Mini-Cassia Care Center

In the surveyor’s words

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

• Actual harm, isolatedF684May 27, 2022

  Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 7 of 13 residents (#6, #13, #26, #35, #44, #48, and #51) whose records were reviewed for quality of care. Specifically: - Resident #35 suffered harm when she sustained a [CONDITION(S)] with pain after a fall and the fracture was not diagnosed until 10 days after the fall. - Resident #48 and #51 were at risk for undetected injury and neurological changes when fall assessments and neurological assessments were not completed after falls. - Resident #44 was at risk for undetected injury when fall assessments were not completed after falls. […]

• Actual harm, isolatedF686May 27, 2022

  Based on record review and staff interview, it was determined the facility failed to ensure a resident received appropriate care to prevent and treat a pressure ulcer. This was true for 1 of 2 residents (Resident #22) reviewed for wound care. This failure resulted in harm when Resident #22 developed an abrasion on his right trochanter (upper end of the thigh bone that is connected to the hip bone) which became an unstageable pressure ulcer. Findings include: The National Pressure Injury Advisory Panel website, accessed on 6/2/22, defined pressure injury as a localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. […]

• Actual harm, isolatedF689May 27, 2022

  Based on policy review, record review, review of I&A reports, and staff interview, it was determined the facility failed to ensure adequate supervision was provided to residents to prevent falls. This was true for 1 of 5 residents (Resident #47) reviewed for falls. This resulted in harm to Resident #47 when he sustained bruises and a fracture to his finger. Findings include: The facility's policy Fall and Fall Risk Managing, revised 3/2018, documented staff completed a fall risk assessment and enter it into the resident's medical record. Staff would identify the cause of the resident's fall and document interventions related to a resident's specific risks and causes, try to prevent the resident from falling, and try to minimize complications from falling. […]

• No harm, potential for more than minimal, widespreadF812Aug 5, 2026

  Based on observation, interview, policy review, and U.S. Food and Drug Administration 2022 Food Code, the kitchen staff failed to appropriately store and label foods, wash hands prior to donning gloves, and prevent possible cross contamination of opened resident stored food items with kitchen stored food products. This deficient practice had the potential to affect all 58 residents who received meals prepared in the facility's kitchen. Findings include:The facility's Food Receiving and Storage policy dated 3/31/25, documented all foods stored in the refrigerator or freezer are covered, labeled, and dated ( use by date).The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is… […]

• No harm, potential for more than minimal, widespreadF812May 30, 2025

  Based on observation, FDA Food Code, and staff interview, it was determined the facility failed to ensure kitchen equipment was cleaned. These deficiencies had the potential to affect the 56 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes. Findings include: The FDA Food Code Section 4-602.12 Cooking and Baking Equipment documented food-contact surfaces of cooking equipment must be cleaned to prevent encrustation's that may impede heat transfer necessary to adequately cook food. […]