deficit, bipolar disorder, depression. Then, discharged on January 11, 2023. A five-day admission MDS (minimum data set) dated December 28, 2022 revealed a BIMS (Brief Interview for Mental Status) score of 10, indicating that Resident #47 had moderate cognitive impairment. The MDS also revealed that the resident required maximal assistance to complete lower body dressing and putting on/taking off footwear. Indicating that a helper does more than half of the effort, assisting with lifts or holds trunk or limbs. Resident #47's progress notes revealed no evidence of documentation regarding the incident that occurred on January 1, 2023 at approximately 6:55PM. An interview was conducted on December 31, 2024 at 8:27AM an accounting clerk (Staff #25) were the personnel record of the perpetrator (previous employed certified nursing assistant/CNA/Staff #510) was reviewed. The review revealed two employee statements completed by the perpetrator dated November 8, 2022 and November 9, 2022, a corrective action form of a 2nd written warning with the date of November 10, 2022, an incomplete employee statement regarding the perpetrator's behavior dated December 30, 2022, and, a personnel action form of voluntary termination dated January 10, 2023 with an employee statement from the perpetrator. It was determined with Staff #25 that there was no documentation of a corrective action form of a 1st written warning, and as well as no other documentation of the incomplete employee statement dated December 30, 2022 regarding inappropriate behavior of the perpetrator. A review of the perpetrator's (previous employed CNA/Staff #510) corrective action form of a 2nd written warning dated November 10, 2022 revealed that the perpetrator continued to refuse their assignments verbally stated that she was not going to do the new room assignments and walked away from the station. The form also revealed that the perpetrator made her co-workers feel intimidated and uncomfortable to work with, and that the perpetrator creates their own assignments. A phone interview with the witness (a previous employed certified nursing assistant/Staff #509) on December 31, 2024 at 9:46AM but were unsuccessful as she did not respond or return the call. An interview was conducted on December 31, 2024 at 9:49AM with a previous employed licensed practical nurse (LPN/Staff #508), where staff #508 stated that the perpetrator could be very inappropriate and required consistent re-

Based 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. Findings include: Resident # 3 was admitted to the facility on May 15, 2024, with diagnoses that included atrial fibrillation, dysphagia, morbid obesity, and chronic pain syndrome. A care plan with the revision date of October 5, 2023 revealed the resident's preference to not have a male assist with shower or baths. The quarterly Minimum Data Set (MDS) dated December 4, 2024 revealed a Brief Interview Mental Status (BIMS) score of 14 indicating the resident is cognitively intact. The MDS also indicated the resident has complete dependence for showers and shower transfers. A Weekly Skin Integrity Data Assessment dated January 1, 2025 indicated the resident had a rash on the arms and groin. A progress note dated June 9, 2024 revealed resident refusal of a shower and was advised that another shower would not be offered until his next shower day. A progress note dated June 13, 2024 revealed the resident requested a day time shower, but "it was explained to him that he would be showered this evening". The resident also requested to have a female Certified Nurse Assistant (CNA) shower him, and declined the offer for a shower with the male CNA twice. A progress note dated August 6, 2024 revealed the resident was educated regarding his refusal of a shower. The interventions and task reports for May 2024 through December 2024 provided by the facility revealed the resident bath days were Saturday and Wednesdays. Based on the documentation received by the facility, the following was revealed: - May 2024, 8 of 9 ordered bi-weekly showers were missed. -June 2024, 8 of 9 ordered bi-weekly showers were missed. -July 2024, 9 of 9 ordered bi-weekly showers were missed. -August 2024, 6 of 9 ordered bi-weekly showers were missed. -September 2024, 1 of 7 ordered bi-weekly showers were missed. -October 2024 ,3 of 9 ordered bi-weekly showers were missed. -November 2024 ,2 of 9 ordered bi-weekly showers were missed. -December 2024, 3 of 8 ordered bi-weekly showers were missed. Regarding Resident # 8 Resident # 8 was admitted to the facility on June 29, 2024, with diagnoses that included paralysis of dominant side after a stroke, lupus, morbid obesity, diabetes, congestive heart failure, and muscle weakness. The quarterly MDS dated December 15, 2024 revealed a Brief Interview Mental Status (BIMS) score of 14, which indicated resident was cognitively intact. The MDS also indicated the resident required supervision or touching assistance for showers/bathing. A care plan with the revision date of December 20, 2024, revealed the resident required extensive assistance by one staff member while showering. A progress note dated August 9, 2024, revealed the resident was educated about refusing showers. A progress note dated January 6, 2023 revealed the resident requ

