Casa De Paz Health Care Center

In the surveyor’s words

From the most serious findings on record at Casa De Paz Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 21, 2021

  Based on observation, record review, policy review, staff interview, and Advanced Registered Nurse interview, the facility failed to complete a thorough physical assessment for 2 of 3 residents reviewed (Resident #1 & #3). Resident #1 complained of constipation, experienced vomiting, and requested to be seen by the physician and be sent to the hospital. Resident #1 had emesis during the night of [DATE]-[DATE], and the facility failed to complete a thorough assessment or notify the physician until the resident transferred to the local hospital on [DATE] at 3:30 PM, after the resident complained of pain with distended abdomen and hypoactive bowel sounds. Resident #1 expired in the hospital after being there less than 10 hours. […]

• Actual harm, isolatedF695Mar 16, 2023

  Based on observation, record review, the State Long-Term Care Ombudsman, resident, and staff interviews, the facility failed to provide sufficient oxygen supply for a 1 of 1 resident (Resident #16) during dining. Due to the lack of a sufficient oxygen supply, harm occurred to the resident when she became unresponsive and turned blue. The facility reported a census of 47 residents. Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of heart failure, atrial fibrillation, chronic obstructive pulmonary disease, cardiomyopathy, renal disease, diabetes mellitus, anxiety and depression. The MDS identified a Brief Interview for Mental Status (BIMS) of 10, indicating moderate cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF847Mar 16, 2023

  Based on record reviews, Residents' Representatives, and staff interviews the facility failed to explicitly grant residents or their Representative the right to rescind from a voluntary arbitration agreement within 30 calendar days of signing for 47 out 47 residents reviewed. The facility reported a census of 47. Findings Included: The undated Voluntary Arbitration Agreement reviewed on 3/15/23 at 4:49 PM identified a section labeled the Right to Change Your Mind: The Resident will receive from the facility a copy of this agreement upon it being fully executed. The agreement may be canceled via a written notice sent to the facility administrator by certified mail, return receipt requested, within ten (10) business days of the date it is executed by the Resident. […]

• No harm, potential for more than minimal, patternF812Apr 9, 2026

  Based 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.Findings include:During continuous observation on 4/6/26 from 10:20 AM to 10:40AM during the initial kitchen tour revealed:a. Four large plastic cereal containers with no open dates noted. b. A five gallon bucket of flour with no open date noted. c. Half eaten bowl of soup with spoon in bowl in the freezer of the fridge/freezer. Interview on 4/6/25 at 10:25 AM with Staff B dietary aide revealed that the half eaten bowl of soup with a spoon should not have been in the freezer. […]

• No harm, potential for more than minimal, patternF880Apr 9, 2026

  Based 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.Findings include:Observation on 4/8/26 at 9:57 AM, showed Staff F, Registered Nurse (RN), donned a gown and gloves, then placed a barrier on the wound cart. With gloved hands, Staff F accessed her pocket to retrieve the wound cart key, unlocked the cart, and obtained necessary supplies (solution, ointment, kerlix, gauze, and q-tips), placing them on the barrier. […]