Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mi Casa Nursing Center during CMS and state inspections, most recent first.
A resident with multiple neurologic and functional impairments, but intact cognition, reported feeling neglected after being left in a wet brief and requested that law enforcement be called. The resident’s spouse alleged that an RN and CNA provided rough care during a brief change, ignored the resident after he asked them to stop, and left his bed remote out of reach, and she filed police reports for abuse and neglect on two occasions. The ED documented the concern, briefly interviewed the resident and spouse, concluded that care had been provided, and decided not to report the later allegation to the State Survey Agency, APS, or other required entities because the resident’s account differed from his wife’s, despite facility policy requiring that all alleged violations of abuse or neglect be reported within specified timeframes regardless of how the allegation is characterized.
A resident with multiple neurologic and medical conditions, but intact cognition, reported feeling neglected after being left in a wet brief for several hours and requested that law enforcement be called. The resident’s wife alleged that an RN and CNA provided rough incontinence care after a urinal spill, ignored the resident’s pleas to stop, then ignored him for the rest of the night and left his bed remote out of reach; she stated that police reports were filed for two separate incidents and that the later allegation was not reported to any state agency. The Executive Director documented the concern, interviewed the resident and his wife, obtained staff statements, and concluded that care had been provided, deciding not to report the later allegation to the State Survey Agency, APS, or other required officials. This decision conflicted with facility policy, which required that all alleged violations of abuse or neglect, whether or not explicitly labeled as such and regardless of conflicting accounts, be reported within specified timeframes to the administrator and appropriate state authorities.
A resident with a PEG tube and intact cognition, dependent on staff for nutrition, repeatedly refused a bolus feeding and water flush, verbally saying no and physically pushing the tube away. An LPN, assisted by two CNAs, proceeded with the midnight bolus and flush while the resident attempted to kick and push the feeding away, and the CNAs held the resident’s hands and knees down so the LPN could continue the treatment. Facility documentation and staff records show that the staff forcefully administered the tube feeding flush against the resident’s expressed wishes, in violation of the resident’s rights to be free from abuse and to refuse treatment.
A resident with complex medical needs did not receive a required wound dressing change as ordered, and the LPN on duty charted the treatment as completed despite not performing it. The DON confirmed the omission after the resident reported the missed care, and facility policy requires accurate documentation of all treatments provided.
Two residents experienced deficiencies in bowel and bladder care, including a resident with severe cognitive impairment who did not receive timely intervention for constipation, resulting in hospitalization for severe fecal impaction, and another resident with an indwelling catheter who did not receive catheter care as ordered, with inconsistent documentation and no evidence of physician notification regarding missed care.
Staff were observed delivering and transporting uncovered beverages, such as coffee, water, and juice, to residents' rooms and bedside tables, including in areas with Enhanced Barrier Precautions. These actions did not follow facility expectations or infection control policies, as confirmed by interviews with dietary and nursing staff.
A resident with significant physical and cognitive impairments was found with a severely torn fall mat next to their bed, exposing internal materials and creating an infection control concern. Staff confirmed the mat could not be properly cleaned and should have been removed according to facility policy, which requires the removal of compromised equipment to prevent infection risks.
A resident with multiple health conditions and a recent fracture was not allowed to make an informed choice about continuing specialized rehab services, despite being cognitively intact and expressing a desire to continue therapy. The care plan did not reflect the resident's wishes, and staff communication failures led to the discontinuation of therapy, even though insurance coverage was still active.
A resident with a documented DNR advance directive did not have their code status entered into the electronic clinical record or incorporated into the care plan, as required by facility policy. The DNR order was only present in the hard chart, making it inaccessible to staff using electronic records, and the process for entering such directives was not consistently followed.
A resident admitted for orthopedic aftercare with multiple comorbidities did not receive ordered PT and OT services for an extended period, despite ongoing insurance coverage and medical necessity. Miscommunication among staff led to a gap in therapy, with no physician order for discharge and no documentation of the resident's rehab goals in the care plan. The resident was not included in care planning discussions and reported not understanding why therapy was stopped, resulting in unmet rehabilitation needs.
