Inspection Reports for
Casas Adobes Post Acute Rehabilitation Center

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.

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 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.

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 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 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.

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.