Health inspection·March 14, 2019

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to obtain informed consent before increasing an antipsychotic (a class of medications used to treat behavioral disturbances) medication dosage for one (Resident 6) out of five residents. Residents Affected - Few This failure was a violation of the resident/resident representative's right to be informed of the risks associated with increasing the dosage of an antipsychotic medication. Findings: During a concurrent interview and record review on 3/14/19, at 12:38 p.m., the Director of Nursing (DON) acknowledged the record did not contain documentation that informed consent was obtained and should have been done prior to increasing the medication. During review of the resident's record the antipsychotic medication was increased from two times per day to three times per day on 3/12/19. There was no documentation of informed consent being obtained in the record for Resident 6. The facility policy and procedure titled Psychopharmacological Medication Use, dated 09/12/17, indicates in Section 10.3 If Physician/Prescriber of a resident in a skilled nursing facility prescribes, orders, or increases an order for a psychotherapeutic medication for the resident, the physician/prescriber shall do the following . Section 10.3.1 Provide information that is material to the resident's decision to accept or refuse any proposed administration of psychotherapeutic drugs including . Sections 10.3.1.7 The resident has the right to accept or refuse proposed treatment. Section 10.3.2 indicates Obtain informed consent of the resident for purposes of prescribing, ordering, or increasing an order for the medication . Section 10.3.3 indicates Obtain informed consent of the resident's authorized representative for purposes of prescribing, ordering, or increasing an order for the medication personally or via telecommunication. Page 1 of 7 555023 555023 03/14/2019 Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review the facility failed to ensure a comprehensive, person-centered, care plan was developed for two out 13 sampled residents (Resident 19 and Resident 26) when: Residents Affected - Few 1. Resident 26's care plan did not include information about the use of the wanderguard (A Roam Alert bracelet---a wrist or ankle band used to track persons at risk from leaving a facility without being accompanied by an authorized person. The device alarms when the person moves outside of a defined area) to prevent elopement from the facility 2. Resident 19 had no care plan for type 2 diabetes (a disease when your blood sugar is too high and the body does not make enough insulin) and receiving insulin (a hormone that controls blood sugar) This failed practice placed the residents at risk for harm and delay in treatment and interventions related to their disease processes. Findings: 1. During a review of Resident 26's clinical record on 3/12/19, at 12:32 p.m., several nursing notes contained documentation of the resident's wandering throughout the facility. During a concurrent chart review and interview on 3/13/19, at 9:27 a.m., Licensed Nurse (LN2) indicated that Resident 26 has on a wanderguard to prevent him from leaving the facility without being accompanied by a staff member. LN 2 was unable to find documentation of the wanderguard in the care plan. The facility policy and procedure titled Elopement Prevention dated 3/29/17, indicates under procedure # 5c The interdisciplinary team will develop a comprehensive elopement prevention plan as part of the interdisciplinary care plan to include prevention measures such as implementation of wandering prevention technology. During a concurrent record review and interview on 3/14/19, at 9:53 a.m., the DON acknowledged the wanderguard was not on the careplan but should have been according to the Elopement Prevention policy # 8e: The process for the application and care of the Roam alert bracelet (wanderguard) is as follows: Document the application and location of the bracelet in the care plan. 2. During a review of Resident 19's clinical record on 3/13/19 at 10:50 a.m., indicated a diagnosis of type 2 diabetes. Resident 19's Physician orders dated 2/13/19-3/13/19 indicated the resident was receiving Lantus 5 units (insulin) at bedtime and Novolog (insulin) three times a day with meals per sliding scale (progressive increase in pre-meal insulin dose based on blood sugar ranges). During an interview and concurrent record review on 3/13/19 at 10:55 a.m., the director of nursing (DON) acknowledged there was no care plan implemented for insulin use for Resident 19 and there should have been. DON further indicated the facility monitors for signs and symptoms of hyper/hypoglycemia (high/low blood sugars) but did not implement a care plan. The facility policy and procedure titled Person Centered/Comprehensive Care Plans dated 1/24/17, indicated .a comprehensive care plan will be developed for each medical center resident .the plan will 555023 Page 2 of 7 555023 03/14/2019 Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108

