Mission De La Casa

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were implemented during the facility's COVID-19 (name of disease caused from SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2, a type of coronavirus]) outbreak (when a disease spreads to more people than usual, and caused by an infectious agent, such bacteria, viruses, or parasites) when:1. [...]

Inspectors wroteBased on interview and document review, the facility failed to have qualified, full-time oversight of Food and Nutrition Services in accordance with State requirements when the Registered Dietitian did not fulfill the role in the Dietitian job description, and the staff put in charge of supervising the kitchen were not qualified. This deficient practice could result in compromising the safety and nutritional status of residents through potential transmission of foodborne illness and decreased quality of food for 144 residents, who received food from the kitchen out of a census of 151.

Inspectors wroteBased observation, interview, and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. ADS was unable to accurately demonstrate the procedure for testing the concentration, according to manufacturer specifications, of the sanitizing solution used on food contact surfaces. Cook C was unable to accurately identify the acceptable calibration temperature for two thermometers in an ice water solution. These failures had the potential to result in ineffective sanitation practices and the use of inaccurate temperature-measuring devices for verifying safe food temperatures, thereby increasing the risk of foodborne illness among a high-risk population of 144 residents who consumed food prepared in the facility's kitchen. At the time, the facility's census was 151.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:Discard unused pork leftovers following dinner service on 08/10/2025. Discard 2 expired raw thawing turkey loaves with a use by date of 08/09/2025. Maintain food at or below 41 F in the one-door refrigerator, as required for proper refrigeration. Maintain cleanliness of 4 out of 12 knives. These deficiencies had the potential to compromise food safety and increase the risk of foodborne illness for 144 of the 151 residents who consumed meals prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow residents to store perishable food brought in by visitors and family. This failure had the potential to result in decreased food intake leading to weight loss and/or food related medical complications for 144 residents who ate food by mouth out of a census of 151.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the outside waste collection area in good condition. This failure had the potential to create unsafe and unsanitary conditions by attracting pests, such as rodents and insects, which could carry and spread disease, posing a risk of foodborne illness to all 151 residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered care plans for 11 of 29 sampled residents (Residents 15, 22, 64, 55, 92, 78, 70, 89, 136, 60, and 67) when care plans for: 1. Resident 15's diagnosis of schizophrenia (a chronic mental health condition that affects a person's thoughts, feelings, and behavior) was not developed;2. Residents 22 and 64's use of bed rails (an adjustable metal or rigid plastic bars that attach to the bed, like side rails, bed side rails, safety rails, grab bars and assist bars) were not developed; 3. Residents 55, 92, 78, 70, 89, 60, and 67's interventions for use of positioning device (e.g. bed rails) were not implemented; and 4. Resident 136's care plan for use of bed rails was resolved, and a new care plan for continued use of bed rails was not developed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' care plan for siderails were reviewed and updated quarterly for safety and effectiveness for 19 of 29 sampled residents (Resident 31, 38, 4. 59, 96, 54, 97, 109, 110, 11, 138, 142, 145, 151, 150, 26, 81, 62 and 151) when:1. Residents 31, 38, 4. 59, 96, 54, 97, 109, 110, 11,138, 142, 145, and 151 were without revised quarterly care plan; and2. Residents 150, 26, 81, 62 and 151, were without revised bed rails care plan. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-beingFindings: 1a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice for four (Resident 116, 130, 22 and 64) of 59 sampled residents when:For Resident 116, the Blood Glucose (BG) testing was performed one hour prior to insulin given and two hours prior to breakfast being served and there was no monitoring for episodes of hyperglycemia or hypoglycemia, andFor Resident 130, 22 and 64, there was no physician order for the use of side rails or positional bars. This failure had the potential to result in Resident 116's blood glucose not being treated appropriately and jeopardize their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of bed rails (BR, adjustable rigid bars attached to the side of the bed) for 38 out of 114 residents when:1. There was no Bedrail Use and Entrapment Risk Evaluation completed prior to the use of BR for two of 114 residents (Resident 130,and 64 );2. There was no documentation that indicated alternatives were offered and/or attempted prior to the use of side rails for 20 out of 114 residents (Residents 159, 140, 83, 46, 141, 129, 160, 136, 60, 67, 101, 125, 31, 38, 98, 53, 138, 142, 151 and 96) who used them;3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a pre-admission screening and resident review (PASARR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was accurately completed for one of three residents (Resident 8). This failure had the potential for inaccurate care and services provided to residents with mental disorder (MD), intellectual disability (ID), or related conditions.