Based 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. Findings include: Regarding resident #30 Resident #30 was admitted to the facility on June 21, 2023 with diagnoses of Covid-19, Type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease (COPD) and mild Protein-Calorie Malnutrition. Review of the 5-day Minimum Data Sat (MDS) dated June 25, 2023, revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating resident had moderate cognitive impairment. Further review of the MDS revealed that the resident had no behaviors exhibited; and that the resident required extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. The care plan dated July 10, 2023 revealed the resident needed assistance with ADL (activities of daily living) to maintain or attain the highest level of function. Intervention included to assist the resident with mobility and ADLs as needed. The NP (nurse practitioner progress note dated August 2, 2023 revealed that the resident was transferred to the facility for rehabilitation and continued medical management. Physical examination included that the resident was alert and oriented x 3. Review of the facility's investigation report dated August 5, 2023 revealed that on August 3, 2023 at approximately 11:35 a.m. the resident reported to a certified nursing assistant (CNA/staff #108) that a licensed practical nurse (LPN/staff #100) threw thrown his television remote at him because his volume was too high; and that, the LPN removed the batteries from his television remote. Per the report, in an interview with the resident conducted by the facility, the resident reported that he did not like being alone so he had his TV on; and, he fell asleep and may have rolled onto his TV remote causing it to turn his TV up. The documentation also included that the resident reported that the (LPN/staff #100) came in his room and told him that he cannot have his TV on; and that, the LPN grabbed his remote, turned the TV down and left his room with his remote. The resident reported that the LPN came back in his room and tossed the remote back to him; however, the resident noticed that the batteries to his remote had been removed. Per the documentation, the resident screamed back at the LPN and used profanity that he wanted his batteries back; and, the LPN brought the batteries back and "tossed them on his lap". The facility report also included documentation of an interview was conducted with (LPN/staff #100) conducted by the facility. The documentation included that the incident took place at approximately 2:00 a.m. on August 3, 2023 and the LPN (staff #100) reported that she went to the resident's room to turn down his

Based 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. Findings include: Resident #10 was admitted to the facility on 04/02/2024 with diagnoses of chronic hepatic failure, hypertension, congestive heart failure, chronic kidney disease with end stage renal disease, and hyperkalemia. The nutrition care plan dated 04/04/2024 included a goal for the resident's skin to improve. The skin integrity documentation dated 04/09/2024 included cellulitis and blisters to the left lower extremity (LLE) and right lower extremity (RLE). The provider note dated 04/10/2024 included that the resident had cellulitis on bilateral lower extremities (BLE) and edema. Treatment included antibiotics for 5 days which was noted as completed; and that, the problem still persisted. A physician order dated 04/10/2024 included a treatment to cleanse bilateral foot blister with NS (normal saline), pat dry, wrap with kerlix daily every day shift and as needed if soiled. A provider note dated 04/14/2024 revealed that the resident still had BLE swelling; and that, antibiotics were ordered for leg cellulitis. The physician order dated 04/15/2024 revealed an order to cleanse left lower extremity open blister with saline, apply non-adherent pad to open area and wrap with ace wrap one time a day for cellulitis. The skin integrity note dated 04/16/2024 included right and left lower extremity cellulitis with blisters. The skin integrity note dated 04/23/2024 revealed right and left lower extremity cellulitis (lymphedema) with blisters. The skin integrity dated 04/30/2024 included lymphedema. The Wound Observation Tool was dated 04/30/2024 revealed that the left lower extremity wound was unchanged and had large serous drainage. Wound measurement was 40 cm (centimeter) length x 40 cm (width) x 0 cm (depth). Per the documentation, there were no signs of infection and treatment included iodoform and kerlix dressing. The wound treatment orders for the bilateral foot blisters and the left lower extremity were transcribed onto the Treatment Administration Record (TAR) for April 2024 and revealed the resident refused treatment and dressing change on 04/15/2024; and, treatment/dressing change on bilateral foot blisters was not documented as administered on 04/14/2024, 04/21/2024, 04/26/2024 and 04/30/2024. Continued review of the TAR revealed that treatment/dressing change on the left lower extremity was not documented as administered on 04/21/2024, 04/26/2024 and 04/30/2024. The TAR for May 2024 revealed that the treatments for the bilateral foot blisters and the left lower extremity were documented as refused on 05/01/2024. Despite documentation of the wounds and treatment orders, the clinical record revealed no evidence that the resident's wounds were car