F 0656 Level of Harm - Minimal harm or potential for actual harm include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs .resident care plan will be designed to: incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect treatment goals, prevent declines in the resident's functional status and/or functional levels. Residents Affected - Few 555023 Page 3 of 7 555023 03/14/2019 Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the facility failed to ensure PRN(as needed) psychotropic (any medication affecting the mind, emotions and behavior) medications, after 14 days, had an order for duration or an end date for two out of five sampled residents (Resident 6 and Resident 19). This facility failure places residents at risks for adverse side effects from the continued use of psychotropic medications. Findings: 1) During clinical record review of Resident 6, the pharmacist documented in a consultation report, dated 2/12/19 that Resident has a PRN (as needed) order for Lorazepam (a medication used to treat anxiety), which has been in place for greater than 14 days without a stop date Recommendation: If PRN Lorazepam cannot be discontinued at this time, please extend order for no more than 90 days then reassess behavior and need for continued use. The physician's response: I decline the recommendation. During a concurrent record review and interview on 3/14/19, at 11:55a.m., the DON acknowledged the pharmacist's recommendation, the physician's response to the medication, and that the order for lorazepam still did not have a stop date. The DON acknowledged a stop date for the lorazepam should be in place. 2) During a review of Resident 19's clinical record on 3/14/19 at 11:16 a.m., indicated the resident was on Rozerem (a sedative medication used for the inability to sleep) for anxiety manifested by insomnia (inability to sleep) Resident 19's Physician orders dated 3/1/19-3/31/19 indicated the resident was on Rozerem 8mg tablet by mouth at bedtime PRN, with the start date of 12/18/18 and no end date. The Pharmacists MMR (medication monthly review) dated 1/7/19, indicated . Resident 19 had a PRN order for sedative/hypnotic, ROZEREM for over 14 days . the recommendation was to discontinue PRN Rozerem .if the medication cannot be discontinued the prescriber needs to document the indication for use, the intended duration of therapy, and rationale for the extended time period. Further review of the Pharmacists MMR indicated the physician declined the Pharmacists recommendation and continues the Rozerem without a duration for use. During an interview and concurrent record review on 3/14/19 at 11:20 a.m., the director of nursing (DON) acknowledged the physician orders for PRN Rozerem, and had a start date of 12/18/18 with no end date. DON further indicated the physician orders should have a duration for use. The facility policy and procedure titled Psychopharmacological Medication Use dated 9/12/17, indicated .prn orders for psychotropic drugs are limited to 14 days .if the prescribing physician believes that it is appropriate for the PRN order to be extended beyond the 14 days he or she should document their rational in the resident's medical record and indicate the duration for the PRN order 555023 Page 4 of 7 555023 03/14/2019 Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to discard expired medications and supplies. These facility failures had the potential for adverse reactions to patients. Findings: The facility policy and procedure titled Disposal/Destruction of Expired or Discontinued Medications dated 1/1/13 indicated the facility will dispose of expired medications and supplies. 1. During an observation and concurrent interview on 3/13/19 at 10:38 a.m. in the second floor med room a box of [NAME] point syringes (tube with a nozzle and bulb for pulling in and ejecting liquid) with an expiration date of 2/2015 were available for use on residents. The director of nursing (DON) confirmed these expired supplies should have been discarded. 2. During an observation and concurrent interview on 3/13/19 at 10:38 a.m. in the second floor med room six liter bags of dextrose (medical fluids used intravenously) with an expiration date of 2/16/19 were available for use on residents. The director of nursing (DON) confirmed these expired medications should have been discarded. 3. During an observation and concurrent interview on 3/13/19 at 10:38 a.m. in the second floor med room one biopatch (protective dressing cover used to reduce risk for infections) with expiration date of 10/2018 was available for use on residents. The director of nursing (DON) confirmed the expired patch should have been discarded. 4. During an observation and concurrent interview on 3/13/19 at 10:38 a.m. in the second floor med room [ROOM NUMBER] blood vial tubing with preservatives had expiration dates of 7/2016. Eight blood vial tubing's had expiration dates of 11/2016 and were available for resident use. The director of nursing (DON) confirmed the expired tubing's should have been discarded. 