The facility failed to provide adequate staffing, resulting in delayed care for residents. A resident at risk for skin breakdown did not receive timely continence care, while another resident requiring assistance with transfers reported long wait times for call-light responses. Staff interviews confirmed the challenges posed by staffing shortages, with the facility's management acknowledging the issue but failing to resolve it effectively.
The facility failed to maintain adequate staffing levels, resulting in prolonged call light response times and unmet resident needs. Observations and interviews revealed that residents often waited over 30 minutes for assistance, with staffing levels falling short of the facility's requirements. The DON and Staffing Coordinator acknowledged the challenges in hiring sufficient CNAs, impacting the quality of care and posing risks to residents.
A resident with multiple health issues reported that a CNA was mean and disrespectful, turning off the call light without providing care. The CNA rudely told the resident to watch her tone and refused to let another CNA take over care. The DON confirmed the incident and noted the CNA's history of attitude concerns.
A facility failed to protect a resident from verbal abuse by a CNA, who had a history of inappropriate behavior. Additionally, the facility did not prevent physical and emotional abuse between two residents, one of whom used a backscratcher to hit the other. Interviews revealed a lack of staff intervention and inadequate implementation of abuse prevention policies, leading to an unsafe environment.
The facility failed to provide consistent showers to three residents, leading to hygiene issues and skin conditions. A resident who is completely dependent on staff for showers missed numerous scheduled showers, resulting in a rash. Another resident required extensive assistance and missed several showers, leading to untreated skin conditions. A third resident experienced long periods without showers, contributing to a recurring yeast rash. Interviews revealed ongoing staffing issues and unaddressed concerns despite repeated discussions.
A facility failed to protect residents from abuse, resulting in two incidents. In one case, a resident reported an LPN threw a remote at him, which the LPN denied, but another LPN corroborated the resident's account. The facility deemed the abuse unsubstantiated but terminated the LPN for poor service. In another case, a cognitively impaired resident gripped another resident's shoulders, causing pain. The facility substantiated this abuse. The facility's abuse prevention policy was not effectively implemented.
A resident with multiple chronic conditions experienced inadequate wound care management, leading to hospitalization. Despite treatment orders for cellulitis and blisters, the facility failed to consistently administer care, and the resident's noncompliance was not addressed in the care plan. Maggots were later found in the wound, prompting another hospital transfer. Interviews revealed that staff nurses were responsible for wound treatments, but documentation was lacking.
Failure to Report and Investigate Allegation of Staff-to-Resident Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse and neglect reporting policy after an allegation of staff-to-resident abuse and neglect involving Resident #70. Resident #70 had multiple significant diagnoses, including hemiplegia and hemiparesis, protein-calorie malnutrition, facial weakness, dysphagia, muscle weakness, aphasia following cerebral infarction, cognitive, social, or emotional deficit, frontal lobe and executive function deficit, atrial fibrillation, hydrocephalus, convulsions, and headache. An admission MDS showed a BIMS score of 14, indicating intact cognition, and documented that the resident had exhibited rejecting care behaviors. A care plan initiated in late December identified the resident as being at risk for alteration in psychosocial well-being due to staff failure to honor resident choices during care. On December 27, 2025, the Executive Director (ED) documented a Concern & Comment Form after the resident stated he felt neglected because he had been left in a wet brief for a few hours and requested that law enforcement be called for neglect. The form noted that the concern was reported to the ED and that the ED spoke with the resident and his wife that afternoon. The resident and his wife reported that he did not receive care upon arrival from the hospital. The ED’s handwritten investigation notes concluded the same day that the resident had received care throughout the night, including at arrival, at midnight, and when the nurse checked his feeding pump. The ED documented that the concern was resolved at the time it was shared and that the investigation findings were concluded within about 40 minutes. In a later interview, the resident’s wife reported that during the night in question, an RN and a CNA responded to the resident’s call light for a brief change after he spilled his bedside urinal, and that they turned him back and forth aggressively during the brief change despite his request for them to stop. She stated that the RN made a comment to the assisting staff that they needed to get out of the room or else the resident would get them fired, and that staff then ignored the resident for the rest of the night and left his bed remote