30 Reports
Inspection Report — May 19, 2026
Complaint Investigation
Date: May 19, 2026
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On-site complaint investigation at a Nursing Care Institution, conducted 19 May 2026.
Complaint Details
An offsite follow up survey was conducted on May 19, 2026. There were no deficiencies cited.
Findings
This inspection resulted in no citations or deficiency findings.
Inspection Report — Apr 14, 2026
Complaint Investigation
Date: Apr 14, 2026
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On-site complaint investigation of complaints 00162367, 00160989, 00160990, 00160860, 00160798, 00160694 and 00164688 at a Nursing Care Institution, conducted 14 April 2026.
Complaint Details
The complaint survey was conducted on April 14, 2026, investigating intake numbers 00162367, 00160989, 00160990, 00160860, 00160798, 00160694 and 00164688. Federal complaint intake numbers investigated included 2806523, 2792598, 2794662, 2794647, 2791701, 2793301, and 2974567.
Findings
Two deficiencies were cited related to failure to protect residents from abuse. One deficiency involved failure to protect residents from physical abuse by another resident; the other deficiency had no evidence text provided.
Deficiencies (2)
§483.12 — The facility failed to protect the resident’s right to be free from physical abuse by another resident for two of the four sampled residents (#2 and #3). This deficient practice could place residents at risk for physical harm, injury and psychological distress.
R9-10-410 — No evidence text provided for this deficiency related to abuse.
Report Facts
Deficiencies cited: 2
Inspection Report — Feb 9, 2026
Complaint Investigation
Date: Feb 9, 2026
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On-site complaint investigation of intake #00156965 at Casas Adobes Post Acute Rehab Center, conducted 9 February 2026.
Complaint Details
An onsite complaint survey was conducted on February 9, 2026 for the investigation of intake #00156965. Federal comments noted compliance with 42 CFR Part 483 for intake #2724310.
Findings
This inspection resulted in no citations or deficiency findings.
Report Facts
Complaints investigated: 1
Inspection Report — Jan 15, 2026
Date: Jan 15, 2026
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On-site inspection of type Other at Casas Adobes Post Acute Rehab Center, conducted 15 January 2026, with a Nursing Care Institution worksheet.
Findings
Two deficiencies were found related to fire safety and corridor door maintenance. One deficiency lacked evidence details, while the other noted failure to maintain patient room corridor doors, posing potential harm to residents.
Deficiencies (2)
No evidence text provided for the deficiency related to cooking facilities protection according to NFPA 96.
Corridor - Doors — The facility failed to maintain proper maintenance of patient room corridor doors, which could cause harm to residents.
Report Facts
Deficiencies cited: 2
Inspection Report — Jan 7, 2026
Complaint Investigation
Date: Jan 7, 2026
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On-site complaint investigation of intakes #2703088, #2699684, #2692878, #2626007, #2624925, #2618706, and #2617097 at a Nursing Care Institution, conducted 7 January 2026.
Complaint Details
An onsite complaint survey was conducted on January 7, 2026 for the investigation of intakes #2703088, #2699684, #2692878, #2626007, #2624925, #2618706, and #2617097. There are no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Nov 19, 2025
Complaint Investigation
Date: Nov 19, 2025
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On-site complaint investigation of complaints 00144695, 00146219, 2615156 and 2629784 at a Nursing Care Institution, conducted between October 1 and November 19, 2025.
Complaint Details
The onsite complaint survey investigated complaints #00144695 and 00146219 as well as complaints #2615156 and 2629784. No deficiencies were noted.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 4
Inspection Report — Aug 29, 2025
Complaint Investigation
Date: Aug 29, 2025
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On-site complaint investigation of complaints 2602755, 00142454, and 2601512 at a Nursing Care Institution, conducted 29 August 2025.
Complaint Details
The investigation of complaints 2602755 and 00142454 was conducted on August 29, 2025. The investigation of complaints 2602755 and 2601512 was conducted on August 29, 2025. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Aug 22, 2025
Complaint Investigation
Date: Aug 22, 2025
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On-site complaint investigation of intake numbers 00141042, 00140931, 00224963, 00215931, and 00215929 at a Nursing Care Institution, conducted 22 August 2025.
