Inspection Reports for
Casa De Oro Center
1005 LUJAN HILL ROAD, LAS CRUCES, NM, 88005
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
35 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
393% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 21, 2025
Visit Reason
The inspection was conducted due to allegations of misappropriation of resident property, specifically diversion of narcotic medications, and failure to report and investigate these allegations properly.
Complaint Details
The complaint involved allegations of diversion of narcotic medications by LPN #16, including forged signatures on controlled drug records and undocumented medication administrations affecting residents R #16, R #17, and R #24. The facility failed to report these allegations timely and failed to conduct a thorough investigation.
Findings
The facility failed to timely report allegations of misappropriation of resident property to the State Agency, failed to thoroughly investigate allegations of narcotic medication diversion, failed to ensure narcotic medications were administered as ordered, and failed to maintain complete and accurate controlled drug records and medication administration records (MARs) for multiple residents.
Deficiencies (4)
Failed to timely report allegations of misappropriation of resident property to the State Agency within 24 hours.
Failed to thoroughly investigate allegations of misappropriation of narcotic medications, including failure to document interviews and review all relevant medical records.
Failed to ensure narcotic medications were administered as ordered, including administration earlier than ordered and at higher doses than ordered.
Failed to maintain complete and accurate controlled drug records and medication administration records for multiple residents, including missing pages and undocumented medication administrations.
Report Facts
Residents reviewed for misappropriation: 7
Residents affected by misappropriation findings: 4
Missing controlled drug record periods: 3
Medication administrations documented earlier than ordered: 3
Medication administrations missing documentation: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #16 | Licensed Practical Nurse | Suspected of diverting narcotic medications and forging signatures on controlled drug records. |
| DON | Director of Nursing | Interviewed regarding investigation and confirmed failures in reporting and documentation. |
| CMA #16 | Certified Medication Aide | Reported suspected forged signatures and participated in investigation. |
| UM #16 | Unit Manager | Participated in investigation and interviews related to narcotic medication diversion. |
| NP #16 | Nurse Practitioner | Provided clinical perspective on medication administration and pain management. |
| LPN #17 | Licensed Practical Nurse | Interviewed regarding narcotic medication administration policies. |
| CMA #17 | Certified Medication Aide | Interviewed regarding narcotic medication documentation and administration. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 13, 2025
Visit Reason
The inspection was conducted due to complaints and incidents related to multiple resident elopements and failure to report these elopements to the State Agency, as well as concerns about medication security.
Complaint Details
The complaint investigation was triggered by multiple resident elopements on 04/20/25, 04/22/25, and 04/24/25 involving residents R #1, R #2, and R #3. The facility failed to recognize elopement risks, secure exit doors and gates, and report elopements to the State Agency. One resident (R #1) was missing for approximately 30 hours, resulting in hospitalization for emergency dialysis, dehydration, and sunburn. Immediate jeopardy was identified and later lifted after the facility implemented corrective actions.
Findings
The facility failed to report elopements of residents to the State Agency and did not adequately secure exit doors and gates, resulting in multiple elopements including one resident missing for approximately 30 hours and hospitalized. Additionally, medication and treatment carts were found unlocked, posing a risk of residents accessing medications not prescribed to them.
Deficiencies (3)
Failed to timely report suspected abuse, neglect, or theft related to resident elopements to the State Agency.
Failed to keep residents free from accident hazards and provide adequate supervision to prevent accidents, resulting in multiple elopements and immediate jeopardy to resident health or safety.
Failed to secure medications in medication and treatment carts, leaving them unlocked and accessible.