out of reach. She also stated that two police reports had been filed regarding abuse and neglect during his stay, and that the incident from December 27, 2025, was not reported by the facility to any state agency except the police. The ED confirmed in interview that he was informed of the wife’s allegation of neglect on December 27, that he spoke with both the wife and the resident, and that because the resident contradicted the wife’s allegation, he decided not to report the incident to the State Survey Agency, APS, or other required entities, despite facility policy requiring that all alleged violations be reported. Staff interviews further described the events and the facility’s handling of the allegation. The RN identified as being involved stated that she did not recall any allegation of abuse, neglect, or rough care being made to her or against her, and denied ignoring the resident or making the statement about staff being fired. A CNA who assisted with care that night reported that the resident had a history of making allegations and that he received two-person care at all times; she described assisting with a full bed change after the resident spilled his urinal and later being contacted by the previous DON to write a statement after the resident reported that night shift had neglected him. Another CNA stated she was instructed to provide care in pairs because the resident was having issues with staff and reporting that no care was being given. Despite these multiple accounts and the wife’s explicit allegation of neglect, the ED acknowledged that he did not report the December 27 allegation to state agencies, relying instead on his own assessment that the incident was not abuse or neglect. Review of the facility’s policies showed that abuse included the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and that neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The reporting policy required that all alleged violations be reported immediately, but no later than 2 hours if abuse or serious bodily injury was involved, or within 24 hours if not, to the administrator and to other officials, including the State Survey Agency and APS. The policy also specified that an individual reporting an alleged violation did not need to label it as abuse or neglect for it to trigger a facility investigation and reporting, and that all alleged violations, whether oral or written, must be reported to the administrator and other officials in accordance with state law. Despite this, the ED stated that he did not report the December 27 allegation to any state agency because he did not deem it necessary after the resident contradicted his wife’s account, thereby failing to follow the facility’s abuse and neglect reporting policy for this allegation.
Failure to Report Alleged Staff-to-Resident Abuse and Neglect to Required Agencies
Penalty
Summary
The facility failed to report an incident involving alleged staff-to-resident abuse and neglect to the required state agencies after a resident and his wife reported concerns about his care. The resident had multiple significant medical conditions, including hemiplegia and hemiparesis, protein-calorie malnutrition, facial weakness, dysphagia, muscle weakness, aphasia following cerebral infarction, cognitive, social, or emotional deficit, frontal lobe and executive function deficit, atrial fibrillation, hydrocephalus, convulsions, and headache. An admission MDS showed a BIMS score of 14, indicating intact cognition, and documented that the resident had exhibited rejecting care behaviors for 1–3 days. A care plan focus was initiated for risk of alteration in psychosocial well-being related to staff failure to honor resident choices during care on a prior date. On a later date, the Executive Director (ED) completed a handwritten Concern & Comment Form after the resident stated he felt neglected because he had been left in a wet brief for a few hours and requested that law enforcement be called for neglect. The ED documented that the resident and his wife reported that he did not receive care upon arrival from the hospital, and the ED’s investigation concluded that the resident had received care throughout the night, including at midnight and when his feeding pump was checked. The ED recorded that the concern was resolved at the time it was shared and that the resident was informed that a specific RN would no longer provide his care, as requested. The facility’s internal investigation included obtaining written statements from staff about the incident. In a subsequent interview, the resident’s wife stated that during the night in question, an RN and a CNA responded to the resident’s call light after he spilled his bedside urinal and that they turned him aggressively during a brief change, ignored his requests to stop, and then ignored him for the rest of the night, leaving his bed remote out of reach. She reported that two police reports were filed during his stay, one for an earlier incident and another for this night, and asserted that the later incident was not reported by the facility to any state agency except the police. The ED confirmed that he was aware of the allegation of neglect made by the wife, that he spoke with both the wife and the resident, and that the resident contradicted the wife’s allegation. The ED stated that, because he had conflicting statements and did not