Complaint Details
The complaint survey was conducted on August 22, 2025, investigating intake numbers 00141042, 00140931, 00224963, 00215931, and 00215929. Federal intake numbers 2589820, 2588627, 2237490, 2237370, and 2237378 were also investigated. No deficiencies were cited.
Findings
No deficiencies were found during this complaint investigation.
Report Facts
Complaints investigated: 5
Complaints investigated: 5
Inspection Report — Jun 21, 2025
Complaint Investigation
Date: Jun 21, 2025
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On-site complaint investigation of multiple complaints at a Nursing Care Institution, conducted 21 June 2025.
Complaint Details
AMENDED September 9, 2025: The investigation of Complaints AZ00201744, AZ00201740, AZ00195202, AZ00195993, AZ00195445, AZ00195514, AZ00193123, AZ00192742, AZ00192844, AZ00192634, AZ00192588, AZ00195417, AZ00195250, AZ00191747, AZ00190303, AZ00190187, AZ00190229, AZ00190142, AZ00187466, AZ00192122, AZ00192191, AZ00193542, AZ00195261, AZ00194757, AZ00194184, AZ00194138, AZ00194194, AZ00193968, AZ00194050, AZ00194030, AZ00194006, AZ00193864, AZ00193934, AZ00195641, AZ00200653, AZ00199792, AZ00197111, AZ00197115, AZ00204017, AZ00197196, AZ00198803, AZ00196309, AZ00195635, AZ00202316, AZ00202336, AZ00201064, AZ00201742, AZ00201723, AZ00201706, AZ00200828, AZ00200593, AZ00200776, AZ00204811, AZ00205789, AZ00209113, AZ00209459, AZ00209754, AZ00208366, AZ00209935, AZ00210210, AZ00210222, AZ00210296, AZ00211172, AZ00212341, AZ00214302, AZ00215931, AZ00203899, AZ00201029, AZ00201945, AZ00203456, AZ00196015, AZ00195538 was conducted on June 17, 2025 through June 21, 2025.
Findings
The inspection found four deficiencies related to failure to follow physician orders, failure to prevent resident abuse, and medication administration errors. Plans of correction were provided for three deficiencies; one deficiency had no plan provided.
Deficiencies (4)
R9-10-403 — The facility failed to ensure physician orders were followed as written based on record review, staff interviews, and policy review.
§483.12 — The facility failed to ensure that two residents did not abuse other residents, risking physical harm.
§483.45 — The facility failed to ensure medications were administered as ordered by the physician for one resident (#10), risking medication errors and uncontrolled pain.
R9-10-410 — The facility failed to ensure that residents were not abused based on clinical records, policy review, and staff interviews.
Report Facts
Deficiencies cited: 4
Inspection Report — May 6, 2025
Complaint Investigation
Date: May 6, 2025
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On-site complaint investigation of intakes AZ00220230, AZ00191036, AZ00190998, AZ00189966, AZ00189948, and 00127006 at a Nursing Care Institution, conducted 6 May 2025.
Complaint Details
A complaint survey was conducted on May 06, 2025 for the investigation of intakes #'s: AZ00220230, AZ00191036, AZ00190998, AZ00189966, AZ00189948, 00127006. Federal comments also reference complaint intakes AZ00220225, AZ00191035, AZ00190998, AZ00189967, AZ00189948, AZ00224188. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 6
Inspection Report — Mar 3, 2025
Complaint Investigation
Date: Mar 3, 2025
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On-site complaint investigation of intakes 00108851, AZ00223435, and AZ00223460 at a Nursing Care Institution, conducted 3 March 2025.
Complaint Details
An onsite complaint survey was conducted on February 27, 2025 through March 3, 2025 for intake 00108851, AZ00223435, and AZ00223460. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Feb 10, 2025
Complaint Investigation
Date: Feb 10, 2025
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On-site complaint investigation of intake AZ00222699 at a Nursing Care Institution, conducted 10 February 2025.
Complaint Details
An onsite complaint survey was conducted on February 10, 2025 for the investigation of intake # AZ00222699. There were no deficiencies cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Jan 22, 2025
Complaint Investigation
Date: Jan 22, 2025
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On-site complaint investigation of intake numbers AZ00222206 and AZ00222205 at a Nursing Care Institution, conducted 22 January 2025.