Report Facts
Residents sampled for elopement: 3
Resident missing duration: 30
Residents affected by medication cart deficiency: 37
Date of elopements: Apr 20, 2025
Date of elopements: Apr 22, 2025
Date of elopements: Apr 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Assistant #2 | Reported finding residents R #1 and R #3 outside the facility on 04/22/25 | |
| Administrator | Did not report elopements to State Agency and confirmed knowledge of elopements | |
| CNA #1 | Reported observations related to resident R #2 elopement risk and missing resident R #1 | |
| LPN #1 | Confirmed staff awareness of R #2 as elopement risk | |
| Maintenance Director (MD) #1 | Confirmed south courtyard gate was never locked | |
| Unit Manager #4 | Confirmed medication and treatment carts should be secured | |
| RN #3 | Confirmed medication and treatment carts were unlocked during observation | |
| Business Office Manager (BOM) | Reported facility search and law enforcement involvement for missing resident R #1 | |
| CMA #3 | Noticed resident R #1 was missing during medication pass |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 3, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to document required discharge information, failure to revise care plans for residents needing lift devices, failure to develop and implement discharge planning, failure to complete discharge summaries, and failure to provide appropriate catheter care.
Complaint Details
The complaint investigation substantiated multiple deficiencies including failure to document discharge information, revise care plans, develop discharge planning, complete discharge summaries, and provide appropriate catheter care.
Findings
The facility failed to have the physician document required discharge information for one resident, failed to revise care plans for three residents requiring lift devices, failed to develop and implement discharge planning for one resident, failed to complete discharge summaries including medication lists and recapitulation of stay, and failed to ensure appropriate Foley catheter care for one resident.
Deficiencies (5)
Failed to have the physician document required discharge information for resident #26.
Failed to revise care plans for residents #8, #9, and #10 to reflect need for lift devices and two-person assistance.
Failed to develop and implement discharge planning process for resident #26, including individualized discharge goals and involvement of resident and POA.
Failed to complete discharge summary including recapitulation of stay and medication list for resident #26.
Failed to ensure appropriate Foley catheter care for resident #13; catheter tubing was dragging on the floor.
Report Facts
Residents reviewed for discharge documentation: 1
Residents reviewed for care plan revision: 3
Residents observed for catheter care: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed lack of physician documentation and discharge summary for resident #26, and notification of POA. | |
| Director of Nursing (DON) | Confirmed care plans for residents #8, #9, and #10 were not revised to reflect lift device needs and two-person assistance; confirmed catheter tubing care issues for resident #13. | |
| Social Worker | Confirmed not involved in discharge planning or documentation for resident #26. | |
| LPN #8 | Confirmed Foley catheter tubing for resident #13 was dragging on the floor. |
Inspection Report
Routine
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
The inspection was conducted to assess compliance with wound care orders and the implementation of pressure ulcer care for residents, specifically reviewing wound care practices and documentation for residents with pressure ulcers.
Findings
The facility failed to ensure wound care orders were implemented, wound care was completed, and staff documented wound care for one resident with a stage 3 pressure ulcer. Staff did not enter wound care orders, did not document wound care provided, and failed to communicate with the wound care consultant, leading to potential risks of worsening pressure ulcers.
Deficiencies (1)
Failure to implement wound care orders, complete wound care, and document wound care for resident with stage 3 pressure ulcer
Report Facts
Residents reviewed for pressure ulcers: 3
Residents affected: 1
Wound care documentation missing: 7
Wound care order dates: 3
Monitoring period: 3
Audit frequency: 4
Audit frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Assisted wound care nurse with wound care and packing, did not document wound care |
| DON | Director of Nursing | Interviewed regarding failure to enter wound care orders and lack of documentation |
| facility wound care nurse | Did not document communication with wound care consultant or wound care provided |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Oct 28, 2024
Visit Reason
The inspection was conducted based on complaints alleging multiple deficiencies including environmental issues, abuse, failure to report abuse, inaccurate assessments, incomplete care plans, inadequate wound care, insufficient staffing, and medication errors.
Complaint Details
The complaint investigation substantiated multiple allegations of abuse including verbal abuse by CNA #16, physical abuse by RN #24, and failure to protect residents from abuse. Immediate jeopardy was identified related to abuse and failure to report. The facility failed to report abuse allegations timely to the State Survey Agency for residents #12, #16, #94, and #117. The facility also failed to protect residents from abuse and failed to provide adequate supervision and care.
