Casa De Oro Center

During an annual inspection, a small sample of residents is reviewed in multiple categories. As a result, CMS does not uncover every error or deficient practice by the nursing home. The most recent annual inspection of Casa De Oro Center occurred on December 7, 2021, during which CMS discovered multiple deficiencies. 

Deficiencies in Caring for Daily Resident Needs  

Inspectors found that Casa De Oro Center failed to respect patient dignity in the following instances:  

• Failure to change resident’s clothing after spilling food on them twice at mealtime 
• Failing to knock on two patient doors before entering  

The inspector also found that the facility failed to provide showers to patients according to their preferred schedules. Some patients were left without showers for as long as a week at a time. Inspectors observed patients that were notably dirty with greasy, unkempt hair, complaining that they were not showered often enough.  

Medical Negligence 

Casa De Oro Center failed to notify a resident’s daughter, who was the resident’s power of attorney, when the resident developed pneumonia. The daughter did not become aware of the diagnosis until 11 days later and requested the resident’s transfer to the hospital. This was also the subject of a complaint investigation that occurred on the same date. 

The facility failed to chart an accurate assessment of three residents:  

• A resident that lacked bottom dentures received food she could not eat. 
• A resident with a continuous positive airway pressure machine required respiratory treatment that was not charted, and the equipment was not cleaned and disinfected weekly to prevent infection.  
• A resident’s Kennedy ulcer, which is considered terminal, was incorrectly coded as a pressure ulcer. 

The facility failed to develop and implement a care plan for three out of three residents reviewed for care plans, including residents with the following: 

• A CPAP machine 
• Hypertension 
• Diabetes with dependency on solution medication  

Casa De Oro Center’s staff failed to provide appropriate Foley catheter care for three out of three residents sampled. Improper catheter care creates a heightened risk of infection. The inspector found the following deficiencies:  

• Allowing a patient to self-administer a catheter without providing documentation, a medical assessment of the patient’s ability to do so, or supplies and equipment 
• Failing to provide a privacy cover, which violated the patient’s dignity 
• Storing two residents’ catheter bags on the floor 

The facility failed to provide adequate pain management for one of two patients sampled. The inspector observed the patient rocking back and forth and displaying anxiety while talking about the pain. Upon investigating, the inspector found the following: 

• The medication was not provided as prescribed on multiple occasions. 
• The pain level was not monitored.  
• Changes in the pain level were not reported to the physician.  

The facility failed to implement an antibiotic use monitoring program that includes staff training and 48-hour re-evaluation timeouts.  

Unreported Patient Abuse 

In the case of one of two residents sampled for abuse, the facility failed to report the incident within two hours of occurrence. The resident’s roommate had attacked him and jumped on his chest shortly after midnight. This was not reported to the Department of Health Improvement until more than 12 hours later at 1:25 in the afternoon.  

Inadequate Staff Training 

A file review of three licensed practical nurses employed by the facility revealed that one of the nurses did not have any nursing competency. In addition, the facility failed to provide the required 12 hours of annual training for two of the three certified nursing assistants sampled.  

Negligent Practices 

The inspection uncovered the following instances of negligence: 

• Unlocked medication carts  
• Incomplete advance directive paperwork  
• Incorrect diagnosis recorded in a patient’s chart