Complaint Details
An onsite complaint survey was conducted on January 22, 2025 for the investigation of intake # AZ00222206 and intake # AZ00222205. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Dec 10, 2024
Complaint Investigation
Date: Dec 10, 2024
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On-site complaint investigation of intakes AZ00219730, AZ00203645, AZ00201129, AZ00200510, and AZ00200438 at a Nursing Care Institution, conducted 10 December 2024.
Complaint Details
An onsite complaint survey was conducted on December 10, 2024 for the investigation of intake # AZ00219730, AZ00203645, AZ00201129, AZ00200510, AZ00200438. Federal comments also note investigation of intake # AZ00219724, AZ00203642, AZ00201128, AZ00200508, AZ00200438. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Sep 30, 2024
Complaint Investigation
Date: Sep 30, 2024
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On-site complaint investigation of complaint AZ00216435 at a Nursing Care Institution, conducted 30 September 2024. The investigation also included complaint AZ00216432 as noted in the Federal Comments.
Complaint Details
An onsite complaint survey was conducted on September 30, 2024 for the investigation of AZ00216435 and AZ00216432. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Sep 4, 2024
Complaint Investigation
Date: Sep 4, 2024
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On-site complaint investigation of intakes AZ00215241, AZ00215096, and AZ00215240 at a Nursing Care Institution, conducted 3-4 September 2024.
Complaint Details
An onsite complaint survey was conducted on September 3, 2024 through September 4, 2024 for the investigation of intake # AZ00215241 and AZ00215096. Federal comments note investigation of intake # AZ00215240 and AZ00215096. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Aug 9, 2024
Complaint Investigation
Date: Aug 9, 2024
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On-site complaint investigation of multiple complaints including AZ00139941, AZ00152944, AZ00159316, AZ00159483, AZ00159816, AZ00161635, AZ00161660, AZ00163878, AZ00164787, AZ00172245, AZ00181008, AZ00173873, AZ00172356, AZ00176140, AZ00173588, AZ00163446, AZ00181528, AZ00176364, AZ00177118, AZ00164891, AZ00181414, AZ00165363, AZ00181680, AZ00173130, AZ00173008, AZ00165362, AZ00175799, AZ00181854, AZ00164236, AZ00159816, AZ00162921, AZ00165003, AZ00172694, AZ00178477, AZ00178820, AZ00179778, AZ00180482, AZ00181800, AZ00181993, AZ00182652, AZ00181272, AZ00182345, AZ00182675, AZ00183034, AZ00183383, AZ00175640, AZ00175884, AZ00180462, AZ00176302, AZ00179854, AZ00180963, AZ00175798, AZ00180480, AZ00179374, AZ00181128 at a Nursing Care Institution, conducted 5 to 9 August 2024.
Complaint Details
A complaint survey was conducted from August 5 through August 9, 2024 for multiple intakes including AZ00139941, AZ00152944, AZ00159316, AZ00159483, AZ00159816, AZ00161635, AZ00161660, AZ00163878, AZ00164787, AZ00172245, AZ00181008, AZ00173873, AZ00172356, AZ00176140, AZ00173588, AZ00163446, AZ00181528, AZ00176364, AZ00177118, AZ00164891, AZ00181414, AZ00165363, AZ00181680, AZ00173130, AZ00173008, AZ00165362, AZ00175799, AZ00181854, AZ00164236, AZ00159816, AZ00162921, AZ00165003, AZ00172694, AZ00178477, AZ00178820, AZ00179778, AZ00180482, AZ00181800, AZ00181993, AZ00182652, AZ00181272, AZ00182345, AZ00182675, AZ00183034, AZ00183383, AZ00175640, AZ00175884, AZ00180462, AZ00176302, AZ00179854, AZ00180963, AZ00175798, AZ00180480, AZ00179374, AZ00181128.
Findings
The inspection found two deficiencies related to resident abuse and failure to prevent elopement. The facility failed to ensure residents were not subjected to abuse and did not adequately prevent two residents from eloping.
Deficiencies (2)
R9-10-410 — The facility failed to ensure 15 residents were not subjected to abuse, including incidents of resident-to-resident altercations resulting in physical contact and agitation.
R9-10-425 — The facility failed to ensure residents were free from conditions causing physical injury by not preventing two residents from eloping despite known high risk.