Findings
The facility was found deficient in providing a safe and homelike environment, preventing abuse and neglect, timely reporting of abuse, accurate resident assessments, comprehensive and timely care planning, proper wound care, adequate staffing, and pharmaceutical services. Immediate jeopardy was identified related to abuse and failure to report. Several residents experienced physical and verbal abuse, and the facility failed to implement appropriate interventions and documentation.
Deficiencies (12)
Failed to provide a comfortable and homelike environment including maintenance of walls, vents, commodes, and crash carts.
Failed to protect residents from verbal and physical abuse by staff, resulting in immediate jeopardy.
Failed to timely report allegations of abuse to the State Survey Agency.
Failed to ensure accurate Minimum Data Set assessments for residents with UTIs and feeding tubes.
Failed to develop and implement complete, person-centered care plans including care for PEG tubes and pressure injuries.
Failed to review and revise care plans timely and with appropriate interdisciplinary team participation.
Failed to complete wound care as ordered for a resident with a foot wound.
Failed to keep residents free from accidents by not implementing adequate fall prevention interventions.
Failed to properly manage enteral feeding tubes including administration of feeding and care of insertion sites.
Failed to provide sufficient nursing staff to meet resident needs, resulting in delayed care and missed showers.
Failed to provide pharmaceutical services to ensure residents received ordered medications.
Failed to maintain complete and accurate medical records including documentation of PEG tube care and medication use.
Report Facts
Residents sampled for environment: 8
Residents affected by abuse: 3
Residents reviewed for care plans: 8
Residents reviewed for wound care: 2
Residents reviewed for falls: 1
Residents reviewed for staffing: 2
Residents reviewed for medications: 3
Residents reviewed for documentation accuracy: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #16 | Named in verbal abuse findings and substantiated complaint for calling resident lazy | |
| RN #24 | Named in physical abuse findings for dragging and hitting residents #94 and #117 | |
| LPN #24 | Witnessed abuse and reported injuries for resident #94 | |
| CNA #24 | Witnessed abuse and reported incident involving RN #24 and resident #117 | |
| RN #16 | Reported verbal abuse by CNA #16 and actions taken | |
| DON | Director of Nursing | Interviewed regarding abuse, care plans, wound care, staffing, and medication issues |
| NA #16 | Nursing Assistant | Interviewed regarding staffing and resident #12 care |
| CNA #18 | Interviewed regarding staffing and resident #66 care | |
| CMA #8 | Interviewed regarding medication administration for resident #133 | |
| NP #16 | Nurse Practitioner | Ordered wound care and heel protectors for resident #12 |
| NP #1 | Nurse Practitioner | Ordered PEG tube site care for resident #14 |
| LPN #16 | Nurse for resident #13 who stopped tube feeding early |
Inspection Report
Routine
Deficiencies: 18
Date: Oct 28, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, safety, care planning, medication management, abuse prevention, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to update residents' medical records and care plans, inadequate environmental maintenance, failure to prevent abuse and neglect, inaccurate assessments, incomplete care plans, improper medication management, insufficient staffing, and lack of proper training and documentation.
Deficiencies (18)
Failed to update resident's code status in medical records and care plans.
Failed to maintain a safe, clean, and homelike environment including paint, vents, commodes, and crash carts.
Failed to protect residents from verbal and physical abuse, resulting in immediate jeopardy.
Failed to timely report allegations of abuse to the State Survey Agency.
Failed to ensure accurate Minimum Data Set (MDS) assessments for residents.
Failed to develop and implement comprehensive person-centered care plans for residents.
Failed to review and revise care plans timely and with appropriate interdisciplinary team participation.
Failed to provide treatment and care according to orders and resident preferences, including hospice care documentation.
Failed to keep residents free from accidents by not identifying and implementing fall prevention interventions.
Failed to properly manage enteral feeding tubes including administration times and site care.
Failed to ensure safe and appropriate dialysis care including communication and monitoring.
Failed to provide sufficient nursing staff to meet resident needs and respond timely to call bells.
Failed to ensure licensed pharmacist's recommendations were reviewed and implemented or rationalized.
Failed to ensure psychotropic medications were only used when necessary and with appropriate diagnosis.
Failed to properly store medications including documenting refrigerator temperatures and securing treatment carts.
