Health inspection·November 5, 2024

F656 Develop/Implement Comprehensive Care Plan §483.21(b) Comprehensive Care Plans §483.21(b)(1) Residents Affected - Few Based on interview and record review, the facility failed to ensure Resident 1 ' s burn wound care plan included wound measurements and documentation requirements to monitor wound progression towards healing. This failure resulted in resident ' s burn wounds not being measured and documentation performed as required. Finding: During a concurrent review of Resident 1 ' s medical record and interview with the Director of Nursing (DON) on 10/15/24 at 2:00 p.m., the DON reported that on 10/5/24 a License Vocational Nurse (LVN) poured coffee into Resident 1 ' s mug. Resident 1 started sipping the coffee and then accidentally dropped the mug on his lap. Resident 1 sustained a third degree burn on both thighs. The DON reported weekly measurements and documentation of the wounds were performed. The burn wounds were only measured and documented on 10/6/24. The DON confirmed the record does not contain any other measurements and documentation of the resident ' s burn wounds. During a concurrent review of Resident 1 ' s burn wounds care plan and interview with the Assistant Director of Nursing (ADON) on 10/15/24 at 3:35 p.m., the care plan was asked where it indicates when the wounds need to be measured and/or documented weekly. The ADON reviewed the care plan thoroughly and stated I agree, this care plan does not say the wounds need to be measured and documented weekly . A review of the facility policy and procedure titled Documentation of Wounds and Skin Conditions, dated 10/26/23, indicated Resident skin conditions will be accurately assessed, treated, and documented until resolved. 6. Document weekly on the event until resolved. 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555023 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Dorinda 300 Hot Springs Road Santa Barbara, CA 93108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm

F658 Services Provided Meet Professional Standards §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. Residents Affected - Few Based on interview and record review, the facility failed to implement standards of practice when Resident 1 ' s burn wounds were not assessed and documented according to standards of practice and its policy. This failure resulted in resident ' s burn wounds only being assessed and documented only one time. Findings: According to the national institute of health NIH (2023) at https://www.nih.gov. The frequency of burn wound assessments depends on the stage of healing and the patient's needs. Initial assessment: Patients with burns should be seen the day after the injury to assess pain, adjust medication, and check dressing changes. Subsequent assessments: Patients are typically seen weekly until the wound heals. However, if there are concerns about pain control or wound care, the patient may need to be seen daily. A review of the facility policy and procedure titled Documentation of Wounds and Skin Conditions, dated 10/26/23, indicated Resident skin conditions will be accurately assessed, treated, and documented until resolved. 5. Open a Skin Integrity observation as indicated in the electronic health record EHR for each affected area that is expected to take 14 days or longer to resolve. Note: indicate the affected area in the short description. b. Skin integrity- non pressure ulcer for non-pressure skin problems. 6. Document weekly on the event until resolved. During a concurrent review of Resident 1 ' s medical record and interview with the Director of Nursing (DON) on 10/15/24 at 2:00 p.m., the DON reported that on 10/5/24 resident sustained a third degree burn on both thighs. The burn wounds were assessed and documented on 10/6/24. The DON confirmed the record does not contain any other documentation of the resident ' s burn wounds. The DON was asked how the facility assesses, monitors, and documents the progression of the burn wounds. The DON reported weekly documentation of the wounds are performed. The DON further explained their computer software system has an observation template to document and describe a wound initially, then, weekly thereafter or until wound is resolved. A copy of a blank Skin Integrity observation template was provided. Then, DON was asked if there was a completed observation documentation for Resident 1 ' s wounds. DON replied No, this resident does not have one (Skin Integrity observation documentation). No, we did not initiate the weekly observation for this resident and yes, we should have done it. The DON acknowledged Resident 1 ' s wounds will take longer than 14 days to resolve therefore they should have opened and document under the Skin Integrity observation/template documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555023 If continuation sheet Page 2 of 2