Report Facts
Deficiencies cited: 2
Inspection Report — Jul 11, 2024
Complaint Investigation
Date: Jul 11, 2024
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On-site complaint investigation of intakes AZ00212822, AZ00212697, AZ00200342, AZ00200028, AZ00199513, AZ00212820, AZ00212696, AZ00200340, and AZ00200027 at a Nursing Care Institution, conducted 11 July 2024.
Complaint Details
An onsite complaint survey was conducted on July 11, 2024 for the investigation of intake # AZ00212822, AZ00212697, AZ00200342, AZ00200028, AZ00199513. Federal comments also note investigation of intake # AZ00212820, AZ00212696, AZ00200340, AZ00200027. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Jun 14, 2024
Complaint Investigation
Date: Jun 14, 2024
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The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent resident-to-resident abuse involving Resident #55 as the aggressor and Resident #44 as the victim.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect residents from all types of abuse including physical abuse by another resident.
Report Facts
Incidents of aggression: 5
Medication review date: Apr 18, 2023
Interview date: Jun 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #21 | Licensed Practical Nurse (LPN) | Interviewed about prevention of resident-to-resident altercations |
| Staff #31 | Director of Nursing (DON) | Provided details on handling of resident altercations and facility interventions |
| Staff #51 | Operations Manager | Participated in interview regarding resident altercations |
| Staff #41 | Visiting Director of Nursing | Participated in interview regarding resident altercations |
| Staff #61 | Clinical Resource Staff | Participated in interview regarding resident altercations |
Inspection Report — Apr 12, 2024
Complaint Investigation
Date: Apr 12, 2024
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On-site complaint investigation of complaints AZ00201994, AZ00208648, AZ00201133, AZ00199531, AZ00201993, AZ00208645, AZ00201132 and AZ00199531 at a Nursing Care Institution, conducted 11 and 12 April 2024.
Complaint Details
The complaint survey was conducted on April 11 and April 12, 2024 for the investigation of intake numbers AZ00201994, AZ00208648, AZ00201133, AZ00199531, AZ00201993, AZ00208645, AZ00201132 and AZ00199531.
Findings
The inspection found two deficiencies related to failure to protect residents from abuse by other residents. The facility did not ensure residents' rights to be free from abuse were upheld, resulting in incidents involving multiple residents.
Deficiencies (2)
§483.12 — The facility failed to protect five residents from abuse by other residents, resulting in physical altercations causing injury and requiring hospital transfer for one resident.
R9-10-410 — The administrator failed to ensure residents were not subjected to abuse, as evidenced by multiple incidents of resident-on-resident aggression and inadequate prevention measures.
Report Facts
Deficiencies cited: 2
Complaints investigated: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #8 | Certified Nursing Assistant | Witnessed incident between residents #4 and #5 and separated them. |
| Staff #3 | Certified Nursing Assistant | Witnessed altercation between residents #2 and #3 and separated them. |
Inspection Report — Mar 29, 2024
Date: Mar 29, 2024
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On-site inspection of type Other with Nursing Care Institution worksheet at Casas Adobes Post Acute Rehab Center conducted 29 March 2024.
Findings
The inspection found four deficiencies related to emergency preparedness planning, exit door locking mechanisms, corridor door maintenance, and fire/smoke damper inspections. The facility acknowledged the findings and provided plans of correction.
Deficiencies (4)
Based on record review and interview the facility failed to maintain their Emergency Preparedness Plan on the community risk assessments. The facility Emergency Plan had two separate facility based risk assessments with differing top risks, which may cause harm during an emergency.
NFPA 101 Life Safety Code 2012 Chapter 19 Section 19.2.2.2.4 — The facility failed to maintain special locking exit doors so that the force required to release the doors exceeded the allowed limit, with panic bars activating irreversible release at 28 and 35 lbf instead of less than 15 lbf.
NFPA 101 Life Safety Code 2012 Chapter 19 Section 19.3.6.3.5 — The facility failed to maintain several corridor doors, including door 619 which had excessive gaps allowing heat and smoke transfer, potentially harming patients and staff.
NFPA 101 Life Safety Code 2012 Chapter 21 Section 21.5.2.1 — The facility failed to inspect and maintain fire/smoke dampers or fusible links, with the last documented inspection dated March 28, 2019, which may cause harm during an emergency.
