Other·September 19, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health Licensing and Certification during a Standard Abbreviated Survey. Complaint: CA00623796 - Substantiated - F684 Entity Reported Incident CA00623834 Substantiated -F684 Representing the Department: 33340 - HFES The inspection was limited to the investigation of the complaint and the Entity Reported Incident investigated, and does not reflect 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) 08/15/2019 §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, interview and record review, the facility failed to: a) Provide adequate supervision and assistance while Resident 1 was self-propelling via wheelchair on 2/10/19 at night (11 pm to 11:30 pm) b) Assess risk for elopement and wandering 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: 52FI11 Facility ID: CA050000062 If continuation sheet 1 of 7 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: _______________ 055684 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN 2225 De La Vina St Santa Barbara, CA 93105 (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 after witnessing attempts of wandering and elopement, c) Develop and implement comprehensive, person-centered care plan goals and interventions related to wandering and elopement, d) Follow its "Elopement Risk Policy", and, e) Identify elopement and wandering as a "problem" in the fall care plan. for one of three sampled residents (Resident 1) identified to require extensive assist during transfers and mobility and high risk for falls. As a result of these failures, Resident 1 wandered into a dark facility patio on 2/10/19 after 11:30 p.m., fell from his wheelchair, sustained a blunt force trauma to the face and head and died. Findings: Record review of Resident 1's clinical record (facesheet) dated 2/12/19 indicated, Resident 1 was admitted with diagnoses including traumatic brain injury (disruption in brain function, caused by an external force to the head), muscle weakness, and difficulty walking. Review of the clinical record entitled, "Fall Risk Assessment," dated 1/29/19 revealed, Resident 1 was a high risk for falls due to: disoriented x 3 (person, place and time) at all times; history of 1-2 falls in past 30 days; chair bound; balance problem while standing and walking; requires use of assistive devices (i.e. cane, w/c, walker, furniture); takes 3-4 medications that put the resident at risk of falling; and has 1-2 predisposing conditions that can lead to a fall. Review of "History and Physical Examination", dated 1/31/19, signed by Resident 1's primary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52FI11 Facility ID: CA050000062 If continuation sheet 2 of 7 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: _______________ 055684 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN 2225 De La Vina St Santa Barbara, CA 93105 (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 physician indicated, Resident 1 did "not have the capacity to understand and make decisions." Review of the "Minimum Date Set" (comprehensive resident assessment), dated 2/5/19, indicated Resident 1 had moderately impaired cognition (mental awareness). Resident 1 required extensive assistance with 2 person-assist with activities of daily living including transfers, bed mobility, walking movement between locations. Resident 1 used walker and wheelchair for mobility. Review of the care plan titled "the resident is high risk for falls" initiated on 1/30/19, identified Resident 1 was a high risk for falls related to confusion/disorientation related to hepatic encephalopathy (disease, damage, or malfunction of the brain), history of falls, and history of cirrhosis (scarring of the liver). The care plan included intervention to allow Resident to propel himself to encourage mobility and independence and frequent visual check and monitoring of whereabouts throughout the shift. Review of the care plan initiated on 2/1/19 identified Resident 1 had impaired cognitive (mental process) function, forgetfulness or impaired thought processes related to dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and history of TBI (traumatic brain injury). The care plan interventions included to cue, reorient and supervise the resident as needed. Review of the care plan initiated on 2/1/19 identified Resident 1 has communication problems due to TBI. The care plan included intervention to anticipate and meet needs, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52FI11 Facility ID: CA050000062 If continuation sheet 3 of 7 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: _______________ 055684 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN 2225 De La Vina St Santa Barbara, CA 93105 (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 ensure/provide safe environment, and avoid isolation. Review of "Progress Notes" electronically signed by a Licensed Nurse (LN 1) on 2/1/19 at 2:55 pm., documented, Resident 1 was up in a wheelchair propelling himself, confused, at risk for fall, and attempted to transfer himself independently. Review of "Progress Notes" esigned by LN 2 on 2/1/19 at 10:23 p.m., documented, Resident 1 was confused and was "trying to leave the facility". Review of "Progress Notes" electronically signed by LN 3 on 2/3/19 at 3:45 p.m. documented, Resident 1 was "propelling himself in the hall." Resident 1 "attempted to elope" from the facility, and was redirected by staff. During an interview on 6/4/19 at 1:53 p.m. LN 3 indicated, Resident 