Inspectors wroteBased on interview and record review the facility failed to follow its Policy & Procedure (P&P) titled, Dignity and Respect Psychoactive Medications, dated 2025, for one of 30 sampled residents (Resident 15), when the facility failed to monitor Resident 15 for behaviors related to her diagnosed mental illness. This failure had the potential for Resident 15's behavior related to a diagnosed mental illness to go unnoticed by staff, contributing to a potential in psychosocial harm to Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system for physician prescribed fortified diets (a diet with added nutrients, such as calories and protein, to increase the nutritional value of the diet, especially for individuals with or at risk for weight loss and/or malnutrition). This failure had the potential to result in weight loss and or further complicate medical conditions for 1 sampled resident (Resident 3) who was on a physician prescribed fortified diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure lunch menus were followed on 08/11/2025 as evidenced by:Resident 163 received a mixed fruit cup instead of 1 fresh apple as indicated on the menu. Resident 143 received tarter sauce when it was not indicated on the menu. These deficiencies had the potential to compromise the medical and nutritional status of Residents 163 out of 143.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dryer's lint filter compartment and lint trap cleaning log were routinely maintained. The facility's documentation indicated laundry staff did not clean the dryer lint for several hours on multiple days. This failure had the potential to for an excess accumulation of lint that could catch on fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was free from flies. This failure had the potential to compromise food safety and increase the risk of foodborne illness for 144 of the 151 residents who consumed meals prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to sanitize the food thermometer between measuring the temperatures of different food items. This had the potential to affect 138 of 138 residents who received food from the dietary department.

Inspectors wrote2. An admission Record revealed the facility admitted Resident #67 on 03/31/2023. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder (11/04/2018) and post-traumatic stress disorder (PTSD) (onset date 11/05/2018). Resident #67's Level I PASARR, dated 03/31/2023, revealed the resident was diagnosed with major depressive disorder; however, the resident's diagnosis of PTSD was not reflected. The Level I PASARR was Positive, due to a suspected MI [mental illness]. A letter from the Department of Health Care Services to the facility, dated 04/12/2023, indicated the Level II evaluation was not completed because the resident had no serious mental illness (SMI). The letter indicated the case was closed. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the medication error rate was five percent (%) or less. Medication administration observations revealed 2 medication errors out of 25 total opportunities, resulting in a medication error rate of 8%, affecting 2 (Resident #137 and Resident #105) out of 5 residents observed during medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure supervision was provided to one of three residents (Resident 1) who was assessed to be high risk for falls, totally dependent on staff for transferring, and required close monitoring (staff made rounds and observed the residents at risk of falling) when Resident 1 was left sitting in her wheelchair in the hallway without staff watching and/or supervising her on [DATE], at 6:45 a.m., when staff went inside another resident's room. This failure resulted in Resident 1 falling on the floor and sustaining a subdural hematoma (occurs when a blood vessel in the space between the skull and the brain is damaged; blood escapes from the blood vessel, leading to the formation of a blood clot that places pressure on the brain and damages it) on the right temporal region (a region at the side of the head behind the eyes). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policies and procedures for ensuring the reporting of injuries of unknown source for one of two sampled residents (1) to other officials (including to the California Department Public Health (CDPH) and adult protective services (APS) where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures after when Resident 1 sustained a subdural hemorrhage (is a kind of intracranial hemorrhage, which is the bleeding in the area between the brain and the skull) with multiple rib fractures on 2/19/24 and transferred to an acute hospital for intensive care unit (ICU, provides the critical care and life support for actually ill and injured patients) monitoring and management, and facility's investigation did not identify the reason or cause [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Licensed vocational nurse L (LVN L) did not wear face mask properly while in the nurses station with other staff; 2. A certified nursing assistant was wearing a disposable face mask underneath another disposable facemask; 3. Clean linen in the hallway was not covered; 4. Gloves were worn in the hallway; 5. Housekeeping staff did not properly wear a face mask; 6. Resident 119 was not monitored daily for signs and symptoms of COVID 19 (corona virus disease 19; a highly contagious respiratory disease); 7. Activity assistant did not wear face mask properly; 8. Certified nursing assistant did not wear face mask properly; and 9. Certified nursing assistant did not provide hand hygene after care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain residents' privacy, dignity and respect for three of 24 sampled residents (Residents 48, 47 and 99) when: 1. The activity aid (ACA) was standing in front of Resident 48 while assisting the resident in the hallway with the lunch meal. 2. Resident 47 was using the bathroom and the door was left opened. 3. During GT administration observation Resident 99's room door was open, and her abdomen was exposed to public view in the hallway. These failures had the potential to affect Resident 48 47 and 99's self-esteem and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure needs were accommodated for five of 24 sampled residents (Residents 99, 52, 119, 114, 122) when call light devices were not within reach of the residents. This failure had the potential for a delayed response and not meeting the resident's needs.