deem the later incident to be abuse, he did not report it to the State Survey Agency, APS, or other required state entities, despite facility policy requiring that all alleged violations be reported within specified timeframes regardless of how they are characterized. Additional staff interviews showed that staff were aware of the requirement to report allegations of abuse and neglect promptly to facility leadership. The RN identified as involved denied that any allegation of rough care or neglect had been made to or about her and denied ignoring the resident or making threatening statements. Other CNAs and an LPN recalled that the resident had a history of making allegations, that he was to receive two-person care, and that there had been prior incidents involving staff being fired. One CNA reported being contacted by the previous DON and asked to provide a written statement after the resident alleged that night-shift staff had neglected him. The facility’s abuse and neglect policies defined abuse and neglect broadly and required that all alleged violations, whether oral or written, be reported immediately (within 2 hours if abuse or serious bodily injury was involved, or within 24 hours otherwise) to the administrator and appropriate state officials, and that staff did not need to explicitly label an event as abuse or neglect for it to be considered reportable. Despite these policy requirements, the ED acknowledged that the later allegation of neglect was not reported to the required state agencies.
Abusive Administration of Tube Feeding Flush Despite Resident Refusal
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to honor the resident’s right to refuse treatment during enteral feeding care. The resident was admitted with hemiplegia and hemiparesis following cerebral infarction, malnutrition, facial weakness, and dysarthria, and had a PEG tube due to dysphagia and dependence on staff for eating. A care plan and enteral feeding order directed Jevity 1.5 bolus feeds every four hours with a 50 mL purified water flush after each feeding. Documentation showed the resident occasionally became confused and resistive with care, including PEG tube care, and had been known to reject care. On one occasion, a behavior note documented that during a bolus feeding the resident became combative, pushed the nurse’s hands away, and said “no more food and water,” after which the LPN explained the need for the water flush and the resident agreed to the flush. A subsequent behavior note recorded that at a midnight bolus feeding, the LPN, assisted by two CNAs, proceeded with the bolus and water flush while the resident tried to kick staff and push the food away, repeatedly saying “no more food, no more water.” During this episode, the two CNAs held the resident’s hands and knees down while the LPN administered the bolus and flush. A later note the same night documented that the resident refused food and the bolus was not given. The resident’s admission MDS showed a BIMS score of 14, indicating cognitively intact status, and confirmed dependence on staff for eating and use of a PEG tube, with a history of rejecting care. In an interview, the resident reported refusing multiple times by pushing the tube away and verbally stating he did not want the treatment or the flush because it caused him to go to the bathroom, and stated that when he tried to push it away, the nurse brought more staff to hold him down while she flushed against his wishes. Personnel and termination documents for the LPN and both CNAs indicated that they participated in resident abuse by forcefully administering treatment and physically holding the resident’s extremities so that the tube feeding flush could be given despite the resident’s clear refusals. Facility policies in effect at the time stated that residents have the right to be free from abuse, including physical restraint not required to treat medical symptoms, and the right to request, refuse, and discontinue treatment.
Failure to Accurately Document and Perform Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to accurately document and perform wound treatment for a resident with multiple complex medical conditions, including surgical aftercare, diabetes, infection, and an abdominal surgical wound. The resident was admitted with an order for specific wound care, including cleansing with normal saline, application of Adaptic on biological mesh, packing with acetic acid-soaked gauze, and covering with a dry dressing, to be performed every shift. Documentation showed that the wound care was charted as completed on both the day and night shifts of a specific date. However, during an interview, the LPN assigned to the night shift admitted that she did not perform the wound care due to a busy shift and was unaware of a change in the wound care order. She also stated that she mistakenly charted the treatment as completed. The DON confirmed that the wound care was missed on the night shift, as reported by both the resident and the LPN, despite documentation indicating otherwise. The facility's policy requires that nursing documentation accurately reflect the care provided and the resident's progress. The inaccurate documentation and failure to perform the ordered wound care resulted in a deficiency, as the medical record did not provide an accurate representation of the resident's experience or care received.
