Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 325047

Casa De Oro Center

100 federal citations on record , including 4 at the Immediate Jeopardy level, and 5 federal enforcement actions totaling $68,554.

Abuse Icon Special Focus Status 4 Immediate Jeopardy

Record summary

Federal record · Q1 2026
100
Total citations
82
Last 3 years
4
Actual harm+
5
Federal penalties
$68,554
Total fines
1
Overall ★ rating

Most common violation categories here

Care Planning24 Quality of Care20 Resident Rights20 Medication & Pharmacy12 Abuse & Neglect9

Most common F-tags at this facility

F8427 F6577 F6095 F6894 F7614

Citation history

100 on record
SurveyF-TagViolationSeveritySource
Aug 21, 2025F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.EComplaint
Aug 21, 2025F760Ensure that residents are free from significant medication errors.EComplaint
Aug 21, 2025F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EComplaint
Aug 21, 2025F658Ensure services provided by the nursing facility meet professional standards of quality.EComplaint
Aug 21, 2025F610Respond appropriately to all alleged violations.EComplaint
Aug 21, 2025F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.EComplaint
May 13, 2025F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.EComplaint
May 13, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.KComplaint
May 13, 2025F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Mar 3, 2025F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DComplaint
Mar 3, 2025F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.DComplaint
Mar 3, 2025F660Plan the resident's discharge to meet the resident's goals and needs.DComplaint
Mar 3, 2025F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DComplaint
Mar 3, 2025F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.DComplaint
Jan 8, 2025F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DComplaint
Oct 28, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DComplaint
Oct 28, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DComplaint
Oct 28, 2024F658Ensure services provided by the nursing facility meet professional standards of quality.DComplaint
Oct 28, 2024F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DComplaint
Oct 28, 2024F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.EComplaint
Oct 28, 2024F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.DComplaint
Oct 28, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.EComplaint
Oct 28, 2024F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.EComplaint
Oct 28, 2024F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.EComplaint
Oct 28, 2024F641Ensure each resident receives an accurate assessment.DComplaint
Oct 28, 2024F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.KComplaint
Oct 28, 2024F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.KComplaint
Oct 28, 2024F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.EComplaint
Oct 28, 2024F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.FStandard
Oct 28, 2024F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.FStandard
Oct 28, 2024F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EStandard
Oct 28, 2024F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.EStandard
Oct 28, 2024F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.EStandard
Oct 28, 2024F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.DStandard
Oct 28, 2024F698Provide safe, appropriate dialysis care/services for a resident who requires such services.EStandard
Oct 28, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.EStandard
Oct 28, 2024F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.DStandard
Jun 20, 2024F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DComplaint
Jun 20, 2024F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.EComplaint
Jun 20, 2024F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DComplaint
Jun 20, 2024F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.DComplaint
Jun 20, 2024F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.DComplaint
Jun 20, 2024F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Jun 20, 2024F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.CComplaint
Jun 20, 2024F583Keep residents' personal and medical records private and confidential.FComplaint
Feb 28, 2024F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.EComplaint
Feb 28, 2024F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.EComplaint
Feb 28, 2024F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.EComplaint
Feb 28, 2024F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.EComplaint
Feb 28, 2024F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.EComplaint
Feb 28, 2024F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.EComplaint
Feb 28, 2024F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).EComplaint
Feb 28, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.EComplaint
Feb 28, 2024F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.EComplaint
Feb 28, 2024F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.EComplaint
Nov 20, 2023F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.FComplaint
Nov 20, 2023F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.EComplaint
Nov 20, 2023F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.EComplaint
Nov 20, 2023F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.EStandard
Nov 20, 2023F880Provide and implement an infection prevention and control program.FStandard
Nov 20, 2023F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.EStandard
Nov 20, 2023F825Provide or get specialized rehabilitative services as required for a resident.EStandard
Nov 20, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.EStandard
Nov 20, 2023F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.EStandard
Nov 20, 2023F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.EStandard
Nov 20, 2023F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.EStandard
Nov 20, 2023F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.EStandard
Nov 20, 2023F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.EStandard
Nov 20, 2023F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.EStandard
Nov 20, 2023F730Observe each nurse aide's job performance and give regular training.EStandard
Nov 20, 2023F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.EStandard
Nov 20, 2023F658Ensure services provided by the nursing facility meet professional standards of quality.EStandard
Nov 20, 2023F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.EStandard
Nov 20, 2023F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.EStandard
Nov 20, 2023F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.DStandard
Nov 20, 2023F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.EStandard
Nov 20, 2023F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.EStandard
Nov 20, 2023F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.EStandard
Aug 15, 2023F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.EComplaint
Aug 15, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.EComplaint
Aug 15, 2023F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.EComplaint
Aug 15, 2023F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.EComplaint
Feb 28, 2023F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.EStandard
Feb 28, 2023F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.DStandard
Feb 28, 2023F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.DStandard
Feb 28, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Feb 28, 2023F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.EStandard
Feb 28, 2023F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.EStandard
Feb 28, 2023F732Post nurse staffing information every day.CStandard
Feb 28, 2023F698Provide safe, appropriate dialysis care/services for a resident who requires such services.EStandard
Feb 28, 2023F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.EStandard
Feb 28, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.KStandard
Feb 28, 2023F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.EStandard
Feb 28, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.EStandard
Feb 28, 2023F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.EStandard
Feb 28, 2023F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.EStandard
Feb 28, 2023F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.EStandard
Feb 28, 2023F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.EStandard
Feb 28, 2023F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.EStandard
Feb 28, 2023F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).EStandard

Federal enforcement history

Federal regulators have imposed 5 enforcement actions against this facility, including 2 civil money penalties totaling $68,554 and 3 payment-denial actions spanning 69 days.

DateTypeFinePayment denial
May 13, 2025Fine$34,515—
May 13, 2025Payment Denial—Jun 12, 2025 · 28 days
Oct 28, 2024Fine$34,039—
Oct 28, 2024Payment Denial—Nov 13, 2024 · 6 days
Nov 20, 2023Payment Denial—Feb 20, 2024 · 35 days
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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