Based 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) were not subjected to abuse a staff and another resident. Findings include: Regarding resident #30: Resident #30 was admitted to the facility on June 21, 2023 with diagnoses of Covid-19, Type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease (COPD) and mild Protein-Calorie Malnutrition. Review of the 5-day Minimum Data Sat (MDS) dated June 25, 2023, revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating resident had moderate cognitive impairment. Further review of the MDS revealed that the resident had no behaviors exhibited; and that the resident required extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. The care plan dated July 10, 2023 revealed the resident needed assistance with ADL (activities of daily living) to maintain or attain the highest level of function. Intervention included to assist the resident with mobility and ADLs as needed. The NP (nurse practitioner progress note dated August 2, 2023 revealed that the resident was transferred to the facility for rehabilitation and continued medical management. Physical examination included that the resident was alert and oriented x 3. Review of the facility's investigation report dated August 5, 2023 revealed that on August 3, 2023 at approximately 11:35 a.m. the resident reported to a certified nursing assistant (CNA/staff #108) that a licensed practical nurse (LPN/staff #100) threw thrown his television remote at him because his volume was too high; and that, the LPN removed the batteries from his television remote. Per the report, in an interview with the resident conducted by the facility, the resident reported that he did not like being alone so he had his TV on; and, he fell asleep and may have rolled onto his TV remote causing it to turn his TV up. The documentation also included that the resident reported that the (LPN/staff #100) came in his room and told him that he cannot have his TV on; and that, the LPN grabbed his remote, turned the TV down and left his room with his remote. The resident reported that the LPN came back in his room and tossed the remote back to him; however, the resident noticed that the batteries to his remote had been removed. Per the documentation, the resident screamed back at the LPN and used profanity that he wanted his batteries back; and, the LPN brought the batteries back and "tossed them on his lap". The facility report also included documentation of an interview was conducted with (LPN/staff #100) conducted by the facility. The documentation included that the incident took place at approximately 2:00 a.m. on August 3, 2023 and the LPN (staff #100) reported that she went to the resident's room to turn down his TV because it was very loud and found the resident sleeping. She reported

Based on clinical record review, staff interviews, and facility documentation and policies, the facility failed to ensure nursing care services were provided for one resident (#10). Findings include: Resident #10 was admitted to the facility on 04/02/2024 with diagnoses of chronic hepatic failure, hypertension, congestive heart failure, chronic kidney disease with end stage renal disease, and hyperkalemia. The nutrition care plan dated 04/04/2024 included a goal for the resident's skin to improve. The skin integrity documentation dated 04/09/2024 included cellulitis and blisters to the left lower extremity (LLE) and right lower extremity (RLE). The provider note dated 04/10/2024 included that the resident had cellulitis on bilateral lower extremities (BLE) and edema. Treatment included antibiotics for 5 days which was noted as completed; and that, the problem still persisted. A physician order dated 04/10/2024 included a treatment to cleanse bilateral foot blister with NS (normal saline), pat dry, wrap with kerlix daily every day shift and as needed if soiled. A provider note dated 04/14/2024 revealed that the resident still had BLE swelling; and that, antibiotics were ordered for leg cellulitis. The physician order dated 04/15/2024 revealed an order to cleanse left lower extremity open blister with saline, apply non-adherent pad to open area and wrap with ace wrap one time a day for cellulitis. The skin integrity note dated 04/16/2024 included right and left lower extremity cellulitis with blisters. The skin integrity note dated 04/23/2024 revealed right and left lower extremity cellulitis (lymphedema) with blisters. The skin integrity dated 04/30/2024 included lymphedema. The Wound Observation Tool was dated 04/30/2024 revealed that the left lower extremity wound was unchanged and had large serous drainage. Wound measurement was 40 cm (centimeter) length x 40 cm (width) x 0 cm (depth). Per the documentation, there were no signs of infection and treatment included iodoform and kerlix dressing. The wound treatment orders for the bilateral foot blisters and the left lower extremity were transcribed onto the Treatment Administration Record (TAR) for April 2024 and revealed the resident refused treatment and dressing change on 04/15/2024; and, treatment/dressing change on bilateral foot blisters was not documented as administered on 04/14/2024, 04/21/2024, 04/26/2024 and 04/30/2024. Continued review of the TAR revealed that treatment/dressing change on the left lower extremity was not documented as administered on 04/21/2024, 04/26/2024 and 04/30/2024. The TAR for May 2024 revealed that the treatments for the bilateral foot blisters and the left lower extremity were documented as refused on 05/01/2024. Despite documentation of the wounds and treatment orders, the clinical record revealed no evidence that the resident's wounds were care planned with interventions. The clinical record revealed that the resident was transferred to the hospital on 05/02