Failed to procure and store food properly including visible dates and documenting refrigerator temperatures.
Failed to provide Quality Assurance and Performance Improvement (QAPI) training to staff.
Failed to include performance reviews as part of annual training for nurse aides.
Report Facts
Residents affected: 6
Residents affected: 6
Residents affected: 3
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 9
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 127
Residents affected: 127
Nurse aides: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #16 | Named in verbal abuse and resident neglect findings | |
| RN #24 | Named in physical abuse and neglect findings | |
| LPN #24 | Named in abuse and injury findings | |
| CNA #25 | Named in abuse and injury findings | |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including abuse, care plans, medication, staffing, and training |
| Administrator | Interviewed regarding QAPI training and abuse investigations | |
| CMA #8 | Confirmed medication refrigerator temperature documentation issues | |
| CMA #9 | Confirmed medication refrigerator temperature documentation issues | |
| NA #16 | Interviewed regarding resident care and call bell response | |
| CNA #17 | Interviewed regarding resident care and abuse allegations | |
| CNA #18 | Interviewed regarding staffing and resident care | |
| LPN #36 | Interviewed regarding treatment cart security | |
| NP #1 | Interviewed regarding PEG tube care orders | |
| Medical Director | Interviewed regarding psychotropic medication use | |
| Staff Development Coordinator | Interviewed regarding CNA training and performance reviews |
Inspection Report
Routine
Census: 126
Deficiencies: 8
Date: Jun 20, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including resident privacy, environment, abuse reporting, transfer notifications, care planning, CPR procedures, and medical record accuracy.
Findings
The facility was found deficient in safeguarding resident medical record confidentiality, maintaining a clean and homelike environment, timely reporting of suspected abuse, providing written transfer and bed hold notifications, revising care plans to reflect current resident status, ensuring staff knowledge and tracking of CPR certification, and maintaining complete and accurate medical records.
Deficiencies (8)
Failed to safeguard resident medical record information, leaving computer screens unlocked with resident data visible.
Failed to provide a comfortable and homelike environment by not picking up dirty tissues and used gloves left on the floor.
Failed to timely report injuries of unknown source within two hours to the State Agency for one resident.
Failed to provide written notice of transfer to resident representatives and Ombudsman for one resident.
Failed to provide written notice of bed hold policy to resident representatives for one resident.
Failed to revise care plan to reflect resident's ability to eat independently.
Failed to ensure staff knew CPR procedures, check pulse and airway, and track CPR certification for all Full Code residents.
Failed to maintain complete and accurate medical records, including documentation of a resident's bruise.
Report Facts
Residents affected: 126
Residents affected: 73
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA #11 | Certified Medication Aide | Confirmed computer was left unlocked with resident information visible |
| LPN #11 | Licensed Practical Nurse | Assessed resident's bruise and did not document or report it |
| Activities Coordinator | Confirmed presence of dirty tissues and latex glove on floor | |
| Administrator | Provided census data and commented on reporting failures | |
| Unit Manager #21 | Responsible for transfer and bed hold notification processes | |
| Dietician | Confirmed resident ate independently without supervision | |
| MDS Assistant | Confirmed care plan was not updated to reflect resident's independence | |
| CNA #1 | Certified Nursing Assistant | Responded to resident emergency and described CPR procedure |
| CNA #2 | Certified Nursing Assistant | Received residents' code status sheet and notified nurse in emergencies |
| CNA #3 | Certified Nursing Assistant | Asked nurses for resident code status and would yell for help |
| CNA #4 | Certified Nursing Assistant | Described code status location and emergency response |
| CNA #5 | Certified Nursing Assistant | Knew some residents' code status and would ask nurse or DON |
| CNA #6 | Certified Nursing Assistant | Knew code status location but was not CPR certified |
| DON | Director of Nursing | Expected nurses to know code status and CNAs to initiate CPR if certified |
| Payroll Staff | Did not track CPR certifications until recently | |
| Unit Manager | Notified about expectations for documenting bruises and resident changes |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Feb 28, 2024
Visit Reason
The inspection was conducted following complaints and allegations related to resident rights, abuse investigations, notification failures, involuntary seclusion, psychotropic medication use, and documentation accuracy at Casa DE Oro Center.