1 was confused and had a habit of wandering. LN 1 indicated Resident 1 had attempted to "elope" and leave the facility twice (2/1/19 and 2/3/19). Record review revealed, the facility was unable to provide documentation to indicate the facility assessed, initiated, developed and implemented a plan of care for wandering and elopement in order to provide the necessary supervision to prevent unsupervised fall, injury and/or death for Resident 1. During an interview on 4/9/19 at 9:03 a.m. the Director of Nursing (DON) confirmed the facility did not develop an elopement care plan for Resident 1. The facility was unable to provide documentation to indicate a plan of care was developed for Resident 1's wandering behavior. Review of the facility policy and procedure titled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52FI11 Facility ID: CA050000062 If continuation sheet 4 of 7 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: _______________ 055684 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN 2225 De La Vina St Santa Barbara, CA 93105 (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 "Elopement Risk Policy" with revision date April 2018 indicated "an elopement risk care plan will be written and implemented immediately for residents and patients: a. with a prior history or incident or attempt or actual elopement from home, prior living situation or this facility regardless of the severity or outcome of that history." Review of "Progress Notes" dated 2/11/19 at 4:09 a.m., revealed the following documentation on the date on the incident on 2/10/19: - At 11 pm Resident 1 was up in wheelchair "in front of the computer (at the front lobby area) with other staff hanging out with him." - At around 11:15 - 11:20 pm, about 15-20 minutes later, staff saw Resident 1 passing by Station 2, propelling (use of wheelchair) himself. - At 11:25 pm, 10 minutes later, a nurse saw Resident 1 passing by Station 1 making left turn towards the hallway. - At 11:30 pm, CNA 1 (Incoming CNA for the 11 p.m. to 7 a.m. shift) after "verbal hand-off", did not find Resident 1 in his bed, instead, Resident 1 was outside Room 8. CNA 1 directed Resident 1 to the main lobby, which is about 18 feet to the patio where Resident 1 fell. - At around 11:40 pm, about 10 minutes later, CNA 1 found Resident 1 lying on the front patio ground, with blood on the face, unresponsive, no pulse and no respiration. -Resident 1 was pronounced dead at approximately 11:50 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52FI11 Facility ID: CA050000062 If continuation sheet 5 of 7 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: _______________ 055684 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN 2225 De La Vina St Santa Barbara, CA 93105 (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 Review of the above "Progress Notes" revealed, late in the night and during the change of shift, staff were aware that Resident 1 was able to move independently by propelling himself via his wheelchair, and within a very short span of time (5 to 10 minutes), Resident 1 was found at different areas of the facility. At this time of the night, and with Resident 1's known behavior of wandering, there was no evidence that the staff kept Resident 1 within eyesight at all times. The facility was unable to provide documentation to indicate Resident 1 was redirected back to his room or other area where he can be seen constantly, or offered any kind of activity to occupy him. There was no evidence that staff anticipated Resident 1 going to the main patio which was in close proximity to where Resident 1 was last seen at the main lobby. The main lobby was 18 feet to the patio. The patio, at this time was dark and no staff available to supervise his movements. Observation on 7/2/19 11:19 a.m. indicated the main lobby was 18 feet to the patio's unsecured door. The computer area was in close proximity to the main entrance that opens to the parking lot and onto a busy city street. During an interview on 5/30/19 at 1:45 pm, American Medical Response (AMR) Clinical Manager indicated, AMR received the facility's 911 call on 2/10/19 at 23:47 and arrived at the facility at 23:54. According to AMR Resident 1 was found at a dark patio on the concrete (no outdoor lightening). The resident was in supine (on his back) position with his head propped on a pillow, bleeding from face and nose, and pulseless. Review of the "Coroner Report," dated 2/11/2019, indicated on 2/10/19, at approximately 2345 hours, decedent, (Resident 1) was located unresponsive on the ground of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52FI11 Facility ID: CA050000062 If continuation sheet 6 of 7 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: _______________ 055684 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE CALIFORNIAN 2225 De La Vina St Santa Barbara, CA 93105 (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 the patio at [name of facility] skilled nursing facility. He had "blunt force head injuries on the right side of his face that were the result of an unwitnessed fall from his wheel chair....., all trauma was consistent with a ground level fall." The report further indicated "Cause of Death: It was determined that the decedent (Resident 1) died as a result of the following cause: complications of blunt force head trauma due to: unwitnessed fall from wheelchair." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 52FI11 Facility ID: CA050000062 If continuation sheet 7 of 7