Deficient Bowel and Catheter Care for Two Residents
Penalty
Summary
A deficiency was identified regarding the care and services provided to two residents with bowel and bladder management needs. One resident with a history of intracranial injury, full fecal incontinence, and severe cognitive impairment did not have a documented bowel movement for more than three days, as evidenced by CNA task documentation. Despite facility protocols and staff interviews indicating that lack of bowel movement should trigger nursing intervention and physician notification, there was no evidence that the resident received any medication or intervention for constipation until after the resident was hospitalized for severe constipation. The clinical record showed no physician order for stool softeners or laxatives until after the hospital admission, and the resident was ultimately diagnosed with a large, retained stool mass requiring medical intervention. Another resident with an indwelling catheter for neurogenic bladder and severe cognitive impairment did not receive catheter care as ordered by the physician. The care plan and physician orders required catheter care and securing the catheter with an anchoring device every shift, as well as regular monitoring of the catheter tubing and bag. However, review of the CNA Bowel and Bladder Elimination Report revealed inconsistent and infrequent documentation of catheter care, with several days showing only a single check or no documentation at all. There was no evidence that the physician was notified about the missed catheter care, nor any documentation explaining the lapses. Staff interviews confirmed that both CNAs and nurses were responsible for monitoring and documenting bowel movements and catheter care, and that the facility's electronic medical record system was designed to alert staff to issues such as missed bowel movements. Despite these systems and protocols, the required care was not consistently provided or documented for the two residents, resulting in deficiencies related to the management of constipation and catheter care.
Uncovered Beverage Delivery During Meal Service
Penalty
Summary
Staff failed to follow proper food handling practices during the distribution of beverages to residents, as observed on multiple occasions. Beverages, including coffee, water, juice, and dairy, were repeatedly transported and delivered to resident rooms and bedside tables without covers. These uncovered beverages were observed being carried through hallways, placed on bedside tables, and retrieved from food trolleys, including in areas where residents were on Enhanced Barrier Precautions (EBP). Staff members, including nursing and dietary staff, were seen handling and delivering these uncovered drinks over varying distances within the facility. Interviews with facility staff, including the Kitchen Manager and Registered Dietitian, confirmed that the expectation was for all beverages to be covered during delivery to prevent contamination. However, the observed practice did not align with this expectation, as staff distributed uncovered beverages to residents. Facility policies on infection prevention and control, as well as surveillance of infection-related practices, were referenced, but the observed actions did not adhere to these standards.
Failure to Remove Damaged Fall Mat Creates Infection Control Deficiency
Penalty
Summary
A resident with quadriplegia, legal blindness, and aphasia was admitted to the facility and identified as being at risk for falls, with a fall mat care plan in place. During an observation, a blue fall mat next to the resident's bed was found to be ripped apart approximately three-quarters of the way, exposing the internal sponge-like material. This condition was noted in the presence of the resident and their representatives. The resident's clinical records indicated severely impaired decision-making abilities. Staff, including a Registered Nurse and the Infection Preventionist, confirmed that the torn mat could not be properly cleaned and posed an infection control concern, as it could harbor potentially infectious organisms. The facility's policies required removal of products with compromised integrity and identified proper cleaning, disinfection, and disposal of equipment as essential to infection prevention. The presence of the damaged fall mat in the resident's environment demonstrated a failure to implement effective infection control measures as outlined in facility policy.
