Casa De Las Campanas

Inspectors wroteBased on interview and record review, the facility failed to adequately assess and monitor one of three sampled residents (Resident 1) who had a change in condition. This failure had the potential for Resident 1 to experience discomfort and further deterioration in health condition.

Inspectors wroteBased on interview and record review, the facility failed to update the plan of care for one of three residents (Resident 1) reviewed for falls. This failure had the potential for Resident 1 to experience subsequent falls and/or injuries. On 8/22/25 Resident 1's facility's record was reviewed. The admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included fracture of right femur (a broken thigh bone) and generalized muscle weakness. A review of the Fall Evaluation dated 6/5/25 indicated Resident 1 was at high risk for falling. During a review of Resident 1's Progress Notes, the Fall Note dated 8/1/25 at 10:19 A.M. indicated, .found resident on the floor, left side of the bed, head slightly under the bed. When asked, [Resident 1] stated he wanted to reach his wheelchair to go to the bathroom and hit his head on the side of the bed. [...]

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to keep one of five sampled residents (Resident 1) safe from medication errors. This failure caused Resident 1 to receive the wrong medication and posed a risk to Resident 1's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and nutritional supplements were properly stored for 3 out of 4 medication storage rooms reviewed for medication storage and for one of four residents when:1. Resident 78 had medications unsecured at bedside,2. Station one medication room had an expired medication, and a bottle of nutritional supplement,3. Expired medications and a box of nutritional supplements were stored in the main central supply room. These failures had the potential for unsafe and ineffective use of medications and supplements with decreased therapeutic effectiveness when used past the expiration date. In addition, this failure had the potential for Resident 78's medications to be accessible to unauthorized staff and residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served was in a palatable, flavorful manner, and at the preferred temperature for six residents who complained about the food's taste and temperature. The facility had a census of 50. This failure had the potential for residents to decrease meal intake and lead to weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure food items in the reach-in refrigerator in the kitchen had an open date, and expired food was not removed for two of two reach-in refrigerators. This failure placed residents at risk of acquiring foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control standards of practice when:1. An used syringe was found on top of a resident's dresser (Resident 2), and2. A blood pressure cuff was used for multiple residents without sanitizing in between use for four of four residents observed during medication pass. This failure had the potential to spread infection amongst the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident's ability to self-administer medications for one of one resident reviewed for self-administration of medications. (Resident 78). This failure had the potential for Resident 78 to over medicate and affect Resident 78's health and safety.

Inspectors wroteBased on interviews and record review, the facility failed to provide a written and follow-up initiation of the advance directives for one of 15 sampled residents (Resident 9). This failure had the potential to prevent Resident 9's wishes from being honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's authorized responsible party had signed the informed consent for the use of the psychotropic medication (medications that affect brain activities associated with mental processes and behaviors) prior to administering the medications for one of five sampled residents reviewed for unnecessary medications (Resident 7). This failure increases the risk of inappropriate use of psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify a resident and/or the resident's representative notices of transfer/discharge and bed hold for one of two residents reviewed for hospitalization. (Resident 45). This failure had the potential for the resident and/or the resident's representative not to have information regarding the transfer/discharge as well as bed hold rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to promote healing when a pressure injury (a wound caused by prolonged pressure) had developed for one of four sampled residents (Resident 3) when weekly wound assessments were not conducted and Resident 3's wound stages were not accurately assessed. These failures had the potential for Resident 3 to have delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive systematic approach to ensure effective monitoring to maintain acceptable parameters of nutritional status for 1 of 5 sampled Residents (Resident 3) when: 1. The facility did not follow their policy for change of condition (physical change-weight loss) when Resident 3 was not placed on weekly weights (measurement of body weight).2. The Registered Dietitian (RD) did not reassess Resident 3's weight loss to determine appropriate interventions.3. Resident 3's weight loss was not communicated to the physician.4. The Interdisciplinary Team (IDT- a team comprised of professionals from various disciplines who work in collaboration to address residents' needs) did not address the severe unplanned weight loss.5. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer blood pressure medication for one of four residents reviewed for medication errors. (Resident 25)This failure has the potential to affect Resident 25's health and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication administration for one of three residents (Resident 1) observed during medication pass when a medication for an overactive bladder (a condition where there is a frequent sensation of needing to urinate) was not administered per the physician's order. This deficient practice had the potential to cause the resident harm.

Inspectors wroteBased on observation, and interview the facility failed to ensure staff followed infection control precautions when staff were observed without face masks. This failure had the potential for the spread of infection to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff received appropriate training in food sanitation and food safety according to standards of practice and facility policy when: 1. Three dietary aides did not demonstrate the proper method of testing the sanitizer solution used for sanitization (the process of safely removing waste to prevent disease transmission and improve hygiene) on equipment and prep surfaces to prevent cross contamination. 2. Two Cooks did not correctly verbalize the 2-step cool down process for foods that require a cool down process prior to serving. 3. Staff In-services were not being conducted by a qualified kitchen staff member with the proper credentials and to carry out in-service trainings. [...]

Inspectors wroteBased on observation, staff interview, and document review, the facility failed to ensure an emergency menu with the appropriate food and water supplies was developed to meet the nutritional and therapeutic needs of the residents, according to facility policy and regulation standards. This failure had the potential to result in further compromising the nutritional and health status of the facility's 50 medically vulnerable residents, or its 97 licensed beds.

