Inspection Reports for
Casas Adobes Post Acute Rehabilitation Center

The complaint investigation involved multiple incidents of resident-to-resident abuse including slapping and hitting among residents #171, #172, #50, #170, #148, and #125. Investigations included staff interviews, review of progress notes, and five-day investigation reports. The facility acknowledged the incidents and implemented interventions such as fifteen-minute checks, staff training on abuse and de-escalation, and behavioral care plans. The investigation also included a review of medication administration errors for resident #10.

The facility failed to prevent resident-to-resident abuse involving multiple residents with behavioral disturbances, resulting in physical altercations and minimal harm. Additionally, the facility failed to administer medications as ordered for one resident, leading to medication errors and potential uncontrolled pain.

The complaint investigation revealed multiple incidents of resident-to-resident abuse involving residents #171, #172, #50, #170, #148, and #125, including physical altercations such as slapping and hitting. The facility conducted five-day investigations for these incidents, placed residents on fifteen-minute checks, and involved law enforcement. Interviews with staff confirmed awareness of abuse and training on abuse prevention. The facility also failed to administer pain medications according to physician orders for resident #10, administering tramadol for pain levels outside the ordered parameters.

The facility failed to ensure that residents were protected from abuse by other residents, with multiple documented incidents of resident-to-resident physical altercations and inadequate monitoring. Additionally, the facility failed to administer medications as ordered by the physician for one resident, resulting in medication errors and potential uncontrolled pain.

Investigation of numerous complaints resulting in four deficiencies related to physician orders, abuse prevention, pharmacy services, and resident abuse.

Complaint survey citing two deficiencies related to abuse prevention and premises safety.

The complaint investigation found substantiated incidents of resident-to-resident abuse involving Resident #55 as the aggressor and Resident #44 as the victim. Multiple altercations were documented from March to April 2023, with interventions including 15-minute checks, medication reviews, and transfer to a behavioral care home. Staff interviews confirmed ongoing efforts to prevent altercations but acknowledged it is not always possible to prevent all interactions.

The facility failed to prevent resident-to-resident abuse, with multiple documented incidents of aggression by Resident #55 towards other residents. The facility implemented interventions including medication adjustments, increased monitoring, and behavioral health involvement. The Director of Nursing and staff described efforts to reduce altercations through environmental changes, staffing, and new activity programs.

The complaint investigation found that Resident #55 was the aggressor in multiple incidents of physical aggression against other residents, including Resident #44. The facility had protocols and interventions in place but failed to fully prevent these altercations. The complaint was substantiated with findings of minimal harm or potential for actual harm affecting a few residents.

The facility failed to prevent resident-to-resident abuse, with multiple documented incidents of physical aggression by Resident #55 towards other residents, including Resident #44. The facility implemented interventions such as medication adjustments, increased monitoring, unit transfers, and psychiatric involvement to manage the aggressor's behavior and reduce altercations.

The complaint investigation found substantiated incidents of resident-to-resident abuse involving five residents (#1, #2, #3, #4, and #5). Multiple incidents of physical and verbal abuse were documented, with some residents requiring 1:1 supervision and hospital transfers. Staff interviews confirmed witnessing altercations and described interventions and training related to abuse prevention.

The facility failed to protect five residents from abuse by other residents, resulting in verbal and physical altercations. Staff interventions and care plans were reviewed, and incidents included resident-to-resident aggression causing injuries and requiring increased supervision and transfers.

The complaint investigation involved incidents where resident #4 physically assaulted resident #5, resident #2 hit resident #3, and resident #3 made contact with resident #1. Some residents required hospital transfer or 1:1 supervision. The allegations were substantiated based on clinical record reviews, staff and resident interviews, and policy review.

The facility failed to protect five residents from abuse by other residents, resulting in verbal and physical altercations. Staff interventions included 1:1 supervision, separation of residents, hospital transfers, and behavioral management. The facility had policies and training in place but incidents still occurred.

Complaint survey citing two deficiencies related to abuse prevention.

The complaint investigation focused on allegations of resident-to-resident abuse, failure to complete required assessments, medication errors including controlled substance handling and administration outside of parameters, unsafe medication practices, and inadequate monitoring of dialysis resident weights and vital signs. The investigation included record reviews, staff interviews, and observations. The findings substantiated failures in protecting residents from abuse and ensuring safe medication and care practices.

The facility failed to protect residents from abuse by other residents, failed to complete a quarterly Minimum Data Set (MDS) assessment timely for one resident, failed to ensure controlled medications were properly administered and accounted for, failed to prevent medication administration outside physician parameters, failed to ensure safe medication supervision, and failed to monitor significant weight changes in a resident receiving dialysis.

The complaint investigation involved incidents of resident-to-resident abuse including physical altercations between residents #1 and #460, #71 and roommate, and #92 and #117. The facility failed to protect residents from abuse and did not follow proper abuse reporting and intervention protocols. Additionally, issues were found with medication administration and documentation, including controlled substances and insulin administration outside prescribed parameters.

The facility failed to protect residents from abuse by other residents, with multiple incidents documented involving physical altercations and verbal disputes. Additionally, the facility failed to ensure controlled medications were properly administered and accounted for according to professional standards, including improper documentation and administration of insulin outside prescribed parameters.

