Mini-Cassia Care Center

Inspectors wroteBased on observation, interview, policy review, and U.S. Food and Drug Administration 2022 Food Code, the kitchen staff failed to appropriately store and label foods, wash hands prior to donning gloves, and prevent possible cross contamination of opened resident stored food items with kitchen stored food products. This deficient practice had the potential to affect all 58 residents who received meals prepared in the facility's kitchen.

Inspectors wroteBased on observation, policy review, resident, and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 4 of 8 residents (#4, #13, #19, and #44) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished sense of worth.

Inspectors wroteBased on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure a resident's call light was within reach for 5 of 18 Residents (#29, #50, #51, #56, and #57) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all 58 residents who resided in the facility whose equipment and environment were observed. This deficient practice created the potential for harm if: a) cross contamination due to equipment not being cleaned between use b) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, undignified, or c) residents were injured due to unsafe areas in the facility.

Inspectors wroteBased on facility's Bowel Management - Clinical Protocol, record review, and staff interview, it was determined the facility failed to follow facility bowel care Clinical Protocol of delivering specific medications when residents do not have BM within 72 hours for 3 of 6 Residents (#4, #31 and #56) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order.

Inspectors wroteBased on record review, staff interview, and policy review, it was determined the facility failed to ensure residents' representatives were immediately notified when residents fell or had a change in condition. This was true for 2 of 4 Residents (#7 and #57) whose records were reviewed for changes in condition. This deficient practice placed residents at risk of harm due to lack of advocacy and support from their representatives when they were unable to make decisions for themselves due to decreased health status and level of consciousness.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure resident's right were protected to be free from abuse. This was true for 1 of 1 resident (Resident #56) observed during lunch assistive feeding. This failure placed all residents at risk for potential abuse and potential physical and psychosocial harm.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 18 residents (Resident #55) whose care plan was reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed.

Inspectors wroteBased on observation, staff interview, policy review, and Occupational Safety and Health Administration (OSHA) Standard, it was determined the facility failed to ensure residents were free from accident hazards for 2 of 18 Residents (#15 and #41) whose room was observed for environmental safety. This deficient practice had the potential to cause physical harm if a power strip cord were to overheat and cause a fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #6) received continuous oxygen via nasal cannula prescribed by the physician. This created the potential for residents to experience respiratory difficulties/impaired breathing and low oxygen saturations.

Inspectors wroteBased on review of the State Operations Manual, Appendix PP dated 7/23/25, policy review, staffing schedules, personnel files, and staff interviews, it was determined the facility failed to ensure full-time employees working as a nurse aide successfully completed a State approved training and competency evaluation program within 4 months of being hired. This was true for 1 of 1 nurse aides (NA #1) whose personnel files were reviewed. This failure had the potential to result in negative outcomes for all residents living in the facility.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to ensure residents were free of medication preparation and administration errors for 1 of 2 residents (Resident #8) observed for medication preparation and administration of insulin. This failed practice placed the resident at risk for not receiving their prescribed medication dosage and other adverse outcomes.

Inspectors wroteBased on observations, interviews, and policy review, it was determined the facility failed to ensure medications were properly stored and not expired. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy.

Inspectors wroteBased on observation, interview, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility.

Inspectors wroteBased on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 3 of 3 residents (#6, #15, and #56) observed for infection control. These failures put residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, FDA Food Code, and staff interview, it was determined the facility failed to ensure kitchen equipment was cleaned. These deficiencies had the potential to affect the 56 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes.

Inspectors wroteBased on observation, review of the Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM), Appendix PP, and resident and staff interviews, it was determined the facility failed to ensure the residents had an environment where housekeeping and maintenance services provided a sanitary shower room in good repair. This was true for 1 of 4 showers used in the facility. This deficient practice created the potential for psychosocial harm if residents felt they were not provided the same homelike environment as other residents.

Inspectors wrote2. Resident #20 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder. An Annual MDS Assessment, dated 3/23/25, documented no at A1500, a PASRR level II was not completed. Resident #20's medical record included documentation of a PASRR level I screening, dated 8/20/21, which identified she had a serious mental illness diagnosis of bipolar disorder. Resident #20's medical record included documentation of an abbreviated PASRR level II screening, dated 8/23/21, which identified she had a diagnosis of serious mental illness per PASRR criteria. On 5/29/25 at 3:28 PM the Regional MDS Nurse stated in 2021, Resident #20's MDS documented yes at A1500, a PASRR level II had been completed, but beginning in 2022, it was marked no in error and it should have been corrected. [...]

Inspectors wroteBased on review of the CMS SOM, Appendix PP, record review, and staff interview, it was determined the facility failed to ensure 1 of 14 residents (Resident #21), mental health needs were evaluated through the State's level II PASRR process. This deficient practice had the potential to cause harm if the resident's mental health needs were not adequately met.

Inspectors wroteBased on staff interview and record review, it was determined the facility failed to ensure PASRR's were completed for 1 of 14 residents (Resident #40) reviewed for PASRR's. This deficient practice had the potential for more than minimal harm when if residents required, but did not receive, specialized services for mental health while residing in the facility.

Inspectors wrote2. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including low back pain, fracture of the right leg, altered mental status, diabetes, and opioid dependence. Resident #27's medical record did not document a baseline care plan was completed. On 5/29/25 at 1:28 PM, the DON stated a baseline care plan was not completed for Resident #27. Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of residents' admission. This was true for 2 of 14 residents (#1 and #27) reviewed for baseline care plans. This failure created the potential for harm if the care plan failed to provide direction for care.

