Inspection Reports for
Mi Casa Nursing Center

The complaint investigation revealed that the LPN did not perform the wound care treatment on the night shift of September 3, 2025, but charted it as done. The Director of Nursing suspended the nurse involved after confirming the missed treatment and inaccurate documentation. The resident reported the missed treatment, and the risk of infection, further surgery, or death was noted.

The facility failed to accurately document and perform wound care treatment for one resident, resulting in a missed wound treatment on the night shift of September 3, 2025. The Licensed Practical Nurse (LPN) did not perform the wound care as ordered but charted it as completed, leading to concerns about resident safety and documentation accuracy.

The complaint investigation was substantiated with findings that the facility failed to honor resident rights to continue therapy, failed to document code status, failed to provide adequate bowel and catheter care, failed to follow food safety protocols, failed to provide ordered rehabilitative services, and failed infection control measures including use of torn fall mats.

The facility was found deficient in multiple areas including failure to honor resident choice in continuing rehabilitative services, failure to document and care plan for resident code status, inadequate bowel and catheter care, improper food handling practices, failure to provide specialized rehabilitative services as ordered, and failure to maintain infection control measures such as replacing a torn fall mat. These deficiencies posed risks of loss of autonomy, inappropriate emergent care, discomfort, infection, and reduced rehabilitation outcomes.

The investigation was complaint-driven, focusing on allegations of inadequate staffing and delayed call-light responses. Complaints were substantiated with interviews from residents, CNAs, and nursing staff confirming delays of up to two hours for assistance and continence care. The facility acknowledged staffing shortages and ongoing efforts to address them.

The facility failed to ensure adequate staffing to meet residents' needs, causing delays in continence care and assistance with activities of daily living. Multiple residents and staff reported long wait times for call-light responses and insufficient CNA coverage, particularly on Station 3. Staffing shortages were acknowledged by facility leadership.

The investigation was complaint-driven, substantiated due to inadequate staffing and multiple resident care concerns including abuse, dignity violations, and hygiene neglect.

The facility was found deficient in maintaining resident dignity, preventing verbal and physical abuse, providing consistent showers and hygiene care, and ensuring adequate staffing levels to meet resident needs. Multiple residents and staff interviews, clinical record reviews, and observations confirmed these deficiencies.

The complaint investigation included allegations that an LPN threw a television remote at a resident and removed batteries, which was unsubstantiated but noted as a customer service issue. Another complaint involved resident-to-resident abuse where resident #15 gripped resident #20 causing pain and bruising, which was substantiated.

The facility failed to protect residents from abuse by staff and other residents, resulting in substantiated and unsubstantiated abuse allegations. Additionally, the facility failed to provide appropriate wound care for a resident, leading to hospitalization. Deficiencies were noted in documentation and treatment compliance.

The facility failed to ensure that two medication carts were secured while left unattended, which could allow unauthorized access to medications. Observations and staff interviews confirmed unlocked medication carts on multiple occasions, posing a potential risk to resident safety.

The facility failed to ensure that two medication carts were secured while left unattended, which could allow unauthorized access to medications. Observations and staff interviews confirmed unlocked medication carts on multiple occasions during the inspection.

The facility was found deficient in multiple areas including failure to obtain physician orders for advance directives, failure to update PASARR Level 1 screening for residents staying longer than 30 days, failure to provide residents or their representatives with written baseline care plan summaries, failure to provide scheduled showers to residents, failure to provide timely and consistent pressure ulcer treatments, administration of opioid pain medication outside ordered parameters, and lack of monitoring for side effects and effectiveness of psychotropic medications.