Failure to Honor Resident Choice in Continuation of Therapy Services
Penalty
Summary
A resident admitted for orthopedic aftercare with multiple comorbidities, including severe osteoporosis, depression, chronic pain, muscle weakness, and difficulty walking, was found to have been denied the right to make choices regarding the continuation of specialized rehabilitative services. Despite being cognitively intact and expressing a clear desire to continue therapy to meet personal mobility goals, the resident's care plan did not reflect this preference. The resident reported confusion about the discontinuation of therapy services and stated that therapy sessions were only missed due to illness. The resident also indicated a lack of communication regarding therapy options, insurance coverage, and care plan meetings, and did not recall any discussions with the insurance company or staff about the continuation of therapy. Interviews with facility staff, including the case manager and a panel of leadership, confirmed that the resident was eligible for continued therapy services and that insurance coverage was still active. However, a breakdown in communication among staff resulted in the resident not receiving the requested therapy services. Facility policies require that residents be informed of changes to their care plan and be allowed to make informed choices about their treatment, but these procedures were not followed in this case.
Failure to Enter and Care Plan DNR Order in Clinical Record
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Non-Hodgkin lymphoma, muscle weakness, and an indwelling urinary catheter, had a documented advance directive indicating Do Not Resuscitate (DNR) status. Despite this, the resident's DNR order was not entered into the electronic clinical record upon admission or readmission, nor was it incorporated into the resident's care plan as required by facility policy. The advance directive was only found in the hard chart at the nursing station and not reflected in the electronic system, making it inaccessible to staff relying on electronic records for code status information. Interviews with nursing staff revealed that the process for entering advance directives into the electronic record was not consistently followed, and there was no centralized system, such as a code book, to alert staff to residents' code statuses. The responsible nurse was unable to locate the code status in the electronic record until after the deficiency was identified, at which point the order was entered. Facility policy requires a physician's order for DNR status and mandates that it be flagged in the chart and included in the care plan, but these steps were not completed for this resident.
Failure to Provide Ordered Rehabilitative Services Due to Communication Breakdown
Penalty
Summary
A resident was admitted for orthopedic aftercare following a right fibula fracture, with additional diagnoses including severe osteoporosis, depression, chronic pain, muscle weakness, and difficulty walking. Upon admission, orders were written for both physical therapy (PT) and occupational therapy (OT) evaluations and treatments, with plans specifying services five times a week for several weeks. The resident was cognitively intact and expressed a desire to participate in therapy to regain strength and mobility, specifically aiming to reduce fall risk and improve ability to use a bedside commode. Despite having insurance coverage for the entire stay, the resident experienced a discontinuation of both PT and OT services after March 20, even though the treatment plans and insurance authorizations extended beyond that date. The clinical record did not reflect a physician order to discharge rehabilitative services, nor did the nursing care plan document the resident's goals for specialized rehab services. The resident reported not receiving therapy for approximately two weeks prior to discharge and was unclear about the reason, despite inquiring with staff. Interviews with facility staff confirmed that there was a miscommunication regarding the resident's coverage and discharge status, resulting in the resident not being re-evaluated or transitioned to restorative or continued rehabilitative services during the gap period. The resident expressed frustration and discouragement about not receiving therapy, feeling weaker, and not achieving her rehabilitation goals. She was not included in care plan meetings or discussions about her therapy, and staff interviews confirmed that the extension of her stay and continued eligibility for services were not effectively communicated to the rehabilitation department. Facility policies required individualized, person-centered care planning and the provision of specialized rehabilitative services as assessed, but these were not followed in this case.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, resulting in several instances where residents did not receive timely care. Resident #22, who was at risk for skin breakdown, did not receive continence care on a specific day, leading a family member to provide care due to unresponsive staff. The facility's records confirmed that staff did not attend to the resident during the day shift, highlighting a lapse in care provision. Resident #77, who required substantial assistance with transfers, reported waiting over two hours for call-light responses and experiencing delays in receiving necessary care. The resident's care plan lacked specific instructions for assistance with activities of daily living, such as transfers, further complicating the situation. Interviews with other residents revealed similar issues, with reports of long wait times for assistance, particularly during peak hours like lunch. Staff interviews corroborated the residents' complaints, with CNAs acknowledging the challenges posed by staffing shortages. The facility's staffing coordinator and DON admitted to being aware of the staffing issues, which were exacerbated by call-offs and inadequate scheduling adjustments. Despite attempts to manage the situation, the facility's staffing levels were insufficient to meet the residents' needs, as evidenced by the numerous complaints and documented instances of delayed care.