Other·October 10, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE AMENDED The following reflects the findings of the California Department of Public Health, Licensing and Certification, during an Investigation of a Facility Reported Incident (FRI): FRI: CA00636685- Substantiated Representing the Department of Public Health: Surveyor ID # 35399, HFEN The inspection was limited to the specific FRI investigated and does not represent the findings of a full inspection of the facility.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed to provide adequate supervision and assistance for one of two sampled residents (Resident 1) to prevent avoidable accident and injury. Resident 1, LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EFKQ11 Facility ID: CA050000046 If continuation sheet 1 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555023 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CASA DORINDA 300 Hot Springs Rd Santa Barbara, CA 93108 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assessed by the facility as severely impaired cognition (mental process) requiring two or more-person assistance during transfers, was left alone and unsupervised in front of the beauty parlor with no staff nearby. A tab alarm (an alarming device that alerts the facility staff when the resident attempts to get up from the wheelchair unassisted) was not attached as ordered by the physician and as required in her plan of care. Resident 1 got up from her wheelchair and fell to the floor. As a result of this failure, Resident 1 fell on the floor and sustained left metacarpal (hand bone) fractures (break of bones), scraped her forehead and suffered pain. Findings: During an observation and concurrent interview of Resident 1, inside her room, on 5/14/19 at 11:30 a.m., Resident 1 was observed with a left hand splint wrapped with a dressing. Resident 1's interview was limited due to the resident's cognitive impairment. Resident 1 was awake and alert to name only. Resident was not able to follow simple commands, and her speech was minimal. During an observation of the second floor on 5/14/19 at 11:30 a.m., where Resident 1's room was located on the West side of the floor. The nursing station (where staff congregates) was located on the middle of the floor. The floor was divided into the West and the East side for residents care assignments. The beauty parlor was located on the East side of the floor, at the very end of the floor, no other rooms were nearby to the east side of the beauty parlor. No other residents' rooms were located in-front of the beauty parlor, only the exit stairwell. There was a long and far distance between the nursing station and the beauty parlor. When FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EFKQ11 Facility ID: CA050000046 If continuation sheet 2 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555023 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CASA DORINDA 300 Hot Springs Rd Santa Barbara, CA 93108 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 was left alone and unsupervised, in front of the beauty parlor (at the end of the floor), it would have been hard to hear from the nursing station when Resident 1 was calling for assistance. Review of Resident 1's face sheet indicated, diagnoses including arthritis, history of falling, delusional disorders (person cannot tell what is real from what is imagined), generalized muscle weakness, and dementia (a condition which causes problems with memory and cognitive functioning) without behavioral disturbances. Review of Resident 1's minimum data set (MDS - comprehensive resident assessment) assessment dated 2/11/19 indicated, Resident 1's BIMS score was 06. BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively. BIMS scores 13 to 15 means: intact cognition. 8 to 12 means: moderately impaired cognition. 0-7 means: severely impaired cognition. Resident 1 required extensive assistance with two persons with bed mobility and transfers. Resident 1 had reduced strength to legs, and was not able to ambulate independently. Resident 1 needed extensive assistance with two or more-person assistance during transfers from bed, chair, wheelchair, and standing position. Review of Resident 1's "Fall Risk Assessment" dated 4/19/19 indicated, Resident 1 was at risk for falls related to several factors including: a. intermittent confusion, poor recall, judgment, safety awareness, b. balance problem while standing and walking requires use of assistive device- e.g. cane, walker, wheelchair c. impaired mobility, d. decline in cognitive skills, other dementia, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EFKQ11 Facility ID: CA050000046 If continuation sheet 3 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555023 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CASA DORINDA 300 Hot Springs Rd