Casa Mora Rehabilitation and Extended Care

In the surveyor’s words

From the most serious findings on record at Casa Mora Rehabilitation and Extended Care, in the surveyor’s own words.

• Immediate jeopardy, patternF578Sep 11, 2025

  Based on observations, interviews, and record review, the facility failed to ensure Advance Directives were properly documented in the medical record for three residents (#2, #12, and #13) out of three residents reviewed for code status. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury or death to Residents #2, #12, and #13 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to an E.Findings included: 1)Review of the Emergency Medical Systems (EMS) run report for Resident #2, dated [DATE], showed: Dispatch to rehab facility for [Resident #2] reported to have pink fluid coming from his tracheostomy tube. […]

• Immediate jeopardy, patternF678Sep 11, 2025

  Based on observations, interviews, and record review, the facility failed to ensure Advance Directives were honored and properly documented in the medical record for three residents (#2, #12, and #13) out of three residents reviewed for code status. Resident #2 received cardiopulmonary resuscitation (CPR), despite his preference to be a Do Not Resuscitate (DNR) code status, after he was found unresponsive by staff on [DATE]. Staff failed to inform the Emergency Response Team (EMT) of the DNR code status and CPR was begun at the facility and conducted during transport and care in the emergency room (ER). […]

• Immediate jeopardy, isolatedF689Sep 11, 2025

  Based on observations, interviews, and record review, the facility failed to provide supervision to prevent elopement for one resident (#1) out of four residents reviewed for elopement risk. On 7/26/25 Resident #1 exited the facility at 6:30 p.m., unnoticed by staff. Resident #1 was mildly impaired, confused, and had an electronic monitoring device in place. Resident #1 followed another resident out the door which was remotely opened by staff. The door alarm was disabled by a resident who was aware of the code after Resident #1 triggered the alarm upon exit. Resident #1 walked approximately 0.2 miles to a hospital near the facility and was returned with assistance of law enforcement to the facility at 9:00 p.m. […]

• Immediate jeopardy, isolatedF600Feb 2, 2024

  Based on record review, review of facility's policies and procedures, resident and staff interviews, the facility failed to protect the residents' rights to be free from neglect. The facility failed to ensure timely evaluation of resident's condition, and immediate physician notification in the presence of an acute change in condition to avoid physical harm for 1 (Resident #98) of 4 residents reviewed for coordination of care. Resident #98 had a diagnosis of Atrial Fibrillation (Type of irregular heartbeat) with long term use of anticoagulant (blood thinner) medication with a potential side effect of bleeding. On 8/28/23 Resident #98 underwent multiple dental extractions, arranged by the facility. […]

• Immediate jeopardy, isolatedF684Feb 2, 2024

  Based on record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement processes to ensure effective coordination between staff, physicians, and outside medical providers in accordance to professional standards of care to meet the needs of 4 (Residents #98, #9, #99, and #110) of 4 residents reviewed. Resident #98 had a diagnosis of Atrial Fibrillation (Type of irregular heartbeat) with long term use of anticoagulant (blood thinner) medication with a potential side effect of bleeding. The facility arranged an appointment for multiple dental extractions for Resident #98. […]