Inspectors wroteBased on observation, interview, and record review, the failed to ensure food safety and sanitation practices in dietary services were maintained for food storage according to standards of practice when: 1. Two ice machines were not cleaned and maintained according to manufacturer's instructions. 2. Three ice machines and one dish machine did not have a proper air gap system to adequately prevent backflow of contaminated fluids. 3. Two reach-in refrigerators used to store facility resident food contained a brownish colored sticky grimy debris on the door gasket (inner rubber sealant that helps to create a vacuum and air-tight seal, forming a barrier to cool the inside of the refrigerator and freezer); and one reach-in refrigerator door had several black and grayish spots on the inside door panel. 4. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure implementation of their policy regarding use and storage of foods brought in from the outside food to ensure safe and sanitary storage, handling, and consumption was followed. This failure had the potential to contaminate residents' outside food stored at the facility, which may result in foodborne illness. The facility census was 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable environment to one of 13 residents (Resident 216) when Resident 216's room temperature was 88°F (degrees Fahrenheit - unit of temperature measurement). This failure had the potential to negatively impact the resident's comfort and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement safe administration of medications for one of 13 residents (Resident 500) when Licensed Nurse (LN) 31 administered Resident 500's medications prepared by LN 2. This failure had the potential for unsafe medication administration and affect the resident's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician's orders were implemented and the physician was notified for 3 of 13 residents (Resident 61, Resident 45 and Resident 55) when: 1. Resident 61's physician order for physical therapy (PT) was not done and was refused. 2. Resident 45's physician order for daily weights was not done and was refused. 3. Resident 55's physician order for wound treatment was not provided. These failures had the potential for further decline in the residents' health and well-being as physician's ordered treatment and services were not provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure procedures for accurate acquiring, receiving, dispensing, and administering of medications for 4 of 13 residents (Resident 314, Resident 315, Resident 316 and Resident 61) when: 1. Resident 314 and 315's pro re nata (PRN - as needed) medication for pain did not have parameters for medication administration. 2. Resident 316's medication was not administered timely per physician's order. 3. Resident 61's Zinc sulfate (supplemental mineral) was not made available and administered per physician's order. These failures had the potential for the facility to provide unsafe medication administration and inability to provide treatment to the residents. Findings 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 6.67% when two medication errors occurred out of 30 opportunities during medication administration. These failures resulted in medications not given to residents in accordance with the physician's orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were securely locked inside a medication cart when a medication drawer was left open and unattended by a nursing staff. This failure had the potential for unauthorized persons to gain access to medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served was in a palatable, flavorful manner that maintained the nutritional value of the menu items served. This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 50.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the dietary recommendations for the finger food diet for an unsampled resident, (Resident 60), reviewed for weight loss. This failure had the potential to negatively impact Resident 60's food intake which could further impair nutrition status and lead to weight loss. The facility census was 50.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a staff adhered to proper infection control practice for one of 13 residents (Resident 1) when the staff did not perform hand hygiene (HH- washing hands with soap and water or use of hand sanitizer to kill microorganisms) before entering a resident's room. This failure had the potential for cross contamination (spread of germs and bacteria) and infection to residents, staff and visitors.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure kitchen equipment was maintained in safe operating condition when two reach-in refrigerators and an ice machine were not maintained according to standards of practice and facility policy. This failure had the potential to expose the facility's 50 residents to potential contaminants that could cause widespread foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 3 Residents were not cared for according to their physician orders and plan of care when staff failed to administer medications to treat chronic conditions, as ordered by physicians. This failure had the potential to have negative affect on residents health and placed residents at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to address the nutritional needs for three (Resident 203, Resident 11, Resident 30) of five residents reviewed for nutritional services when: 1. Resident 11 and Resident 30 were not assessed for food preferences. 2. Resident 203 was not offered an alternate meal after the resident refused the meal served and was not offered condiments to enhance the food's palatability. These failures resulted in Resident 203's continued refusals to eat the meals served by the facility, which could negatively impact the resident's health. In addition, this failure had the potential for Resident 11 and Resident 30 to have decreased food intake, which could lead to weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all food items were labeled and dated. In addition, the facility did not ensure that there were no expired food items. This failure had the potential for residents to become ill due to increased bacteria growth in the food, and/or have decreased food intake leading to weight loss due to poor food palatability.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and ensure one of 13 sampled residents (Resident 2) who kept medications at bedside had a physician order, care plan, and an Interdisciplinary Team (IDT, a group of staff meeting and working together for the benefit of the resident) assessment to determine if safe and clinically appropriate for the resident to self-administer medications. These failures had the potential to result in unsafe medication administration and could have allowed other residents to access unlocked medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician notification regarding a significant weight loss for 1 of 5 residents reviewed for weight loss (Resident 203). This failure had the potential for delayed treatment plan for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a resident's care plan related to weight monitoring for one of 13 residents reviewed for care plans. (Resident 203). This failure resulted in Resident's 203's weekly weights to not be monitored weekly as planned, which could result in a delayed identification of a weight change.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment in accordance with the facility's policy and procedure when physician's orders were not clarified for one of 13 sampled residents (Resident 23). During medication administration, five medications were administered by mouth when the physician's orders were written to be given via a G-Tube (gastrostomy tube, a tube inserted through the belly that brings nutrition or medications directly to the stomach). This failure had the potential for not meeting Resident 23's therapeutic needs and had the potential of causing aspiration (breathing in medication or fluid into the lungs), which could lead to serious lung problems such as pneumonia (lung infection).

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when a random controlled medication use audit for one of four sampled residents (Resident 8) did not reconcile. The medication was signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate it was given to the resident. This failure had the potential to result in misuse or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) and inaccurate accountability of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to request a medication regimen review (MRR) following changes in condition (worsening of an existing problem or the emergence of new signs or symptoms, such as falls); and failed to ensure the consultant pharmacist (CP) identified potential medications contributing to falls and make recommendations to the facility for reduction or discontinuation of one of the medications during the monthly MRRs for one out of two sampled residents (Resident 28). This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects (such as falls) for the resident.