Report Facts
Deficiencies cited: 4
Inspection Report — Mar 28, 2024
Annual Inspection
Date: Mar 28, 2024
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On-site complaint investigation of multiple complaints including AZ00207452, AZ00206016, AZ00198485, AZ001999482, AZ00199510, AZ00208271, AZ00206112, AZ00198646, conducted in conjunction with a Compliance (Annual) Nursing Care Institution survey from March 25 to March 28, 2024.
Complaint Details
A State compliance survey was conducted March 25-28, 2024, in conjunction with investigation of intake numbers AZ00207452, AZ00206016, AZ00198485, AZ001999482, AZ00199510, AZ00208271, AZ00206112, AZ00207452, AZ00208271, and AZ00198646. Federal comments noted recertification survey conducted with investigation of intake numbers AZ00207451, AZ00198483, AZ00199479, AZ00206015, AZ00206065, AZ00199509, AZ00208270, AZ00206112, AZ00199222, and AZ00198646.
Findings
The inspection identified 10 deficiencies related to resident abuse prevention, timely completion of quarterly assessments, medication administration and accountability, accident hazard prevention, dialysis monitoring, and care planning. Plans of correction were provided for all deficiencies.
Deficiencies (10)
§483.12 — The facility failed to protect the rights of three residents to be free from abuse by other residents, resulting in inadequate protection from further abuse.
§483.20(c) — The facility failed to complete a quarterly Minimum Data Set assessment on time for one resident, risking delayed identification of care needs.
§483.21(b)(3) — The facility failed to ensure controlled medications were properly provided and accounted for four residents, risking medication diversion.
§483.25(d) — The facility failed to ensure one resident was free from accident hazards by leaving medications unattended at the bedside without an order for self-administration.
§483.25(l) — The facility failed to ensure safe monitoring of vital signs and weights for one resident receiving dialysis, risking complications.
R9-10-410 — The facility failed to prevent verbal and physical altercations between two residents, despite staff intervention and abuse prevention policies.
R9-10-414 — The facility failed to complete a quarterly Minimum Data Set assessment within the required timeframe for one resident, risking delayed care planning.
R9-10-414 — The facility failed to ensure controlled medications were provided and accounted for according to professional standards for four residents, risking diversion.
R9-10-417 — The facility failed to provide dialysis services in compliance with monitoring requirements, including failure to re-weigh a resident after significant weight changes.
R9-10-425 — The facility failed to ensure one resident was free from conditions that could cause physical injury by leaving medications unattended at the bedside without authorization.
Report Facts
Deficiencies cited: 10
Complaints investigated: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #117 | Involved in abuse incident with resident #92 | |
| Staff #460 | Involved in abuse incident with resident #1 | |
| Staff #194 | Nurse | Signed medication waste record for Hydrocodone-Acetaminophen; involved in controlled medication administration |
| Staff #176 | Administered tramadol to resident #27 | |
| Staff #88 | Licensed Practical Nurse | Interviewed regarding controlled medication wasting procedures |
| Staff #80 | Licensed Practical Nurse | Interviewed regarding controlled medication administration and wasting |
| Staff #51 | Director of Nursing | Interviewed regarding medication administration expectations and abuse prevention |
| Staff #180 | Licensed Practical Nurse | Interviewed regarding medication administration and leaving pills unattended |
| Staff #172 | Certified Nursing Assistant | Interviewed regarding medication administration observations |
| Staff #108 | Licensed Practical Nurse | Interviewed regarding resident medication administration |
| Staff #52 | Behavioral Health Unit Manager | Interviewed regarding abuse in-service training and incident reporting |
| Staff #138 | Certified Nursing Assistant | Interviewed regarding resident altercation |
| Staff #49 | Nurse Manager | Interviewed regarding weight monitoring and dialysis resident care |
| Staff #153 | Certified Nursing Assistant | Interviewed regarding vital signs monitoring |
| Staff #166 | Dietetic Technician, Registered | Interviewed regarding weight monitoring and follow-up |
| Staff #174 | Licensed Practical Nurse | Interviewed regarding weight change concerns |
| Staff #195 | Dietetic Technician, Registered | Documented significant weight loss and suggested re-weigh |
| Staff #196 | Nurse Manager | Interviewed regarding weight monitoring and communication |
Inspection Report — Mar 28, 2024
Complaint Investigation
Date: Mar 28, 2024
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The inspection was conducted to investigate complaints related to resident-to-resident abuse, failure to complete timely quarterly assessments, medication administration errors, medication safety, accident hazards, and dialysis care monitoring at Casas Adobes Post Acute Rehab Center.
