Casa Mora Rehabilitation And Extended Care

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program, specifically in the management of scabies treatment and the use of transmission-based precautions and PPE. One resident with a dermatology-confirmed need for scabies treatment had handwritten dermatologist instructions dated 2/4/26 directing treatment for scabies with Permethrin 5% cream, to be applied from neck down overnight and repeated in one week, with isolation from other residents until the second treatment was completed. However, the physician orders in the facility record instead reflected an order for oral Ivermectin 3 mg tablets, three tablets by mouth once daily for five days for crusted dermatitis, starting 2/5/26. The MAR showed the first Ivermectin dose scheduled for 2/5/26 at 9:00 a.m. with subsequent doses scheduled every five days rather than daily, and the first dose was not administered, documented with a code indicating the medication was awaiting delivery. Staff interviews confirmed that the missed dose was not rescheduled, meaning the resident would receive only four of the five ordered doses. Pharmacy delivery schedules indicated the medication, ordered at 9:54 p.m. on 2/4/26, should have been available in the early morning delivery window on 2/5/26. The facility’s own scabies management policy, effective August 2025, required implementation of contact precautions when scabies was suspected, use of gowns and gloves during close contact, obtaining and applying ordered treatment as directed, maintaining contact precautions and encouraging the resident to remain in the room for 24 hours post-treatment, and retreatment one week later. The policy also noted that symptoms may take weeks to develop and that transmission between treatments is possible. Despite this, the resident’s room was posted with Enhanced Barrier Precautions signage rather than clear contact precautions, and the treatment regimen ordered and scheduled did not align with the dermatologist’s written instructions for Permethrin topical therapy and repeat treatment in one week. Staff interviews revealed confusion about medication availability from the emergency drug kit and the process for handling unavailable medications, as well as differing understandings of pharmacy delivery times. Additional deficiencies were identified in the implementation of transmission-based precautions and PPE availability for other residents on precautions. Observations on 2/7/26 showed rooms posted with both Contact and Enhanced Barrier Precautions signs without PPE stored at the entrance. An LPN could not locate orders supporting contact precautions for two residents and was unsure about the posted precautions, while the CNA assigned to those residents did not know why they were on contact precautions. Another observation found the Activity Director entering and having direct contact with a resident in a room posted for contact precautions without wearing any PPE; PPE was not available outside the room, and the Activity Director initially believed only hand hygiene was required when not providing hands-on care. After re-reading the sign, the Activity Director acknowledged that gown and gloves should have been worn. The DON and RN later confirmed that staff should wear PPE when entering rooms posted for contact precautions, that PPE should be placed outside such rooms, and that nurses should know what type of precautions residents are on. A CNA interview also showed misunderstanding of the differences between Enhanced Barrier Precautions and Contact Precautions, including incorrect statements about required PPE components.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to thoroughly investigate allegations of abuse, neglect, and misappropriation of property involving one cognitively intact resident. The resident, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic pain syndrome, and opioid abuse with intoxication, reported that a CNA befriended her and began taking money from her. She stated she gave the CNA approximately $5,000 or more, including funds for prepaid money cards, and that the CNA still owed her $1,000 for a prepaid card that was never purchased. The resident reported that the CNA had her bank card PIN and would withdraw money from the bank, and that she had informed the previous NHA and SSD about the missing money and reported it to the police, with her POA handling the investigation. The resident further alleged that the CNA used the prepaid cards to buy THC-containing adult gummies for both of them, which they would share each morning, with the CNA advising her on potency and whether to take a half or whole gummy. The allegation of THC use was not documented in the facility’s prior investigation. During interviews, the current NHA and RM acknowledged that the resident had reported giving the CNA her bank card to shop for her and that, during their investigation, they obtained bank statements from the POA confirming that money had been sent to the CNA via a mobile money app. The RM stated that the CNA admitted receiving money to buy prepaid money cards totaling $4,570 but denied knowing why the resident needed them, and the RM admitted never asking the resident about the purpose of the cards, despite later acknowledging that the allegation of drug use would make sense in that context. The CNA confirmed there was money exchanged between her and the resident, that she purchased prepaid money cards worth hundreds of dollars, and that the resident wrote her checks for $500 more than once. She admitted that, as a staff member, she should not have taken money from the resident and that it was against policy, but denied purchasing THC gummies. The medical director stated that staff should not provide a resident with THC and that any such use should be evaluated and monitored by a provider. The facility’s Abuse Prevention Program policy defined exploitation/misappropriation of resident property and required that the NHA or designee initiate and conclude a complete and thorough investigation, including resident and employee interviews, document review, and other investigative steps. The report shows that the facility’s prior investigation did not include inquiry into the alleged THC use, did not document notifications to outside agencies, and did not fully explore the exploitation and misappropriation concerns as required by policy, resulting in a failure to thoroughly investigate the allegations for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Advance Directives, specifically Do Not Resuscitate (DNR) orders, were properly documented and maintained in the medical records for three residents. For one resident, there was no signed DNR Form DH1896 in the medical record, despite the resident returning from the hospital with a DNR status. Staff interviews revealed that although the change in code status was discussed and a verbal order was received, the required DNR form was never completed or signed by the appropriate parties, nor was it placed in the resident's chart. As a result, when the resident experienced a medical emergency, EMS was not provided with the valid DNR documentation, leading to the initiation of CPR against the resident's wishes as indicated by the verbal order and hospital documentation. Another resident's medical record contained both a full code order and a signed DNR Form DH1896, creating confusion regarding the resident's actual code status. Staff were observed to be uncertain about the resident's current status when reviewing the chart, as both orders were present and not properly updated. This improper documentation could have led to inappropriate interventions during a medical emergency. A third resident's DNR Form DH1896 was found to be incomplete, as it was signed by the provider but not by the resident or their representative, rendering the form invalid. Staff confirmed that the resident was capable of signing the form but was not asked to do so upon admission. The facility's policy required proper documentation and verification of Advance Directives, but these procedures were not followed, resulting in discrepancies and lack of clarity in residents' code status documentation.

