Mi Casa Nursing Center
MI CASA NURSING CENTER in MESA, AZ — inspection on September 5, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
missed one wound treatment, but the resident's wound was bad, and the order was for dressing changes twice a day.
The DON stated that the wound care did not happen according to the LPN (Staff #25) and Resident #42, but it was charted by the LPN that she did complete the wound care.
The DON stated that it was not her expectation to see the LPN chart that she completed a treatment that she did not do because it made her question the nurse, and she would expect that if you did not, or could not complete a treatment, her staff should document why and chart properly.
The DON stated that the risk of missing a wound treatment could be infection, having to have more surgery, or death, and the risks of inaccurately charting treatments in the medical record would be the same. A review of a policy titled, Nursing Documentation, was conducted on September 5, 2024, and revealed that the facility would ensure nursing documentation was consistent with professional standards of practice, the state nurse practice act, and any state laws governing the scope of nursing practice.
The policy also revealed that the medical record would reflect a resident's progress toward achieving their person-centered plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status.
The policy also revealed that the medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions.
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