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, as evidenced by multiple instances of prolonged call light response times and insufficient staff coverage. Resident Council meeting minutes and grievance logs highlighted ongoing concerns about staffing, particularly on weekends and during night shifts. Residents reported waiting excessively long for assistance, with some call lights remaining unanswered for over 30 minutes. Observations confirmed these delays, with staff often unavailable or occupied with other tasks, leaving residents without timely care. On specific dates, the facility was notably understaffed, with insufficient numbers of CNAs and nurses to cover the resident census. For instance, on March 16, 2023, the facility had only 3 RNs, 2 LPNs, and 4 CNAs during the day for 116 residents, which did not meet the facility's own staffing requirements. Interviews with staff, including the DON and Staffing Coordinator, acknowledged the staffing shortages and the challenges in hiring and retaining sufficient staff, particularly CNAs. The facility's staffing assessment indicated a need for more staff than were present, leading to compromised resident care. The deficiency was further highlighted by specific incidents where residents' needs were not promptly addressed. For example, a resident reported waiting over an hour for assistance off a bedside commode, and another resident's call light was on for over two hours before receiving medication. These incidents, along with staff interviews, revealed systemic issues in staffing that affected the quality of care provided to residents, with risks of falls, skin issues, and unmet care needs being directly linked to the understaffing problem.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident who was readmitted with multiple diagnoses, including acute and chronic respiratory failure, Type 2 diabetes mellitus with diabetic neuropathy, and chronic obstructive pulmonary disease. The resident was alert and oriented, with no documented behavior or mood issues. An incident occurred where the resident reported that a CNA was mean, turned off the call light without providing care, and was disrespectful during an interaction. The resident expressed upset feelings about the delayed care, and the CNA responded rudely, telling the resident to watch her tone and insisting on continuing care despite another CNA offering to take over. The incident was documented in a facility investigation report, and a corrective action form was issued to the CNA involved. The Director of Nursing confirmed that staff are trained on dignity and respect and expressed that the incident was not conducive to the resident's health. The DON also noted that the CNA had previous attitude concerns and had been written up for insubordination in the past. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity.
Failure to Prevent Resident Abuse and Inadequate Staff Intervention
Penalty
Summary
The facility failed to protect Resident #47 from verbal abuse by an employee, identified as a certified nursing assistant (CNA). The resident, who had moderate cognitive impairment and required maximal assistance for certain activities, was subjected to inappropriate language by the CNA. The incident was reported by another staff member, and interviews with various staff members revealed a pattern of intimidating and inappropriate behavior by the CNA, who had previously received a second written warning for refusing assignments and making coworkers uncomfortable. Despite these warnings, there was no documentation of a first written warning or a complete investigation into the CNA's behavior. In another incident, the facility failed to prevent physical and emotional abuse between two residents, Resident #39 and Resident #41. Resident #39, who had severe cognitive impairment and was dependent on a wheelchair, was involved in an altercation with Resident #41, who was cognitively intact but had a history of behavioral disturbances. The altercation occurred when Resident #41 used a backscratcher to hit Resident #39's hand to stop him from moving a table. Interviews with other residents and staff indicated that such incidents were becoming more common, with residents often feeling the need to intervene due to a lack of staff presence. The facility's policies on abuse prevention and investigation were not effectively implemented, as evidenced by the lack of immediate staff intervention during the altercation and the absence of a thorough investigation into the verbal abuse incident. The Director of Nursing and Executive Director were aware of the incidents but did not take sufficient steps to prevent recurrence, such as separating the involved residents or ensuring adequate supervision in common areas. The facility's failure to address these issues created an unsafe environment for residents, as highlighted by the repeated instances of abuse and the residents' concerns about their safety.
