Inspection Reports for
Mi Casa Nursing Center

The complaint was substantiated. The investigation revealed that the LPN did not perform the wound care as ordered on the night shift of September 3, 2025, but charted it as completed. The Director of Nursing suspended the nurse involved and confirmed the risk of missed wound treatment could lead to infection, additional surgery, or death.

The facility failed to accurately document and perform wound care for Resident #42 as ordered, resulting in a missed wound treatment on the night shift of September 3, 2025. The Licensed Practical Nurse charted the treatment as done but did not perform it, leading to potential risks including infection and prolonged healing.

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.

Recertification survey combined with complaint investigation citing 12 deficiencies related to administration policies, resident rights, infection control, food safety, and care planning.

The complaint investigation revealed substantiated deficiencies related to resident rights, care planning, therapy services, bowel and catheter care, infection control, and food handling practices. The resident (#65) was denied continuation of therapy despite insurance coverage. Resident (#98) lacked documented code status orders. Resident (#12) experienced untreated constipation and resident (#46) had inadequate catheter care. Infection control concerns were noted with a torn fall mat for resident (#2).

The facility failed to ensure a resident's right to continue specialized rehabilitative services, failed to order and care plan for a resident's code status, did not provide appropriate bowel and catheter care, failed to follow proper food handling practices, and did not maintain infection control measures for a resident. These deficiencies could result in loss of autonomy, inappropriate emergent care, complications from constipation and catheter care, risk of foodborne illness, and transmission of infection.

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.

Investigation citing one deficiency related to nursing personnel sufficiency.

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 by multiple resident interviews reporting long wait times for call-light responses (up to two hours), inadequate continence care, and staff shortages. Staff interviews confirmed short staffing and delayed care. Complaints were reported to the Director of Nursing and Staffing Coordinator, who acknowledged staffing shortages and efforts to address them.

The facility failed to provide adequate nursing staff to meet residents' needs timely, leading to delayed continence care, long wait times for call-light responses, and insufficient assistance with activities of daily living. Staffing shortages were confirmed through staff interviews, schedules, and resident complaints.

Complaint investigation citing four deficiencies including staffing, resident dignity, abuse prevention, and care plan nursing care.

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 substantiated issues of verbal abuse by CNA staff #313 towards resident #33, verbal abuse by a former CNA towards resident #47, physical and emotional abuse between residents #39 and #41, failure to provide consistent showers to multiple residents, and inadequate staffing levels impacting resident care and call light response times.

The facility failed to maintain resident dignity, resulting in verbal abuse by staff towards residents and physical/emotional abuse between residents. There were significant deficiencies in providing consistent showers to residents, and the facility was found to be inadequately staffed, impacting resident care and response times.

Complaint survey citing four deficiencies related to abuse prevention, quality of care, resident abuse, and care plan nursing care.

The complaint investigation included allegations that an LPN (staff #100) threw a television remote at resident #30 and removed batteries from it. The facility investigation was unable to substantiate abuse but identified a customer service issue, resulting in the LPN's termination. Another complaint involved resident-to-resident abuse where resident #15 was found to have gripped resident #20 causing pain and bruising; this allegation was substantiated.

The facility failed to protect residents from abuse by staff and other residents, with substantiated resident-to-resident abuse and an unsubstantiated staff abuse allegation resulting in staff termination. Additionally, the facility failed to provide appropriate wound care for a resident, leading to hospitalization.

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.

Life Safety Code recertification survey citing four deficiencies related to egress doors, corridor doors, electrical systems, and power cords.

State compliance survey combined with complaint investigation citing two deficiencies related to administrator policies and medication labeling.

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.

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 written baseline care plan summaries to residents or their representatives, failure to provide showers as scheduled for some 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.