Santa Barbara, CA 93108 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE e. history of falls f. decline in functional status g. joint pain due to osteoarthritis, and f. use of narcotics for pain. Review of Resident 1's "Falls Care Plan Report," dated 8/27/16, indicated risk of falling with several reasons including history of impulsivity and poor safety awareness. The planned interventions included the use of a Tab alarm while resident was on the wheelchair for safety. Review of "Physician Order Report" dated 4/30/19, indicated an active order for the use of a "Tab alarm while on the wheelchair for safety, due to history of falls." Review of the "Tab Alarm Instructions Manual" provided by facility on 5/15/19, in the PATIENT SET-UP & USE part indicated to follow these procedures before each use: 1. Securely mount the pull string monitor to a wheelchair using the clip on the back of the monitor 2. Attach the garment clip to the patient's clothing near the back of their neck between their shoulders. 3. Adjust the string length (using the adjuster) based upon the amount of movement you wish the patient to have prior to setting off the alarm. 4. Test monitor and check battery before each use... 5. When magnet is detached from the monitor the alarm will sound. To silence alarm, replace magnet on metal disc on front of monitor. Review of "Post Fall Observation Detailed Report", dated 5/1/19 at 2:56 p.m., created by licensed nurse (LN 1) caring for Resident 1, indicated, on 5/1/19 at 1:55 p.m., Resident 1 fell in the hallway while in a wheelchair, complained of pain 7/10 (pain scale on 1 to 10, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EFKQ11 Facility ID: CA050000046 If continuation sheet 4 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555023 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CASA DORINDA 300 Hot Springs Rd Santa Barbara, CA 93108 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE zero represents no pain at all while 10 represents the worst imaginable pain) and the tab alarm was not in use at the time of the resident's fall. Review of "Resident Progress Notes", dated 5/1/19 at 4:13 p.m., indicated "Resident is post fall observation, unwitnessed ...Resident left wrist is painful, and forehead scrapped. Administered Norco (narcotic pain medication for moderate to severe pain)." A review of "Radiology Patient Report", dated 5/3/19, indicated Resident 1 sustained 3rd thru 5th metacarpal (hand bone) fractures (breaks) on her left hand, as a result of the fall on 5/1/19. During an interview with certified nursing assistant (CNA 1) on 5/14/19 at 11:48 a.m., CNA 1 was the first person who responded to Resident 1's fall incident on 5/1/19. According to CNA 1, resident was found on the floor laying on her left side with her arm underneath. Resident was alone waiting outside the beauty parlor for her appointment. CNA 1 stated "She (Resident1) can be impulsive and impatient at times. She (Resident1) probably got impatient waiting outside the beauty parlor, got up by herself and fell. She (Resident 1) is forgetful, most of the time." CNA 1 confirmed, "No, there was no alarm sounding ..." During an interview with assistant director of nursing (ADON) on 5/14/19 at 11:56 a.m., ADON responded to Resident 1's fall incident on 5/1/19. ADON stated "I hear [Beautician's name] yelling for help, [Resident's name] was on the floor with her head towards the wall. She (Resident 1) was moaning. With her cognitive impairment, she (Resident 1) thinks she can stand up. But, she can't. She (Resident 1) is impulsive. She (Resident 1) doesn't FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EFKQ11 Facility ID: CA050000046 If continuation sheet 5 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555023 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CASA DORINDA 300 Hot Springs Rd Santa Barbara, CA 93108 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE remember." ADON was asked, if the tab alarm was sounding, when she arrived at the scene. ADON reply "I don't recall any alarm sounding." During an interview with security officer (SO) on 5/14/19 at 12:02 p.m. SO responded to Resident 1's fall incident on 5/1/19. According to SO, he received a radio call on the date resident fell. SO came to the hall outside the beauty parlor, saw resident (Resident 1) laying on her left side on the floor. SO was asked, if the tab alarm was sounding, when he arrived at the scene. SO indicated "there was no alarm ringing" when he arrived at the scene. During an interview with the director of nursing (DON) and concurrent review of Resident 1's clinical record on 5/14/19 at 12:30 p.m., the DON stated "I don't think the tab alarm was on the resident (Resident 1) when she fell." During an interview with licensed nurse (LN 2) on 5/14/19 at 1:15 p.m. LN 2 responded to Resident 1's fall