Inconsistent Showering Practices in LTC Facility
Penalty
Summary
The facility failed to ensure that three residents received consistent showers, which is a deficiency in providing care and assistance for activities of daily living. Resident #3, who is cognitively intact and completely dependent on staff for showers, missed numerous scheduled showers over several months. Despite the resident's preference for a female CNA, the facility did not accommodate this request, leading to missed showers and a rash on the resident's arms and groin. Resident #8, also cognitively intact, required extensive assistance for showers due to paralysis and other health conditions. The resident missed several scheduled showers, and a rash in the skin folds required treatment with anti-fungal powder. The resident expressed concerns about insufficient staffing and the inability to receive showers during the day shift, which contributed to the missed showers. Resident #11, who needs partial assistance with showering, also experienced missed showers, leading to a recurrence of a yeast rash. The resident reported long periods without showers and poor call light response, resulting in prolonged exposure to wet briefs. Interviews with staff and residents highlighted ongoing issues with staffing and the facility's failure to address these concerns, despite repeated discussions in resident council meetings.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of two residents to be free from abuse, resulting in a deficiency. In the first incident, a resident with moderate cognitive impairment reported that an LPN threw his television remote at him and removed the batteries because the TV volume was too high. The LPN denied throwing the remote and stated that she underhand tossed it into the resident's lap. Another LPN corroborated the resident's account, stating that the accused LPN admitted to taking the remote and removing the batteries. The facility's investigation concluded that the allegation of abuse was unsubstantiated, but the LPN was terminated for failing to provide good customer service. In the second incident, a resident with cognitive impairments and a history of aggressive behavior was involved in an altercation with another resident. The aggressor resident, who had moderately impaired cognitive skills, approached the victim from behind and gripped his shoulders, causing pain and a bruise. The victim was unable to free himself and called for help. Staff intervened and separated the residents. The facility's investigation substantiated the allegation of abuse, confirming that the aggressor resident's actions caused harm to the victim. The facility's policy on abuse prevention, which includes preventing physical abuse by any individual, was not effectively implemented in these cases. The policy outlines steps to prevent abuse, including monitoring residents identified as aggressors and separating involved residents. However, the incidents involving the two residents highlight a failure to adhere to these preventive measures, resulting in harm to the residents involved.
Failure to Administer Wound Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide care and treatment for a resident according to professional standards of practice, resulting in the resident's hospitalization. The resident, who had chronic hepatic failure, hypertension, congestive heart failure, chronic kidney disease with end-stage renal disease, and hyperkalemia, was admitted with a nutrition care plan goal for skin improvement. Despite documentation of cellulitis and blisters on the resident's lower extremities, treatment orders were inconsistently administered, and the resident's wounds were not care planned with interventions. The Treatment Administration Record (TAR) showed missed or refused treatments on several occasions, and the resident was eventually transferred to the hospital. Upon return from the hospital, new treatment orders were documented as administered, but the resident's refusal and noncompliance with wound care were not addressed in the care plan. The resident remained non-compliant with wound care, and maggots were found in the wound upon bandage removal, leading to another hospital transfer. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that wound care documentation was expected in the TAR, and staff nurses were responsible for the resident's wound treatments. The CDC notes that untreated or open wounds increase the risk of myiasis, a parasitic infection, which was a concern in this case.
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What surveyors actually found near you
We read the 238 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Palms Post Acute | 0.6 mi | ★★★★★ | 7 | 0 |
| Desert Blossom Health & Rehab Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Advanced Healthcare Of Mesa | 0.7 mi | ★★★★★ | 3 | 0 |
| Alta Mesa Health And Rehabilitation | 1 mi | ★★★★★ | 0 | 0 |
| Citadel Post Acute | 1.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.