Inspectors wroteBased on an observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in minimum data set (MDS, an assessment tool) for one of 24 sampled residents (Resident 61). The resident had declined in activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring), balance during transition and walking, and declined in bowel and bladder continence. These failures had the potential to result in Resident 61 being unable to achieve or maintain optimal status of health, function and quality of life.

Inspectors wroteReview of Resident 47's clinical record indicated she was admitted on [DATE] with diagnosis including schizoaffective disorder (mental disorder including schizophrenia [serious mental disorder in which people cannot distinguish reality] and mood disorder), dementia (memory loss). Further review of Resident 47's clinical record, there was no PASARR documentation found. During an interview with the regional consultant (RC) on 7/8/21 at 10:07 a.m., the RC stated the facility could not find the PASARR. During an interview with the assistant director of nursing (ADON) on 7/8/21 at 11:29 a.m., the ADON stated she could not find Resident 47's completed PASARR. During an interview with the medical records director (MRD) on 7/8/21 at 2:14 p.m., the MRD stated he could not find Resident 47's PASARR. [...]

Inspectors wrote5. During observation and concurrent interview with RN G, on 7/6/21 at 8:15 a.m., RN G was observed preparing medications for Resident 84. As RN G withdrew Dutasteride (medication for urine retention), the capsule still containing medication fell to the floor. RN G administered to Resident 84 what she withdrew from the capsule. Further examination of the capsule that fell on the floor indicated medication was left in the capsule. RN G confirmed this observation and confirmed the Resident 84 received a partial dose. Review of Resident 84's physician orders, dated 6/18/19, indicated the order was for Dutasteride capsule 0.5 mg by mouth once daily. During an interview with the director of nursing (DON), on 7/7/21 at 10:25 a.m., the DON stated RN G should not have given a partial dose to Resident 84. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers for one of 24 sampled residents (Resident 88) when the resident was unable to carry out showers independently. This failure had the potential to negatively affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate new intervention on a fall care plan for a resident with multiple falls, revise, update an individualized and comprehensive person-centered fall care plan and person-centered interventions for three of 24 sampled residents (Residents 32, 61 and 16.) This failure had the potential to put the resident at risk of sustaining injuries and had the potential to result in not meeting the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to implement the policy and procedure for continence management for one of 24 sampled residents (Resident 88) when the resident was not properly assessed for bowel and bladder (B&B) training. This deficient practice had the potential to cause a decline in B&B control.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dialysis services consistently with professional standards and to ensure staff had coordinated residents' care with the dialysis center for one of five sampled residents (Resident 53) receiving hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e., salts and mineral imbalances by using a machine and an artificial kidney) when: 1. Communication with the dialysis center was not properly coordinated when dialysis communication records (DCR) were not completed; 2. Inaccurate access site information and communication with the facility to dialysis center; 3. There was no emergency dialysis kit available in the unit; and 4. The dialysis care plan was not resident- person centered. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store medication when: 1. One of two medication refrigerators were not within the facility's acceptable temperature range of 36 to 36 degrees Fahrenheit (F); 2. A&D ointments were found at Resident 41 and Resident 43's bedside tables. These failures had the potential for medications to lose their potency and effectiveness when administered to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff are aware of the process to measure the sanitizer level of the dishwasher, when cook E (KC E) did not dip the test strip in the sanitizer water for the directed length of time. This failure had the potential to cause food-borne illness in the already immune compromised residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store food for one of 24 sampled residents (Resident 74) when a family member brought food from home and the resident did not consume it within one (1) hour after receiving it. This failure had the potential to lead to food-borne illness (an illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and could compromise the medical condition of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate use of antibiotic (medication for the infection) for one of 24 sampled residents (Resident 66). This failure had the potential for the resident to take unnecessary antibiotics which could lead to resistance to the antibiotic.