Removal Plan

• A whole house audit was completed regarding advance directives and two identified variances were corrected.
• One code status was updated in the medical record, and it is clear to staff of the resident wishes and one next of kin validated the resident's advance directives with a signature.
• The Regional Nurse Consultant educated the clinical management team to the Code Status Response Policy.
• Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team on Code Status Response Policy.
• The morning clinical worksheet was updated.
• ADHOC Quality Assurance meeting was conducted to review the removal plan including the medical director.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that advance directives were honored and properly documented in the medical records for three residents reviewed for code status. One resident, who had a documented preference for Do Not Resuscitate (DNR) status, was found unresponsive by staff and subsequently received cardiopulmonary resuscitation (CPR) both at the facility and during transport to the emergency room. Staff did not inform the Emergency Medical Team (EMT) of the resident's DNR status, and the required signed DNR Form DH1896 was not present in the resident's chart or provided to EMS. Interviews with staff revealed that although the resident returned from the hospital with a DNR order, the process to complete and file the official DNR form was not followed, and the form was never signed or placed in the chart. As a result, EMS initiated full resuscitation efforts, which were continued in the emergency department. Further review of two additional residents' records revealed similar documentation failures. One resident's chart contained both a full code order and a signed DNR form, leading to confusion about the resident's actual code status. Another resident's DNR form was signed by the provider but not by the resident or their representative, rendering the form invalid. Staff interviews confirmed that the process for verifying, documenting, and updating code status orders was inconsistently followed, and that required forms were either missing, incomplete, or not properly filed in the residents' medical records. The facility's policy required that code status and advance directives be verified on admission, documented in the medical record, and that the appropriate state-specific forms be completed and placed at the front of the resident's chart. However, the observed failures included lack of timely completion and filing of DNR forms, lack of communication with families or responsible parties to confirm code status changes, and the presence of conflicting orders in the medical record. These actions and inactions resulted in residents' wishes regarding resuscitation not being honored and created confusion among staff during emergency situations.

Removal Plan

• A house wide audit was completed verifying advanced directives and two identified variances were corrected. One code status was updated in the medical record, and it is clear to staff of the resident wishes and one next of kin validated the resident's advance directives with a signature.
• Regional Nurse Consultant provided education to 100% of the clinical management team related to Advanced Directives.
• Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team related to Advanced Directives, reviewing AD/CS orders, process for completing a DNR order and honoring a resident choice, code blue process and placement of code status in resident hard chart at 97%.
• The Regional President completed the Essential Core Functions: Resident care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Nursing Home Administrator.
• The Director of Risk Management completed the Essential Core Functions: Resident Care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Director of Nursing.
• Code Blue drills started and completed each shift.
• ADHOC Quality Assurance meeting was conducted to review the removal plan including the medical director.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a history of cognitive impairment, mild dementia, and alcohol use disorder exited the facility without staff knowledge or appropriate supervision. The resident, who was assessed as being at risk for elopement and had an electronic wander bracelet in place, was able to leave the facility by following another resident out the door, which was remotely opened by staff. The door alarm was triggered but subsequently disabled by another resident who knew the code, and no staff were present in the reception area to respond to the alarm or monitor the exit. The resident walked approximately 0.2 miles to a nearby hospital and was returned to the facility by law enforcement several hours later. Prior to the incident, the resident had demonstrated behaviors such as wandering, confusion, and expressing a desire to leave the facility. Documentation showed that the resident had a BIMS score indicating moderate cognitive impairment and was independently mobile with a walker. Staff and family interviews confirmed the resident's history of confusion, exit-seeking behavior, and lack of safety awareness. On the day of the incident, staff failed to provide adequate supervision, did not respond to the exit alarm, and allowed a situation where residents could access and disable the alarm system due to unsecured door codes. The facility's records revealed that the elopement was not documented in the abuse/neglect log or the incident and accident report. Staff interviews indicated a lack of awareness and response to the alarm, and video evidence confirmed that no staff were present in the area at the time of the exit. The resident's care plan included interventions for elopement risk, but these were not effectively implemented, resulting in the resident leaving the facility unsupervised and unnoticed for an extended period.