Complaint Details
The complaint investigation included allegations of resident to resident abuse, failure to respect privacy, failure to notify residents and representatives of transfers, failure to provide written notices, failure to report abuse investigations timely, and failure to properly manage psychotropic medications and care plans.
Findings
The facility was found deficient in multiple areas including failure to respect resident privacy, failure to provide written notice for room changes, failure to notify residents and representatives of hospital transfers, failure to prevent involuntary seclusion without proper documentation, failure to timely report abuse investigations to the State Agency, failure to document care and incidents accurately, failure to revise care plans for therapy refusals, and failure to properly manage psychotropic medications.
Deficiencies (10)
Failed to ensure residents were treated with respect and dignity by not allowing a resident to close her door for privacy.
Failed to provide written notice for room/roommate change for a resident.
Failed to notify resident or representative of hospital transfer and reason for room transfer.
Failed to keep resident free from involuntary seclusion by not documenting clinical criteria, least restrictive approach, and ongoing review for placement in secured unit.
Failed to timely report results of abuse investigations to the State Survey Agency within five days.
Failed to notify resident and representative in writing of transfer including appeal rights and ombudsman contact information.
Failed to notify resident or representative in writing of bed hold policy duration for hospital transfer.
Failed to revise care plan to document resident's refusals for physical, occupational, and speech therapy.
Failed to follow mental health provider's recommendation to reduce or discontinue lorazepam and failed to limit antipsychotic medication order to 14 days; inconsistent behavior monitoring.
Failed to maintain complete and accurate medical records documenting incidents, investigations, notifications, and resident responses related to abuse allegations and transfers.
Report Facts
Residents affected: 11
Lorazepam order duration: 60
Lorazepam PRN order duration: 14
Therapy refusal dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #11 | Unit Manager | Mentioned in relation to failure to notify resident representative of hospital transfer and bed hold notice |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including privacy, notifications, abuse reporting, psychotropic medication management, and documentation |
| LPN #21 | Licensed Practical Nurse | Confirmed door to resident #22's room was to be kept open at all times |
| Nurse Aide #21 | Nurse Aide | Reported resident #22 and husband liked door closed but staff reminded resident door must stay open |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident personal funds management, environment and safety, staffing levels, and resident care preferences including showering and bed timing.
Findings
The facility was found deficient in properly managing residents' personal funds statements, maintaining a safe and homelike environment, providing adequate staffing to meet resident needs, and honoring resident preferences for showering and bed times. Multiple residents reported missing personal belongings and clothing, delayed call light responses, insufficient staff on certain units, and missed or delayed showers due to staffing shortages.
Deficiencies (3)
Failed to provide quarterly statements for resident's personal funds accounts.
Failed to maintain a safe, clean, comfortable and homelike environment including repainting walls, covering vents properly, serving meals on appropriate tableware, and protecting residents' personal property.
Failed to provide enough nursing staff daily to meet resident needs, resulting in delayed call light responses and inability to honor resident preferences for bed and shower times.
Report Facts
Residents affected: 1
Residents affected: 20
Residents affected: 127
Residents on 700 unit: 13
Call light wait times: 30
Call light wait times: 45
Staffing counts: 11
Staffing counts: 8
Staffing counts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding failure to send quarterly personal funds statements |
| Maintenance Director | Maintenance Director | Confirmed broken windows and poor paint conditions in resident rooms |
| Dietary Manager | Dietary Manager | Confirmed residents were served lunch on styrofoam plates |
| Social Services Director | Social Services Director | Interviewed regarding missing resident clothing and grievance documentation |
| Social Services Worker | Social Services Worker | Interviewed regarding missing resident property and grievance procedures |
| Unit Manager #2 | Unit Manager | Interviewed regarding procedures for missing property and staffing |
| CNA #33 | Certified Nursing Assistant | Interviewed regarding staffing shortages and care delays |
| RN #32 | Registered Nurse | Interviewed regarding staffing shortages and care delays |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing shortages and showering expectations |
| UM #2 | Unit Manager | Confirmed understaffing and missed showers |
| CNA #11 | Certified Nursing Assistant | Interviewed regarding staffing shortages and showering delays |
Inspection Report
Routine
Deficiencies: 20
Date: Nov 20, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, medication management, environment, staffing, care planning, infection control, and other areas.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights, inadequate management of personal funds, failure to notify physicians of medication refusals, poor environmental conditions, missing resident property, incomplete care plans, insufficient staffing, inadequate training, improper medication storage, poor food quality and temperature control, incomplete wound care documentation, and lapses in infection control practices.