Complaint Details
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.
Findings
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.
Deficiencies (6)
Failed to protect residents (#1, #460, #71, #92, #117) from abuse by other residents.
Failed to complete a quarterly Minimum Data Set (MDS) assessment timely for resident #47.
Failed to ensure controlled medications were provided and accounted for in accordance with professional standards for residents #52, #358, #27.
Administered Insulin Glargine outside of physician ordered parameters for resident #118 on 8 occasions.
Failed to ensure resident #124 was free from accident hazards related to medication self-administration and supervision.
Failed to ensure resident #84 received safe monitoring of vital signs and weights related to dialysis care.
Report Facts
Deficiencies cited: 6
Insulin Glargine administrations outside parameters: 8
Weight loss: 41
Weight gain: 20.4
Medication waste entries: 2
Medications left at bedside: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #52 | Behavioral Health Unit Manager | Interviewed regarding abuse in-service training and abuse reporting procedures. |
| Staff #138 | Certified Nursing Assistant | Interviewed about abuse protocol and familiarity with residents involved in altercation. |
| Staff #49 | Registered Nurse | Interviewed about reporting physical contact incidents and abuse protocol. |
| Staff #51 | Director of Nursing | Interviewed multiple times regarding abuse expectations, medication administration, and weight monitoring. |
| Staff #91 | MDS Coordinator | Interviewed about missing quarterly MDS assessment for resident #47. |
| Staff #194 | Nurse | Signed medication waste record for Hydrocodone-Acetaminophen on February 5, 2024. |
| Staff #88 | Licensed Practical Nurse | Interviewed about controlled medication wasting procedures. |
| Staff #80 | Licensed Practical Nurse | Interviewed about controlled medication administration and wasting procedures. |
| Staff #189 | Registered Nurse | Interviewed about administration of Insulin Glargine outside parameters. |
| Staff #180 | Licensed Practical Nurse | Interviewed about medication administration and supervision. |
| Staff #172 | Certified Nursing Assistant | Interviewed about medication supervision and pills found at bedside. |
| Staff #108 | Licensed Practical Nurse | Interviewed about resident medication self-administration supervision. |
| Staff #196 | Nurse Manager | Interviewed about dialysis resident weight monitoring and notification procedures. |
| Staff #153 | Certified Nursing Assistant | Interviewed about vital signs and weight monitoring for dialysis residents. |
| Staff #174 | Licensed Practical Nurse | Interviewed about weight change concerns and notification. |
| Staff #166 | Dietetic Technician, Registered | Interviewed about weight monitoring and follow-up for dialysis residents. |
Inspection Report — Feb 14, 2024
Complaint Investigation
Date: Feb 14, 2024
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On-site complaint investigation of intakes AZ00205896, AZ00202477, AZ00203131, AZ00203446, AZ00203559, and AZ00203621 at a Nursing Care Institution, conducted 13-14 February 2024.
Complaint Details
A complaint survey was conducted on February 13-14, 2024 for the investigation of intake numbers AZ00205896, AZ00202477, AZ00203131, AZ00203446, AZ00203559, and AZ00203621. Federal comments also referenced investigations of intake numbers AZ00205896, AZ00203618, AZ00203559, AZ00203446, AZ00203448, AZ00202482, and AZ00203131.
Findings
The inspection found two deficiencies related to failure to ensure residents were free from abuse by other residents. The facility documented resident-to-resident altercations with no injuries but failed to prevent these incidents.
Deficiencies (2)
§483.12 — The facility failed to ensure that five residents were free from abuse by other residents, including incidents where residents hit or kicked others, resulting in resident-to-resident altercations without injuries but requiring monitoring and notifications.