Removal Plan

• Resident #1 was put on enhanced supervision and then moved to the secure unit.
• An audit was completed by the DON and the facility's clinical administration team for current residents to ensure accuracy of assessment for cognition and mobility.
• Identified variances were corrected regarding LOA status.
• Staff were educated on the policy and procedures related to resident supervision, following procedures for residents leaving the facility for leave of absence, as well as the facility unauthorized exit protocols.
• Staff were educated by the DON and the facility clinical administration team on the door code process and the process to report unauthorized knowledge of the facility door codes.
• The remote door releases were deactivated.
• Code Silver drills were completed every shift.
• Random audits were completed regarding unauthorized exit, resident LOA status, and resident elopement risk.
• Ad hoc QA meeting was conducted to review the removal plan, which included the medical director.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its established grievance policies and procedures for investigating and following up on resident grievances for five out of six sampled residents. Multiple residents reported that after filing grievances, the facility did not provide follow-up or resolution. One resident stated that grievances regarding being awoken by a CNA and missing items were never addressed, while two other residents reported that their joint grievance about staff not distributing water and using personal phones during care remained unresolved, with no staff discussing the issues with them. Another resident indicated that grievances from a previous month had not been resolved or followed up on, and a fifth resident confirmed that his grievance had not been addressed or followed up by staff. Interviews with staff revealed a lack of clarity and consistency in the grievance follow-up process. The social services staff member interviewed stated that follow-up depended on the specific situation and confirmed that there was no designated person responsible for ensuring residents were informed about the status or resolution of their grievances. This lack of a clear process resulted in residents not being updated or assured that their concerns were being addressed. A review of the facility's grievance policy showed that it requires prompt efforts to resolve concerns, documentation of resident satisfaction upon completion of investigations, and clear assignment of responsibility for follow-up. Despite these requirements, the facility did not ensure that grievances were investigated, resolved, or communicated back to the residents, as evidenced by the residents' statements and staff interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that medications and biologicals were not properly stored and secured for two residents. One resident had a tube of discontinued zinc oxide paste skin cream on the bedside table, which had been brought from the hospital and remained in the room after discontinuation. Another resident had a tube of Betamethasone Valerate cream on the windowsill, and the resident was unsure if the medication belonged to them. Review of the electronic health record confirmed that the zinc oxide was discontinued and the Betamethasone Valerate cream was an active prescription for dermatitis. Interviews with the Director of Nursing (DON) and nursing staff confirmed that there were no residents authorized for self-administration of medication (SAM) at the time of the survey. Staff reported that any medications found in resident rooms should be returned to the pharmacy and that they follow procedures for reporting and securing misplaced medications. The facility policy also discourages residents and visitors from bringing medications into the facility. Additional observations revealed unsecured medications at the 200 hall nurses' station. Prescription medications and an unlocked treatment cart containing prescription drugs were left unattended and out of staff sight, with residents nearby. Facility policies require that medications be stored securely, with medication carts locked when not in use and medications accessible only to authorized personnel. These policies were not followed, resulting in medications being left unsecured in resident areas and at the nurses' station.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a history of encephalopathy, generalized anxiety disorder, mild cognitive impairment, and alcohol use was identified as being at risk for elopement, as documented in their care plan and supported by multiple assessments indicating moderate cognitive impairment and wandering behaviors. The resident had an electronic wander bracelet in place and was subject to interventions such as a leave of absence (LOA) with escort and daily monitoring of the wander device. Despite these measures, the resident exited the facility without following the proper sign-out process, after another resident requested the door be opened by a CNA. The wander guard alarm was triggered but staff did not respond, and it was unclear who silenced the alarm. The resident was found outside the facility by law enforcement and returned unharmed. The incident was not documented in the facility's abuse/neglect log or incident and accident reports for the relevant period. Interviews with staff revealed that the CNA who opened the door did not see the resident leave and did not hear the alarm. Other staff members reported that the resident had exhibited exit-seeking behaviors earlier in the day, and this information had been communicated to nursing staff. The resident's care plan and assessments consistently identified elopement risk, and interventions were in place, but the facility failed to ensure adequate supervision and response to the alarm system. Despite the resident's known risk factors and the occurrence of an unauthorized exit, the facility did not report the incident as required. The Nursing Home Administrator and Director of Nursing stated that they did not consider the event reportable, as they believed the resident was alert, oriented, and not in harm's way. However, the facility's own policies define neglect as the failure to provide necessary services to avoid harm, and require reporting of such incidents. The lack of documentation and reporting of the elopement constituted a failure to comply with regulatory requirements for timely reporting of suspected neglect.