Casa De Paz Health Care Center

Inspectors wroteBased on clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure 1 of 6 resident's (Resident #11) care plan was updated to reflect their transfer status. The facility reported a census of 70 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review the facility failed to provide the appropriate interventions when 1 of 3 residents (Resident #10) experienced a hypoglycemic (low blood sugar) episode. The facility reported a census of 70 residents.

Inspectors wroteBased on record review, staff interviews and facility policy review, the facility filed to ensure proper documentation was completed after 1 of 3 residents (Resident #11) sustained a fall. The facility reported a census of 70 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling foods that were open with open dates. The facility reported a census of 71 residents.

Inspectors wroteBased on observation, infection control policy, and staff interview, the facility failed to perform proper hand hygiene and failed to adhere to infection control guidelines during wound care for 1 of 2 residents observed (Resident #2). The facility reported a total census of 71 residents.

Inspectors wroteBased on personnel file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal History Record Check Request SING form check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff A). The facility reported a census of 71 residents.

Inspectors wroteBased on observations, record review, interviews, and policy reviews, the facility failed to include the necessary healthcare information within the baseline care plan regarding the presence and utilization of a Bilevel Positive Airway Pressure (BiPAP) machine to prevent decline or injury related to diagnoses of sleep apnea, lung disease, and obesity for 1 of 19 residents reviewed (Resident #46). The facility reported a census of 71 residents.

Inspectors wroteBased on clinical document review, observation, staff interview, and policy review the facility failed to assist residents with activities of daily living by not assisting with fingernail trimming for 1 of 1 residents (Resident #8) reviewed. The facility reported a census of 71 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review the facility failed to provide proper transfer techniques while transferring a resident to prevent accidents for 1 of 3 residents (Resident #8) reviewed. The facility reported a census of 71 residents.

Inspectors wroteBased on observations, record review, interviews and policy reviews, the facility failed to address the presence and usage of a Bilevel Positive Airway Pressure (BiPAP) machine. The facility failed to obtain a physician's order, failed to obtain proper machine settings, failed to establish or follow a routine cleaning schedule for 1 out of 19 residents reviewed (Resident # #46). The facility reported a census of 71 residents.

Inspectors wroteBased on interviews with staff and doctors, chart review and policy review, the facility failed to transcribe accurate medication orders for 1 of 3 residents reviewed. Resident #5 required decarboxylase inhibitor medications for treatment of Parkinson's Disease. After a clinic visit with the neurologist, the staff failed to clarify dramatic order changes. After 12 days of the resident getting the wrong dose, the correct order was received and administered. The facility reported a census of 66 residents.

Inspectors wroteBased on interview, record and policy review the facility failed to request and implement physician's orders for monitoring and maintenance of a Gastrojejunostomy tube for 1 of 1 resident reviewed. Resident #5 had a Duapo pump installed in January, shortly thereafter the facility was unable to get the medication cartridges and the pump was not used for over 6 months. Staff failed to get clarification orders on how to maintain the tubing. The facility reported a census of 66 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that resident received dignified and respectful care for 4 of 10 reviewed (Residents #3, #7, #9 and #10). Upon entry to the facility on 8/14/25 it was discovered that 3 residents had urinary catheter bags that did not have privacy bags and were within full view of others. On 8/20/25, Resident #9 expressed that a staff member treated her in a demeaning manner when she raised her voice and got in my face. The facility reported a census of 63 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician's orders for 4 of 10 residents reviewed (Res #7, #2, #9 and #10.) Resident #7 required close monitoring related to fluid overload and frequent Urinary Tract Infections (UTI) due to catheter use. Staff failed to notify the physician with extreme weight gain, and failed to change the catheter as ordered. Residents #7, #2, #9 and #10 had treatment orders that were not completed in the months of July and August with no corresponding explanation in the chart. The facility reported a census of 63 residents.

Inspectors wroteBased on observations,resident and staff interviews and policy review the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 66 residents. Finding Include: 1. Observation on 4/02/25 at 11:55 a.m., test tray was temped after the last resident on level 1 was served and temperatures were as follows: a. Ham- 103.3 degrees b. Mashed potatoes- 124.8 degrees c. Carrots- 107.1 degrees 2. Observation on 4/02/25 at 12:05 p.m., level 2 room trays were sitting on the kitchen carts ready to pass. Staff A, Certified Nursing Assistant (CNA) began passing meal trays. Staff A verified she was taking meal tray into Resident #59's room. Stopped CNA and had staff check the temperature of the food. The temperatures were as follows: a. Ham- 97 degrees b. Mashed potatoes- 131 degrees c. Carrots- 96 degrees. [...]

