Casa Bonita Convalescent Hospital

In the surveyor’s words

From the most serious findings on record at Casa Bonita Convalescent Hospital, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 9, 2026

  Based on observation, interview and record review, the facility failed to ensure,A. a safe environment was provided to prevent a fall (unintentional descent to the ground) for one of two sampled residents (Resident 106) by failing to:1. Ensure Certified Nursing Assistant 5 (CNA 5) provided two-person physical assistance (help from two persons) when providing toileting hygiene (the ability to maintain perineal [area of the body located between the anus [opening located between the buttocks where solid waste leaves the body] and genitals [private parts of the body] hygiene, adjust clothes before and after voiding or passing stool) for Resident 106 as indicated in Resident 106's Minimum Data Set (MDS- a resident assessment tool), dated 6/3/2026.2. […]

• Actual harm, isolatedF689Sep 10, 2025

  Based on interview and record review, the facility failed to provide care and services to prevent a fall (unintentionally coming to rest on the ground, or lower level) for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, by failing to:1. Implement a resident-centered fall prevention plan of care for Resident 1.2. Monitor Resident 1's response to fall prevention interventions. 3. Assess the causative factors of Resident 1's multiple falls per Resident 1's Care Plan (CP, a form where one can summarize a person's health conditions, specific care needs, and current treatments).As a result, on 9/3/2025 at 9:45 AM, Resident 1 fell onto the floor mat on the right side of the bed. […]

• No harm, potential for more than minimal, patternF684Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to provide the necessary care and services for two of two sampled residents (Resident 9 and Resident 88) when: a. The facility failed to follow Resident 9's physician's (health professional who is licensed and trained to practice medicine) order and the care plan (CP) indicating to rotate injection sites during the administration of insulin (a fast-acting vital hormone that regulates blood sugar and is used to treat diabetes [disease characterized by high blood sugar levels due to insufficient insulin production]).b. The facility failed to ensure Resident 88's medications were administered within one hour (before or after) of their prescribed time on 7/8/2026. […]

• No harm, potential for more than minimal, patternF812Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in one of one kitchen (Kitchen 1) when on 7/6/2026, seven waffle packages were not dated.This deficient practice had the potential to result in foodborne illness (an illness caused by eating contaminated food) to the residents being served and consuming the undated waffles.Findings:During an initial tour of Kitchen 1 and concurrent interview on 7/6/2026 at 8:48 AM with the Dietary Supervisor (DS), seven packages of round light tan colored grid- patterned texture patties were observed inside Kitchen 1's freezer and did not have an expiration date or indicate a use-by-date (the final date recommended by the maker for a consumer to use a product while it remains at peak… […]

• No harm, potential for more than minimal, patternF880Jul 9, 2026

  Based on observation, interview and record review, the facility failed to implement infection control practices for three of three (Resident 2, Resident 83, and Resident 88) sampled residents by:a. Failing to ensure a trash can full of trash to the brim with used PPE (personal protective equipment - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) gowns was not kept at Resident 2's bedside. b. Failing to ensure infections control interventions were implemented when on 7/6/2026, Respiratory Therapist (RT) 1 did not use a face shield while providing tracheostomy (a surgically created hole in your windpipe to allow air to your lungs) care to Resident 83, who was a carrier of Carbapenem-Resistant Acinetobacter Baumannii (CRAB,… […]