Casa Dorinda

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 18, 2025

  Based on interview and record review, the facility failed to follow their policy and procedure and implement interventions of a fall care plan to ensure a bed alarm was turned on for one of three sampled residents (Resident 1) while Resident 1 was in bed.This facility failure resulted in Resident 1 getting out of bed, falling to the floor and sustaining an acute displaced right hip fracture (broken hip bone that moved so much a gap formed around the fracture).During a review of Resident 1's Face sheet, [undated], the Face sheet indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease (brain disorder that causes memory loss, confusion, and other cognitive decline), unspecified dementia (loss of brain function), major depressive disorder… […]

• No harm, potential for more than minimal, widespreadF851Dec 5, 2024

  Based on interview and record review, the facility failed to run reports 1700D (employee report), 1702D (individual daily staffing report) and 1702S (staffing summary report) to ensure payroll-based journal (PBJ) data (a system for facilities to submit staffing information on a regular and frequent basis, ensuring accuracy) was received by the Center for Medicare and Medicaid (CMS). This failure resulted in CMS not receiving registered nurse (RN) hours and licensed nursing coverage data for the month of June 2024. […]

• No harm, potential for more than minimal, widespreadF812Apr 12, 2024

  Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when: 1. The high temperature dish machine was not reaching proper wash, rinse and final rinse temperatures in order to effectively sanitize in accordance with the manufacturer's guidelines. 2. The three compartment sink used to wash pots and pans was not implemented in an effective manner to properly wash and sanitize the foodservice equipment. 3. The tube to dispense sanitizer was located in the hand washing sink. These failures had the potential to result in cross contamination and food borne illness in a highly susceptible resident population in which the majority of residents were on oral diets. Cross Reference F801 Findings: 1. […]

• No harm, potential for more than minimal, patternF812Mar 6, 2026

  Based on observation, interview and Policy and Procedure (P/P) the facility failed to ensure food safety requirements was followed and implemented whenFailed to discard leftover in the itchen's walk-in-refrigerator.Take temperature of cold foods for lunch meal service to maintain potentially hazardous food and Time/ Temperature Control for Safety PHF/TCS foods at safe temperatures.Ensure kitchen staff during food preparation for meals served to residents wear appropriate beard restraints. Ensure safe food storage when documenting temperatures on the temperature monitoring log exceed 41 degrees Fahrenheit (F) and went unnoticed due to incorrect guidelines listed on the log.1.During a concurrent observation and interview on 3/3/26 at 11:00 a.m. […]

• No harm, potential for more than minimal, patternF812Dec 5, 2024

  Based on observation, interview and record review, the facility failed to follow food safety requirements when: 1. Three (3) containers of prepared food were mislabeled as to date prepared of expiry date and is ante-dated (written date is one day after date of inspection) 2. One (1) of three (3) red buckets tested was below the recommended concentration of sanitizing solution. These failures has the potential for food borne illnesses affecting residents when safe refrigerated food are mislabelled, food has no use-by date, and sanitizing solutions are not safe when preparing foods. Findings: 1. During an observation on 12/02/24 at 11:36 a.m. at the kitchen freezer section, three stainless steel containers were identified. […]