Deficiencies (20)
Failed to honor resident's right to self-determination by not allowing a resident to return to his room promptly.
Failed to provide quarterly statements for resident's personal funds.
Failed to notify physician of resident's frequent refusal of insulin.
Failed to provide a safe, clean, comfortable, and homelike environment including maintenance and protection of personal property.
Failed to provide timely notification to the Ombudsman of resident transfers.
Failed to notify residents or representatives of bed hold policy duration.
Failed to develop and implement comprehensive, person-centered care plans and revise care plans timely.
Failed to provide treatment in accordance with professional standards, including failure to remove hemodialysis catheter as ordered.
Failed to provide restorative nursing program to maintain resident's functional gains.
Failed to maintain adequate nursing staffing levels to meet resident needs, resulting in delayed call light response and unmet resident preferences.
Failed to provide appropriate behavioral health training to staff to manage physically aggressive residents.
Failed to act on pharmacy recommendations to discontinue or adjust unnecessary medications.
Failed to properly store medications including securing medication carts, labeling expiration dates, and logging refrigerator temperatures.
Failed to ensure meals were served at appropriate temperatures and were palatable.
Failed to accommodate resident food preferences.
Failed to maintain proper food service hygiene including staff wearing hairnets and covering meal trays.
Failed to notify therapy department of resident referral resulting in missed therapy services.
Failed to maintain complete and accurate documentation of showers and wound care.
Failed to maintain proper infection prevention measures including proper PPE doffing, mask wearing, trash disposal, and keeping airborne precaution doors closed.
Failed to complete required annual training and performance reviews for nurse aides.
Report Facts
Residents affected: 20
Residents affected: 127
Residents affected: 54
Residents affected: 7
Residents affected: 3
Residents affected: 2
Residents affected: 3
Residents affected: 5
Residents affected: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Named in behavioral health training deficiency and physical aggression incident | |
| CNA #1 | Named in behavioral health training deficiency and physical aggression incident | |
| CNA #2 | Named in behavioral health training deficiency and physical aggression incident | |
| RN #11 | Confirmed medication cart unlocked and uncovered food trays | |
| LPN #19 | Confirmed medication expiration date missing and temperature log missing | |
| CNA #33 | Reported insufficient staffing to complete care tasks | |
| RN #32 | Reported staffing shortages and single CNA on 700 unit | |
| Unit Manager #2 | Confirmed staffing shortages and shower schedule issues | |
| DON | Director of Nursing | Confirmed multiple deficiencies including staffing, training, medication, wound care, infection control |
| Dietary Manager | Confirmed food temperature and hygiene deficiencies | |
| Wound Care Nurse | Confirmed wound care documentation deficiencies | |
| Housekeeper #11 | Observed improper PPE doffing | |
| Infection Control Nurse | Provided infection control interview | |
| Nurse Educator | Confirmed incomplete annual training for CNAs |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 15, 2023
Visit Reason
The inspection was conducted to assess compliance with care planning, resident safety, and documentation standards at Casa DE Oro Center.
Findings
The facility failed to develop and revise comprehensive, person-centered care plans for residents, did not secure treatment carts properly, and failed to maintain accurate documentation of residents' nutritional and fluid intake. These deficiencies posed potential risks of inadequate care and resident harm.
Deficiencies (4)
Failed to develop a comprehensive person-centered care plan for residents requiring assistance with activities of daily living.
Failed to revise care plan to reflect resident preferences for female caregivers due to past trauma.
