Mi Casa Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 20, 2026

  Based on observations, interviews, clinical record review, weather data review, and review of facility policy and procedure, the facility failed to provide adequate supervision for one resident (#109) who was assessed to have poor safety awareness and required assistance with mobility, while in the courtyard during extreme summer temperatures. Sampled residents for accidents were 3. As a result, Resident #109 remained outdoors for an undetermined period of time in temperatures reaching 103 F and sustained second-degree burns to both thighs requiring emergency medical treatment at the hospital.Findings include:Resident #109 was readmitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, muscle weakness, cognitive communication… […]

• No harm, potential for more than minimal, patternF690Apr 4, 2025

  Based on observation, resident and staff interviews, clinical record review, and facility policy and procedures, the facility failed to provide care and services related to constipation for one resident (#12); and failed to ensure catheter care was provided to one resident (#46) as ordered by the physician. The deficient practice could result in complications and as well as pain and discomfort. Findings include: Resident #12 was admitted on [DATE], with a diagnosis of intracranial injury with loss of consciousness, full incontinence of feces, and diffuse traumatic brain injury without loss of consciousness. Resident #12 was documented as being alert but altered, difficult to assess due to not following commands, moans, but no meaningful conversation. […]

• No harm, potential for more than minimal, patternF812Apr 4, 2025

  Based on observations, staff interviews, and facility policy and procedure, the facility failed to follow proper food handling practices while distributing beverages. This deficient practice can result in contamination of resident beverages, and an increased risk of food-borne related illness. An observation was conducted on a hall with six residents on Enhanced Barrier Precautions (EBP), on April 1, 2025 at approximately 11:39 a.m. A staff member retrieved an uncovered beverage from the bedside table, and delivered the glass and meal to a resident room. Simultaneously, a second staff member returned from a resident room on the far end of the hallway, and retrieved a meal tray which contained a cup of coffee, glass of water and juice, which were all uncovered. […]

• No harm, potential for more than minimal, patternF880Apr 4, 2025

  Based on clinical records, observation, interviews, and policy review, the facility failed to ensure infection control measures were in place for one resident (#2). This deficient practice can result in transmission of preventable illness to residents and staff. Findings include, Resident # 2 was admitted to the facility on [DATE] with diagnosis that include quadriplegia, legal blindness, and aphasia (difficulty speaking). A fall mat care plan, initiated on June 26, 2021, revealed the resident was at risk for falls related to a history of falls. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed the Staff Assessment for Mental Status ability to make decisions regarding tasks of daily life was severely impaired. […]

• No harm, potential for more than minimal, patternF725Jan 30, 2025

  Based on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that adequate staffing was available to provide for the residents needs and care timely. The deficient practice could result in residents not receiving the care needed. Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, obesity, and chronic kidney disease. The baseline care plan dated February 3, 2024 revealed that the resident is at risk for skin breakdown. Interventions included to clean and dry skin after each incontinent episode. […]