The complaint investigation involved multiple incidents of resident-to-resident abuse involving residents #1, #460, #71, #92, #117, and others. The facility was found to have failed to protect residents from abuse and failed to follow abuse reporting protocols. The investigation also included review of medication administration practices revealing failures in controlled medication handling and administration.

The facility failed to protect multiple residents from abuse by other residents, resulting in verbal and physical altercations without adequate prevention. Additionally, the facility failed to ensure controlled medications were properly administered, accounted for, and wasted according to professional standards and facility policies, including several instances of medication given outside prescribed parameters.

The complaint investigation focused on allegations of resident-to-resident abuse, failure to complete timely assessments, medication errors including controlled substance handling, medication safety hazards, and inadequate dialysis care monitoring. The investigation included interviews, record reviews, and policy reviews. The complaint was substantiated with findings of minimal harm or potential for actual harm.

The facility failed to protect residents from abuse by other residents, failed to complete a quarterly Minimum Data Set (MDS) assessment timely for one resident, failed to ensure controlled medications were properly administered and accounted for, failed to prevent medication accident hazards for one resident, and failed to ensure safe monitoring of vital signs and weights for a resident on dialysis. These deficiencies could result in harm or potential harm to residents.

State compliance survey with ten deficiencies including abuse prevention, assessments, care plans, accident hazards, dialysis monitoring, and premises safety.

Recertification survey for Medicare under Life Safety Code 2012 with four deficiencies related to emergency preparedness, egress doors, corridor doors, and HVAC maintenance.

The complaint investigation was substantiated with findings of multiple resident-to-resident altercations occurring between November 13, 2023 and January 31, 2024. Incidents involved residents #1, #2, #3, #4, #5, #6, #7, and #9. Staff intervened, conducted skin checks, notified appropriate parties, and implemented safety measures including 15-minute interval checks and 1:1 supervision. No serious injuries were reported.

The facility failed to ensure that five residents were free from abuse by other residents, with multiple documented incidents of resident altercations involving physical contact but no serious injuries. Staff intervened appropriately, conducted investigations, and implemented 15-minute interval checks and other behavioral supports.

The complaint investigation substantiated multiple resident-to-resident abuse incidents occurring between November 13, 2023 and January 31, 2024. Investigations revealed physical contact such as hitting, kicking, and wheelchair collisions. Staff interviews confirmed training on abuse prevention and intervention. Notifications and follow-up actions were documented.

The facility failed to ensure that five residents were free from abuse by other residents, with multiple documented incidents of physical altercations involving residents in wheelchairs or during therapy sessions. Staff intervened promptly in each case, conducted skin assessments, and implemented 15-minute interval checks. No serious injuries were reported, but minor abrasions and behavioral interventions were noted.

Complaint survey citing two deficiencies related to abuse prevention.

The investigation was complaint-driven, focusing on substantiated incidents of resident-to-resident abuse involving resident #99, with findings confirming ongoing abuse and inadequate care planning.

The facility failed to ensure resident #99 was free from physical abuse by other residents, with multiple documented incidents of wandering into other residents' rooms, resulting in physical altercations and injury. The facility lacked appropriate care plan interventions despite repeated incidents and staff interviews confirmed ongoing issues and policy expectations.

The complaint investigation found substantiated incidents of resident-to-resident abuse involving resident #99, including physical altercations and harm such as reddening of the face after being slapped by another resident.

The facility failed to ensure that resident #99 was free from physical abuse by other residents, with multiple documented incidents of wandering into other residents' rooms, resulting in physical altercations and harm. The facility lacked appropriate care plan interventions for these behaviors despite ongoing incidents.

Complaint survey citing two deficiencies related to abuse prevention.

The facility was found deficient in several areas including failure to obtain informed consent for psychotropic medication, failure to complete weekly weights as ordered, inconsistent provision of restorative nursing services, lack of pre and post dialysis weight monitoring, and incomplete documentation of advanced directives and code status in clinical records.

The facility was found deficient in ensuring informed consent for psychotropic medication, completing weekly weights as ordered, providing consistent restorative nursing services, monitoring pre- and post-dialysis care, and maintaining accurate clinical records regarding advanced directives. Deficiencies were generally of minimal harm or potential for actual harm affecting a few or some residents.

The facility was found deficient in multiple areas including failure to honor residents' rights to dignity, inconsistent advanced directives documentation, failure to report injuries of unknown origin, inaccurate Minimum Data Set assessments, incomplete PASRR screenings, incomplete baseline care plans and discharge planning, inadequate pressure ulcer care, administration of medications outside ordered parameters, lapses in infection control practices including hand hygiene and equipment disinfection, and failure to administer and document influenza and pneumococcal vaccinations.

The facility was found deficient in multiple areas including failure to ensure residents were treated with dignity (knocking before entering rooms), inconsistent advanced directives documentation, failure to report injury of unknown origin, inaccurate Minimum Data Set assessments, incomplete PASRR screening, delayed baseline care plans, ineffective discharge planning, inadequate pressure ulcer care, administration of medications outside ordered parameters, lapses in infection control practices, and failure to administer or document influenza and pneumococcal vaccinations.