Failed to keep residents free from accident hazards by not securing a treatment cart on the 700 hallway.
Failed to ensure resident records were complete and accurate, specifically nutritional and fluid intake documentation.
Report Facts
Residents reviewed: 3
Residents affected: 2
Residents affected: 1
Residents affected: 11
Days with missing documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #11 | Licensed Practical Nurse | Interviewed regarding resident R #11's discomfort with male caregivers and preference for female caregivers |
| RN #12 | Registered Nurse | Confirmed treatment cart on 700 hallway was unlocked and could not be secured |
| DON | Director of Nursing | Confirmed deficiencies in care plans and documentation during interviews |
Inspection Report
Routine
Deficiencies: 17
Date: Feb 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations, including elopement risk, transfer notifications, care planning, restorative nursing, medication management, food safety, and staff training.
Findings
The facility was found deficient in multiple areas including failure to assess elopement risk properly, lack of written transfer and bed hold notices, incomplete care plans, inadequate restorative nursing services, failure to provide treatment for skin conditions, unsafe water temperatures posing immediate jeopardy, improper catheter care, expired medications on medication carts, failure to post nurse staffing information, incomplete behavioral health services, inaccurate documentation of fluid restriction non-compliance, and incomplete staff training on abuse prevention.
Deficiencies (17)
Failed to identify resident's specific clinical criteria for placement in Secured Memory Care Unit and failed to assess elopement risk.
Failed to provide written notice of transfer and bed hold policy to residents and representatives for hospitalizations.
Failed to develop comprehensive person-centered care plans for residents, including for high-risk medications and chronic conditions.
Failed to revise care plans timely to reflect changes in resident status such as hospital admissions, fluid restrictions, and catheter status.
Failed to provide restorative nursing program services for residents discharged from therapy.
Failed to provide treatment for resident's self-inflicted skin sore from picking and scratching.
Failed to ensure residents with limited mobility received appropriate equipment and assistance to maintain mobility (e.g., hand splints).
Failed to protect residents from unsafe water temperatures resulting in immediate jeopardy; water heater access unsecured and water temperatures excessively high.
Failed to ensure Foley catheter tubing was kept off the floor for multiple residents.
Failed to ensure ongoing communication and collaboration with dialysis center for resident receiving dialysis.
Failed to post nurse staffing information in a prominent place.
Failed to provide necessary behavioral health care and services for resident with behavioral health orders.
Failed to properly store medications in medication carts; expired medications found on multiple unit carts.
Failed to store and serve food under sanitary conditions; food items unlabeled, uncovered, and staff failed to perform hand hygiene.
Failed to maintain accurate and complete resident medical records; non-compliance with fluid restrictions not documented.
Failed to provide abuse prohibition training to some licensed nurses and nurse aides.
Failed to provide required in-service training for nurse aides including abuse prevention and training based on facility assessment and performance evaluations.
Report Facts
Residents affected: 7
Residents affected: 4
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 7
Residents affected: 25
Residents affected: 38
Residents affected: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Confirmed no treatment order for resident's skin sore and reported issue to medical provider | |
| LPN #11 | Confirmed resident's soda intake not monitored and catheter tubing touching floor | |
| LPN #12 | Did not complete required abuse prohibition training | |
| LPN #18 | Confirmed residents with poor safety awareness and catheter tubing issues | |
| LPN #21 | Confirmed expired medications on Memory Care medication cart | |
| LPN #22 | Confirmed expired medications on Main Hall medication cart | |
| LPN #23 | Confirmed expired medications on East Hall medication cart | |
| RN #11 | Confirmed soda in resident's room and lack of monitoring | |
| RN #18 | Confirmed resident's hand splint order and observed splint use | |
| DON | Director of Nursing | Confirmed multiple deficiencies including lack of transfer notices, care plan issues, catheter tubing, expired meds, and training gaps |
| Social Worker | Confirmed behavioral health orders in place but no services provided | |
| Human Resources | Confirmed staff training deficiencies for abuse prohibition | |
| Dietary Manager | Confirmed food safety deficiencies in dry pantry and staff hygiene |
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