Inspectors wroteBased on observation, record review, the CMS SOM review, and staff interview, it was determined the facility failed to ensure resident centered care plans were comprehensively written. This was true for 1 of 14 residents(Resident #34) whose care plans were reviewed. This deficient practice placed the resident at risk for harm when their care plan did not reflect the care necessary.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure services provided met professional standards. This was true for 1 of 14 residents (Resident #43) whose physician orders were reviewed. This failure placed Resident #43 at risk for harm from overmedication when his seizure medication orders were not clarified.

Inspectors wroteBased on record review, medication error reports, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 5 of 5 residents (#10, #23, #31, #34, and #44) reviewed for medication errors. This deficient practice created the potential for harm if residents received medications not as prescribed.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 7 of 13 residents (#6, #13, #26, #35, #44, #48, and #51) whose records were reviewed for quality of care. Specifically: - Resident #35 suffered harm when she sustained a hip fracture with pain after a fall and the fracture was not diagnosed until 10 days after the fall. - Resident #48 and #51 were at risk for undetected injury and neurological changes when fall assessments and neurological assessments were not completed after falls. - Resident #44 was at risk for undetected injury when fall assessments were not completed after falls. - Resident #13 was at risk for increased psychiatric symptoms related to missed doses of her antipsychotic medication. [...]

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a resident received appropriate care to prevent and treat a pressure ulcer. This was true for 1 of 2 residents (Resident #22) reviewed for wound care. This failure resulted in harm when Resident #22 developed an abrasion on his right trochanter (upper end of the thigh bone that is connected to the hip bone) which became an unstageable pressure ulcer.

Inspectors wroteBased on policy review, record review, review of I&A reports, and staff interview, it was determined the facility failed to ensure adequate supervision was provided to residents to prevent falls. This was true for 1 of 5 residents (Resident #47) reviewed for falls. This resulted in harm to Resident #47 when he sustained bruises and a fracture to his finger.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of medications for 5 of 15 residents (#6, #12, #17, #37, and #47) reviewed for unnecessary medications. This deficient practice placed residents at risk for receiving medications without knowledge of why the medication was prescribed, the expected benefits, and the risks associated with the medications.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure residents were provided with baths/showers and personal hygiene consistent with their needs. This was true for 9 of 13 residents (#4, #6, #13, #16, #26, #35, #44, #48 and #51) reviewed for ADLs. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, and/or skin impairment due to lack of personal hygiene.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure measures were in place to prevent possible cross-contamination from dirty to clean areas in the kitchen. This had the potential to affect 51 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on staff interview, record review, and policy review, it was determined the facility failed to develop and implement processes to minimize the risk of residents acquiring, transmitting or experiencing complications from Pneumococcal pneumonia. The facility failed to implement an immunization program that tracked residents' Pneumococcal vaccine status, so immunization could be offered or provided as indicated. This was true for 1of 7 residents (Resident #26) reviewed for Pneumococcal vaccination and had the potential to affect all residents residing in the facility.

Inspectors wroteBased on policy review, record review, representative interview, and staff interview, it was determined the facility failed to ensure residents' representatives were immediately notified when residents fell or had a change in condition. This was true for 2 of 2 residents (#35 and #48) whose records were reviewed for changes in condition. This deficient practice placed residents at risk of harm due to lack of advocacy and support from their representatives when they were unable to make decisions for themselves due to decreased health status and level of consciousness.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure residents were provided with a sanitary environment free of unpleasant odors. This was true for 1 of 14 residents (Resident #37) whose environment was observed. This deficient practice created the potential for diminished quality of life and psychosocial distress for Resident #37 when she was placed in a room with a strong odor of urine due to her roommate's lack of compliance with personal hygiene.

Inspectors wroteBased on policy review, record review, review of the State Survey Agency's Long Term Care Reporting Portal, review of I&A reports, and staff interview, it was determined the facility failed to ensure 3 of 14 residents (#26, #52, and #53) reviewed for abuse, neglect, and misappropriation. The facility failed to ensure residents were not abused by a staff member. This failure resulted in the potential for residents to be subjected to ongoing abuse and potential harm.

Inspectors wroteBased on observation, record review, review of I&A reports, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as residents' needs changed. This was true for 4 of 16 residents (#12, #20, #22, and #44) whose care plans were reviewed. This deficient practice placed residents at risk for adverse outcomes if care and services were not provided appropriately due to a lack of information in the care plan.

Inspectors wroteBased in policy review, observation, record review, and staff interview, it was determined the facility failed to ensure residents received respiratory care for a resident receiving oxygen by nasal cannula. This was true for 1 of 2 residents (Resident #26) reviewed for respiratory care. This deficient practice had the potential for harm if the residents experienced discomfort from non-humidified oxygen.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a resident receiving PRN lorazepam (anti-anxiety) had clinical rationale supporting the continued use of the medication beyond 14 days. This was true for 1 of 9 residents (Resident #39) reviewed for unnecessary medications. This deficient practice had the potential for Resident #39 to experience adverse effects from unnecessary psychotropic medications.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control measures were consistently implemented and maintained to provide a safe and sanitary environment during perineal care. This was true for 1 of 1 resident (Resident #55) whose perineal care was observed. This failure created the potential for negative outcomes by exposing a resident to the risk of infection and cross-contamination.