Casitas Care Center

In the surveyor’s words

From the most serious findings on record at Casitas Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF677Aug 13, 2026

  Based on interview and record review, the facility failed to implement the facility's policy on fingernails and toenails care by failing to provide documented evidence that fingernail care was being provided for the month of August 2026 by nursing staff for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice had the potential to result in a negative impact on the residents' self-esteem and self-worth.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident on 3/16/2026 with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arm). […]

• No harm, potential for more than minimal, patternF584Mar 26, 2026

  Based on observation, interview and record review, the facility failed to: 1. Maintain a comfortable sound levels to promote a restful environment for two of three residents (Resident 3 and 89) investigated under the care area Safe/Clean/Homelike Environment. This deficient practice resulted in the residents feeling disrespected, annoyed and awaken unnecessarily. 2. Provide a safe, clean, comfortable, and homelike environment for one of three sampled residents (Resident 91) when there was dust buildup on the base of the resident's facility provided fan and wall. This deficient practice denied Resident 91 the right to a clean, comfortable, and homelike environment and had the potential to negatively impact Resident 91's quality of life. Findings: 1.a. […]

• No harm, potential for more than minimal, patternF605Mar 26, 2026

  Based on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 2) was free from unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure Resident 2 did not have duplicate (more than one [1]) medication treatments with the use of quetiapine (antipsychotic [medication used to treat mental illness]) and clonazepam (a psychotropic drug used for agitation and as anxiolytic [reduce anxiety]) between 12/23/2025 and 3/24/2026. […]

• No harm, potential for more than minimal, patternF755Mar 26, 2026

  Based on observation, interview, and record review the facility failed to: 1.Reconcile (the process of comparing transactions and activity to supporting documentation) four (4) medication emergency kits (eKIT - kit containing medications needed to be used during emergencies) containing Controlled Substance-[CS, medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication, CM]) for March 2026, in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER].) 2.Reconcile two (2) medication eKITs containing CS for March 2026, in two (2) of three (3) inspected Medication Carts (Medication Cart 1 Station 1, Medication Cart AM Station.) 3. […]

• No harm, potential for more than minimal, patternF759Mar 26, 2026

  Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 25 total opportunities contributed to an overall medication error rate of 8% affecting two (2) of four (4) residents observed for medication administration (Resident 18 and 57.) The medication errors were as follows:1. Resident 18 did not receive a form of aspirin (a medication used for cerebrovascular accident [CVA - an interruption in the flow of blood to cells in the brain, mainly caused by hypertension (high blood pressure)] prophylaxis [PPX - prevention]) as ordered by Resident 18's physician. 2. Resident 57 did not receive a form of aspirin as ordered by Resident 57's physician. […]