Inspectors wroteBased on clinical record review, resident grievances, resident interview, staff interview, and policy review the facility failed to ensure 3 of 3 residents ' personal property was protected from loss or theft (Resident #12, #39, #51) . The facility reported a census of 66 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 6 residents (Resident #60) reviewed for PASRR requirements. The facility reported a census of 66 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch and failed to include enhanced barrier precautions for 3 out of 20 sampled residents reviewed for comprehensive care plans (Resident #39, #48 and #66). The facility reported a census of 66 residents.

Inspectors wroteBased on clinical record review, observation, resident interview and staff interviews, the facility failed to prevent accidents and hazards by not properly using a motion detector to prevent a fall that caused the need for an emergency room (ER) visit, facial bruising, laceration to the forehead and the need for pain medication for 1 of 3 residents reviewed (Resident #3). The facility also failed to use adequate transfer techniques while using a mechanical lift for 2 of 3 residents observed (Resident #8 and #44). The facility reported a census of 66 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 2 out of 5 sampled residents reviewed (Resident #48 and #66). The facility reported a census of 66 residents.

Inspectors wroteBased on observation, resident interview, staff interview, and policy review the facility failed to provide appropriate infection prevention practices related to contact and droplet precautions for 1 of 3 residents (Resident #39) reviewed. The facility reported a census of 66 residents.

Inspectors wroteBased on video footage review, staff interviews, and facility policy review the facility failed to count 4 of 4 resident's (Resident #1, #2, #3, and #17) narcotics after they were signed for upon delivery from the pharmacy. The facility reported a census of 67 residents.

Inspectors wroteBased on the observation, video footage review, staff interviews and facility policy review the facility failed to appropriately store the medications of 19 residents after they were signed for upon delivery from the pharmacy. The facility reported a census of 67 residents.

Inspectors wroteBased on observations, facility record review and resident and staff interviews the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 67 residents. Finding Include: 1. Interview on 7/14/24 at 8:59 a.m., with Resident #5 revealed the food is quite often cold. Resident #5 further revealed she does not ask staff to warm it up as she knows the staff work hard and doesn't want to bother them but she really doesn't want to eat the food cold but has to because it is the meal. 2. Lunch tray requested on 7/14/24 for lunch. Staff served chicken, mashed potatoes and gravy, mixed vegetables and banana cream pie. Temperature of food was checked as follows: Chicken- 126.1 degrees Mashed potatoes and gravy- 121.1 degrees Mixed vegetables- 106.4 degrees Banana Cream Pie- 33.1 degrees 3. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 67 residents.

Inspectors wroteBased on observation, staff interview and infection control policy the facility failed to pass clean linens to residents rooms. The facility reported a total census of 67 residents.

Inspectors wroteBased on personnel file reviews, staff interviews, and policy reviews the facility failed to complete the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry and Professional License information prior to employment for 3 of 7 employees reviewed (Staff B, C, D). The facility census was 55.

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents received restorative exercises as planned for 4 of 4 resident's reviewed (Resident #3, #16, #20 and #37). The facility reported a census of 55 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to serve residents the therapeutic menus as ordered for 5 of 5 reviewed. Residents #25, #5 and #43 had pureed diet orders and staff served them oatmeal that was not pureed. Residents #36 and #12 had mechanical soft diets, staff served them corn with the mixed vegetables. The facility reported a census of 55 residents.

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure food was labeled with dates after opening, staff complete hand hygiene before applying gloves and when removing, supplies and ingredients are stored in a safe and sanitary way, and ensure hair is completely covered with a hair net. The facility identified a census of 55 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to notify the ombudsman office of a facility initiated discharges for 3 of 3 residents (Residents #30, #25, #3) reviewed. The facility reported a census of 55 residents.

Inspectors wroteBased on Electronic Health Record review (EHR) and staff interviews the facility failed to submit a comprehensive Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual assessment within the required timeframe for 1 out of 17 residents reviewed (Resident #49). The facility census was 55.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that residents received medications as orders for 1 of 3 residents. After a medication change, staff continued to administer the previous order to Resident #38. The facility reported a census of 55 residents.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide appropriate care to prevent urinary tract infection for 1 resident reviewed (Resident #37). The facility reported a census of 55 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents were free from unnecessary psychotropic medications for 1 of 5 residents reviewed. Resident #43 had an order for Haloperidol as needed (PRN), and a review of the clinical record revealed that the order continued past the 14-day limit for PRN psychotropic medication use. The facility reported a census of 55 residents.

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents remained free from significant medication errors for 1 of 17 residents reviewed (Resident #40). The facility reported a census of 55 residents.

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to prepare and serve pureed food to meet the nutritional needs of 3 of 3 residents reviewed (Residents #5, #25, #43). The facility reported a census of 55 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the binding arbitration agreement provided for the selection of a venue that was convenient to both parties for 3 of 3 residents reviewed for binding arbitration (Residents #107, #52, #44). The facility reported a census of 55 residents.

Inspectors wroteBased on observation, facility documents, pest management company documents, pest management staff interview, resident and staff interviews, the facility failed to maintain pest control in the facility.