R9-10-410 — The administrator failed to ensure that five residents were free from abuse by other residents, with documented incidents of physical altercations and inadequate prevention measures despite staff training and monitoring.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #81 | Certified Nursing Assistant | Interviewed regarding abuse and neglect training and intervention. |
| Staff #20 | Behavioral Health Unit Manager | Interviewed about unit staffing, resident placement, and abuse prevention training. |
| Staff #37 | Restorative Nurse Assistant | Reported resident-to-resident incident involving residents #3 and #9. |
| Staff #133 | Operations Manager | Conducted follow-up visits after resident altercation. |
Inspection Report — Jan 30, 2024
Complaint Investigation
Date: Jan 30, 2024
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On-site complaint investigation of intake AZ00205704 and AZ00205702 at a Nursing Care Institution, conducted 30 January 2024.
Complaint Details
A complaint survey was conducted on January 30, 2024 for the investigation of intake #AZ00205704. A complaint survey was conducted on January 30, 2024 for the investigation of intake #AZ00205702. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Nov 22, 2023
Complaint Investigation
Date: Nov 22, 2023
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On-site complaint investigation of multiple complaints including AZ00190459, AZ00190534, AZ00190923, AZ00192923, AZ00192904, AZ00193291, AZ00203185 and AZ00203206 at a Nursing Care Institution, conducted 21-22 November 2023.
Complaint Details
A complaint survey was conducted on November 21, 2023 through November 22, 2023 for the investigation of intake #s AZ00190459, AZ00190534, AZ00190923, AZ00192923, AZ00192904, AZ00193291, AZ00203185 and AZ00203206. Federal comments noted investigation of intake #s AZ00190459, AZ00190533, AZ00190923, AZ00192923, AZ00192904, AZ00193290, AZ00203184 and AZ00203205.
Findings
The inspection found two deficiencies related to failure to ensure a resident (#99) was free from physical abuse by other residents. The facility did not add care plan interventions for documented wandering and abuse incidents, risking further resident-to-resident abuse.
Deficiencies (2)
§483.12 — 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 and resulting harm. No care plan interventions were added to address these behaviors.
R9-10-410 — The administrator failed to ensure resident #99 was protected from abuse by other residents, despite documented incidents and facility policies. Care planning did not address the resident's wandering and associated risks.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #23 | Licensed Practical Nurse | Interviewed regarding resident #99's wandering and abuse incidents. |
| Staff #49 | Director of Nursing | Interviewed regarding facility policy and handling of resident abuse incidents. |
Inspection Report — Jul 7, 2023
Complaint Investigation
Date: Jul 7, 2023
Visit Reason
On-site complaint investigation of complaints AZ00197392, AZ00197989, AZ00197080 and AZ00197186 at a Nursing Care Institution, conducted 6-7 July 2023.
Complaint Details
An onsite survey was conducted July 6, 2023 through July 7, 2023 and included investigation of the following complaints: #AZ00197392, AZ00197989, AZ00197080 and AZ00197186. No deficiencies were cited. A complaint survey was conducted July 6, 2023 through July 7, 2023 and included investigation of the following complaints: #AZ00197391, AZ00197989, AZ00197080 and AZ00197185. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Dec 8, 2022
Routine
Date: Dec 8, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, restorative nursing services, dialysis care, and clinical record accuracy at Casas Adobes Post Acute Rehab Center.
Findings
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.
Deficiencies (5)
Failure to ensure one of 5 sampled residents was informed of the risks and benefits of a psychotropic medication prior to administration.
Failure to ensure weekly weights for one resident were completed as ordered by the physician.
Failure to provide consistent restorative nursing services according to physician order for one resident.
Failure to ensure ongoing assessment and monitoring for complications before and after dialysis, including pre and post dialysis weights, for one resident.
Failure to ensure clinical record was accurate and complete regarding an advanced directive for one resident.
Report Facts
Sample size: 24
Medication administration days: 5
Weight recorded: 1
Weight value: 128.4
BIMS score: 2
BIMS score: 3
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding expectations for informed consent and nursing follow-through on physician orders | |
| Behavioral Unit Manager | Interviewed regarding responsibility for obtaining weekly weights | |
| Licensed Practical Nurse | Interviewed regarding inability to find weekly weights and dialysis weight monitoring | |
| Restorative Nursing Assistant | Interviewed regarding provision and documentation of restorative nursing services | |
| Social Services Director | Interviewed regarding advanced directive and code status documentation | |
| Social Services Staff | Interviewed regarding process for updating resident code status and paperwork |
Inspection Report — Dec 8, 2022
Annual Inspection
Date: Dec 8, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, restorative nursing services, dialysis care, and clinical record accuracy at Casas Adobes Post Acute Rehab Center.