incident on 5/1/19. LN 2 stated "I was told someone had fallen in the hall. It was [Resident's name]. When I arrived, she (Resident 1) was laying on the floor, on her left side. She (Resident 1) was moaning. She (Resident 1) tries to get up by herself, all the time. She (Resident 1) forgets a lot that she can't. She (Resident 1) has fallen before." LN 2 was asked, if the tab alarm was sounding, when she arrived at the scene. LN 2 reply "I did not hear any alarm sounding at all." During an interview with licensed nurse (LN 1) on 5/14/19 at 1:30 p.m., LN 1 was caring for Resident 1, on 5/1/19, the date of the fall. LN 1 stated "I was with another resident when someone call me to let me know [Resident's name] had fallen while waiting alone at the beauty parlor. When I arrived, she (Resident 1) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EFKQ11 Facility ID: CA050000046 If continuation sheet 6 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555023 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CASA DORINDA 300 Hot Springs Rd Santa Barbara, CA 93108 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was laying on her left side with her arm twisted back. We got her back to her wheel chair. She (Resident 1) had pain on the left hand & wrist. LN 1 was asked, if the tab alarm was sounding, when she arrived at the scene. LN 1 reply "The tab alarm was not sounding at all. The (tab) alarm was not on (attached to) her clothes. The (tab) alarm was connected to the chair. Not on [Resident's name] clothes." LN 1 was asked what she thought cause Resident 1's fall. LN 1 stated "I think improper use of devices." LN 1 was asked to expound on that. LN 1 reply "There was no tab alarm on (attached to) resident and no foot rest on her wheelchair. She (Resident 1) tried to get up by herself and fell." During a second interview with the director of nursing (DON) and concurrent review of Resident 1's clinical record on 5/14/19 at 3:58 p.m., DON stated "I think the tab alarm was not on (attached to the resident), that's why no one heard it. When I interviewed staff regarding the fall incident. I spoke with everyone, no one said anything about the alarm (sounding) because the (tab) alarm was not on (attached to) the resident. This was one of the contributing factors to the fall." Surveyor said "Are you saying the tab alarm was not on (attached to) the resident's clothes when she fell down while waiting alone outside of the beauty parlor." DON reply "Yes, the tab alarm was not on the resident when she fell. I'm being honest with you." On 5/14/19 at 4:05 p.m. the facility's administrator (Admin) was present during DON's second interview. Admin stated " ... Yes, we know the alarm was not on the resident when she fell." During an interview with Certified Nursing Assistant (CNA 2) on 5/10/19 at 9:01 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EFKQ11 Facility ID: CA050000046 If continuation sheet 7 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555023 (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CASA DORINDA 300 Hot Springs Rd Santa Barbara, CA 93108 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CNA 2 was caring for Resident 1, on the date of the fall, 5/1/19. According to CNA 2, Resident 1 was in the dining room for lunch from about 12:15 p.m., to 1:30 p.m. CNA 2 stated "After 1:30 p.m. I took her (Resident 1) from the dining room to the bathroom. She (Resident 1) is a two person assist for transfers. I asked another CNA [CNA 3] to help me. She (Resident 1) used the toilet. We sat her in her wheel chair. At that time, another resident needed me, so another CNA [CNA 3] took her (Resident 1) to the beauty parlor." CNA 2 was asked, if she applied/attached the tab alarm on Resident 1's clothing when she (Resident 1) was sitting on her wheelchair. CNA 2 reply "I didn't put (attached) the tab alarm on her (Resident 1) while she was sitting on her wheelchair, in the bathroom." During an interview with Certified Nursing Assistant (CNA 3) on 5/24/19 at 9:27 a.m., CNA 3 was the CNA who wheeled Resident 1 to the beauty parlor on 5/1/19. CNA 3 stated "Yes, I wheeled her (Resident 1) to the beauty parlor. [CNA 2's name] told me she (Resident1) needed to go to the beauty parlor and since the beauty parlor is located in the East side where I was working. I said I could take her (Resident 1) on my way back to my work area." CNA 3 was asked, if he attached the tab alarm to Resident 1's clothes. CNA 3 reply "I didn't know she (Resident 1) needed the tab alarm, so No, I didn't put (attached) on the tab alarm on her (Resident 1)." CNA 3 confirmed leaving Resident 1 alone, unsupervised, and without the tab alarm attached to her clothing in front of the beauty parlor on 5/1/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EFKQ11 Facility ID: CA050000046 If continuation sheet 8 of 8