555023 Page 5 of 7 555023 03/14/2019 Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure: Residents Affected - Some 1. Dented cans were removed from the pantry 2. An opened bulk food item in the walk in pantry was labeled 3. Refrigerated food items were labeled and dated 4. Expired refrigerated food item was discarded These facility failures had the potential to cause the growth of microorganisms which could lead to foodborne illnesses in an already compromised resident population. Findings: During an observation and concurrent interview of the kitchen on 3/12/19, at 8:30 a.m., the following were noted: 1) Three 46 ounce cans of V 8 juice in the walk in pantry were found to be dented, 2) A large container of black rice on the shelf in the walk in pantry had been opened and was noted labeled. These observations were acknowledged by the Food Services Receiver (FSR) who indicated these findings were not acceptable. During an observation and concurrent interview on 3/12/19, at 8:20 a.m., the following were noted: 1) Refrigerated hot sauce had been opened, but did not contain a label and 2) Two plastic containers of microgreens in the refrigerator had been opened, but did not have a label. Observations acknowledged by FSR who indicated this practice was not acceptable. During an observation and concurrent interview on 3/13/19, at 11:11 a.m., cranberry juice in the walk in refrigerator was opened and dated 2/24/19. The manufacturer's label on the juice indicated not to exceed 14 days in refrigerator after opening. The Dietician (DS) acknowledged the juice had been opened and refrigerated 17 days and should have been discarded. The facility policy and procedure titled Food Storage, dated 5/22/18, indicated in procedure #1 Upon delivery, all food products are inspected for damage, expiration dates or potent hazards . Procedure # 14f of the same policy reads, Refrigerated food storage: All foods should be covered labeled and dated. All foods will be checked to assure that the foods will be consumed by their safe use by dates, frozen or discarded. The facility document titled Food Storage Guidelines, undated, indicate All foods shall be used by the manufacturer's expiration/use by date, or by the discard date indicated below, whichever comes first. Unused foods falling outside these guidelines will be discarded. 555023 Page 6 of 7 555023 03/14/2019 Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure education regarding the risks and benefits of the Influenza vaccine was provided to Residents or Residents responsible party for five of out of 13 sampled Residents (Residents 32, 23, 27, 1, and 30). Residents Affected - Few This deficient practice violated the Resident and responsible party's rights to make an informed decision regarding the risks, potential side effects and benefits to receive or not to receive the Influenza vaccine. Findings: During an interview on 3/14/18 at 9:38 a.m. the Director of Staff Development and Infection Control (DSD) stated, We have them sign a standing order for vaccines on admission, we give them the Vaccine Information Statement from the CDC for education and screen for contraindications. The Annual vaccine orders are standing orders based on Physician assessments, nursing educates them and they can decline, it is all computerized. No consents are required. Record review of influenza vaccine chart reviews indicated: 1. Resident 32 received the Influenza vaccine on 10/21/18 and the most current consent in the chart was dated 10/2/17. 2. Resident 23 received the Influenza vaccine on 10/3/18 and the most current consent in the chart was dated 9/29/16. 3. Resident 27 received the Influenza vaccine on 10/1/18 and the most current consent in the chart was dated 9/29/16, signed by responsible party. 4. Resident 1 received the Influenza vaccine on 10/1/18 and the most current consent in the chart was dated 9/28/18, signed by responsible party. 5. Resident 30 received the Influenza vaccine on 10/10/18 and the most current consent in the chart was dated 10/13/14. During an interview on 3/14/19 at 11:35 a.m., the (DSD) indicated the education regarding influenza vaccines provided to Residents would be documented in the Resident's electronic medical record (e-mar). The DSD confirmed that the Influenza vaccine education for all five residents was not documented in the e-mar. During an interview on 3/14/19 at 12:04 p.m., the Director of Nursing (DON) indicated that the expectation is that nurses document vaccination education and the receipt of educational documents provided to Residents in the e-mar. The facility policy and procedure titled Immunization of Residents dated 2/27/2017, indicated in part . Influenza immunizations will be offered to each resident annually between October 1 and March 31 .unless medically contraindicated or the resident or their legal representative refuses consent .Related forms: Immunization record; Immunization Consent; Vaccination Information Statements . 555023 Page 7 of 7