Findings
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.
Deficiencies (5)
Failed to ensure one resident (#110) was informed of the risks and benefits of a psychotropic medication prior to administration.
Failed to ensure weekly weights for one resident (#12) were completed as ordered by the physician.
Failed to provide one resident (#84) consistent restorative nursing services according to physician order.
Failed to ensure ongoing assessment and monitoring for complications before and after dialysis for one resident (#12).
Failed to ensure the clinical record was accurate and complete regarding an advanced directive for one resident (#105).
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
BIMS scores: 2
Weight recorded: 128.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding informed consent for psychotropic medications and expectations for nursing care | |
| Behavioral Unit Manager | Interviewed regarding weekly weights for resident #12 | |
| Licensed Practical Nurse (LPN) staff #89 | Interviewed regarding missing weekly weights and dialysis monitoring | |
| Restorative Nursing Assistant (RNA) staff #9 | Interviewed regarding restorative nursing services for resident #84 | |
| Licensed Practical Nurse (LPN) staff #117 | Interviewed regarding advanced directive documentation and code status binder | |
| Social Services Director staff #87 and Social Services staff #73 | Interviewed regarding advanced directive changes and documentation |
Inspection Report — Sep 8, 2021
Routine
Date: Sep 8, 2021
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident rights, advanced directives, abuse reporting, assessments, care planning, wound care, medication administration, infection control, and immunizations.
Findings
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.
Deficiencies (11)
Failure to ensure staff knocked on resident room doors prior to entering, violating residents' rights to dignity and respect.
Failure to ensure advanced directives were consistent in the clinical record for one resident.
Failure to timely report an injury of unknown origin to the State Survey Agency.
Failure to ensure Minimum Data Set assessments were accurate for two residents.
Failure to ensure a Level I PASRR screening was completed prior to or upon admission for one resident.
Failure to develop and provide a baseline care plan within 48 hours of admission and provide a summary to resident/representative.
Failure to provide effective discharge planning involving the resident.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including inconsistent wound assessments and treatment.
Failure to ensure resident's drug regimen was free from unnecessary drugs by administering medications outside ordered parameters.
Failure to implement infection prevention and control program including hand hygiene, disinfection of multi-use equipment, and wound care practices.
Failure to develop and implement policies and procedures for flu and pneumonia vaccinations, including failure to administer vaccines and document consent or refusal.
Report Facts
Pressure ulcer measurements: 14
Pressure ulcer measurements: 4.5
Wound measurements: 3.8
Wound measurements: 5
Wound measurements: 10.5
Wound measurements: 5.5
Wound measurements: 2.8
Blood pressure: 101
Blood pressure: 56
Blood sugar: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #89 | Unit Manager / Licensed Practical Nurse | Interviewed regarding knocking policy, care planning, wound care, and infection control |
| Staff #135 | Director of Nursing | Interviewed regarding knocking policy, advanced directives, reporting, assessments, care planning, medication administration, wound care, infection control, and vaccination policies |
| Staff #67 | Certified Nursing Assistant | Interviewed regarding knocking policy |
| Staff #14 | MDS Coordinator / Licensed Practical Nurse | Interviewed regarding MDS assessment accuracy |
| Staff #72 | Assistant Social Services Staff | Interviewed regarding PASRR screening |
| Staff #95 | Licensed Practical Nurse | Interviewed regarding wound care and medication administration |
| Staff #136 | Wound Nurse / Licensed Practical Nurse | Observed and interviewed regarding wound care and infection control practices |
| Staff #45 | Certified Nursing Assistant | Observed and interviewed regarding hand hygiene and equipment disinfection |
| Staff #108 | Certified Nursing Assistant | Interviewed regarding hand hygiene and equipment disinfection |
| Staff #59 | Licensed Practical Nurse / Infection Prevention Nurse | Interviewed regarding infection control practices |
| Staff #134 | Executive Director | Interviewed regarding facility status and policies |
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CMS Survey — Mar 28, 2024
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