Casa Real

In the surveyor’s words

From the most serious findings on record at Casa Real, in the surveyor’s own words.

• Immediate jeopardy, patternF686Jul 16, 2024

  Based on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury; skin damage which results from unrelieved pressure on the body) for 2 (R #50 and #69) of 2 (R #50 and #69) residents reviewed when staff failed to: 1. Timely identify the new wound, monitor for changes in the wound, provide daily treatments as ordered and notify the physician that the wound was worsening for R #50. 2. Complete and document weekly skin evaluations for R #69. This deficient practice likely resulted in R #50's pressure ulcer worsening and leading to an amputation. […]

• Immediate jeopardy, patternF686May 24, 2023

  Based on record review, observation, and interview, the facility failed to ensure that 3 (R #42, 96 and 98) of 3 (R #s 42, 96 and 98) residents reviewed for pressure ulcers received monitoring and care to prevent the development and worsening of pressure ulcers by: 1. Not accurately assessing residents skin upon admission/re-admission or immediately implementing treatment and monitoring for skin issues once identified for R #42, 96 and 98. 2. Not implementing effective interventions to prevent new skin wounds from developing and worsening for R #96 and R #98. […]

• Immediate jeopardy, isolatedF684May 1, 2023

  Based on record review and interview, the facility failed to monitor wound for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents reviewed for wound care of surgical sites by: 1. Not clarify medication and treatment orders from an outside provider and; 2. Not evaluating wound healing and wound treatment. These deficient practices likely result in the resident not receiving the appropriate type of treatment to prevent and treat infection that may possibly result in death. The findings are: A. Record review of the facility policy Skin Integrity and Wound Management, last revised 02/01/23, revealed the following: Practice Standards 4. Identify patient's skin integrity status and need for prevention or treatment interventions . 6. […]

• Actual harm, patternF692Jul 16, 2024

  Based on record review and interview, the facility failed to ensure 1(R #34) of 1(R#34) resident reviewed for dehydration maintain adequate hydration when they failed to: 1. Provide IV (intravenous; a thin plastic tube inserted into a vein using a needle) fluid hydration as ordered by a physician for R #34, 2. Document and monitor fluid intake for R #34. This deficient practice likely resulted in R #34 to have prolonged dehydration and worsened an untreated UTI. The findings are: A. Record review of R #34's face sheet revealed R #34 was admitted into the facility on [DATE]. B. […]

• Actual harm, patternF697May 1, 2023

  Based on record review and interview, the facility failed to provide the necessary care to effectively treat pain for 2 (R #1 and R #3) of 3 (R #1, R #3, and R #4) residents reviewed for having pain medication available. This deficient practice likely resulted in residents experiencing significant pain without sufficient relief. The findings are: Findings for R #1 A. Record review of R #1's physician orders dated 04/03/23 revealed, Oxycodone (narcotic pain medication)- Schedule ll (The drug of other substance has a high potential for abuse and has a currently accepted medical use in treatment in the US or a currently accepted medical use with severe restrictions. […]