Inspection visit
Health inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 the specific inappropriate behavior was
documented for one of four sampled residents, (Resident 9) as stated in the careplan.
Residents Affected - Few
This failure had the potential to inadequately identify what behavior needed to be monitored /planning of
intervention to address the resident's inappropriate behavior.
Findings:
During a review of Resident 9's, admission Record (AR), dated 07/20/21, the AR indicated, Resident 9 had
diagnoses including, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills,
and eventually the ability to carry out daily activities) with late onset and major depressive disorder.
During a review of Resident 9's, Care Plan, dated 10/01/24, the care plan indicated, Monitor and document
episodes of inappropriate behavior directly/indirectly towards staff members. Special Instructions: Please be
specific and document occurrence or quote in progress notes as well. Three Times A Day 02:00 PM, 10:00
PM, 06:00 AM.
During a review Resident 9's, Medication Administration Record (MAR), dated 01/01/24 - 12/04/24, the
MAR indicated inappropriate behavior episodes occurred on the following dates: one episode 03/14/24, one
episode 03/17/24, one episode 06/21/24, four episodes 06/23/24, one episode 06/29/24, one episode
07/20/24, two episodes 07/28/24, one episode 08/04/24, one episode 08/11/24, one emailing staff episode
08/12/24, one episode 08/20/24, one episode 10/09/24, one episode 11/13/24, one episode 11/16/24, two
episodes 11/22/24.
During review of Resident 9's progress notes, dated 01/01/24 - 12/04/24, there was no specific
documentation for the inappropriate behavior being monitored as instructed in the care plan/ special
instructions.
During an interview on 12/4/24 at 3:55 PM with Registered Nurse (RN3),RN3 acknowledged Resident 9
had incidents of inappropriate behavior on multiple occasions this year (2024). RN3 confirmed there were
no progress notes detailing the specifics of the inappropriate behavior episodes.
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 10
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
12/05/2024
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on interview and record review, the facility failed to ensure a care plan for inappropriate behavior
was updated to reflect episodes of inappropriate behaviors in one of four sampled residents ( Resident 9)
per facility's policy and procedure.
This failure had the potential for the Resident 9's inappropriate behaviors to have no effective interventions
in place which can affect the resident's daily interactions with others and vice versa affecting the quality of
life in the facility.
Findings:
During a review of Resident 9's, admission Record (AR), dated 07/20/21, the AR indicated, Resident 9 had
diagnoses including, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills,
and eventually the ability to carry out daily activities) with late onset and major depressive disorder.
During a review of Resident 9's, Medication Administration Record (MAR), dated 01/01/24 - 12/04/24, the
MAR indicated inappropriate behavior episodes occurred on the following dates: one episode 03/14/24, one
episode 03/17/24, one episode 06/21/24, four episodes 06/23/24, one episode 06/29/24, one episode
07/20/24, two episodes 07/28/24, one episode 08/04/24, one episode 08/11/24, one emailing staff episode
08/12/24, one episode 08/20/24, one episode 10/09/24, one episode 11/13/24, one episode 11/16/24, two
episodes 11/22/24.
During a review of Resident 9's, Care Plan titled, Behavioral Symptoms indicated, problem start date of
08/08/2022 and long-term goal target date was 10/12/2024. The care plan further indicated no update was
done or initiated after 08/08/2022
During a review of the facility's, policy and procedure (P&P) titled, Person Centered/Comprehensive Care
Plans, dated 01/24/2017, the P&P indicated, Procedure: Care plans will be revised as changes in the
resident's condition dictates. A review of the care plan will be completed no less than quarterly.
During a review of the facility's policy and procedure (P&P) titled, IDT Care Plan Meeting, dated 11/2/2023,
the P&P indicated, Procedure: IDT members will report on current status and discuss needed changes in
the resident's care plan based upon assessments and observations.
During a review of Resident 9's interdisciplinary reports (IDR), dated from 10/31/23 - 10/01/24, monitoring
of the resident's inappropriate behavior was not addressed in the IDT quarterly meeting notes.
A concurrent interview and record review was conducted on 12/04/24 2:34 PM and 12/5/24 at 10:52 AM
with Minimum Data Set Nurse (MDSN), the MDSN stated, Monitoring behaviors is not as accurate as it
should. MDSN confirmed Resident 9's care plan for monitoring inappropriate behavior target goal date was
10/12/24 and was not updated on 09/30/24 when the quarterly MDS was done.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555023
If continuation sheet
Page 2 of 10
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
12/05/2024
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure a doctor's recommendation for a psychiatric
consultation was followed up for implementation in one of four sampled residents (Resident # 9).
Residents Affected - Few
This failure had the potential and risk for the resident's psychosocial health care needs to be unattended
which can result in the deterioration of the physical, mental, and psychosocial well-being.
Findings:
Review of [NAME] and [NAME], seventh Edition, Mosby's Fundamentals of Nursing, page 336 in the
section titled, Physician's Orders indicates, Nurses follow physician orders unless they believe the orders
are in error or harm clients. Therefore, you need to assess all orders, and if you find one to be erroneous or
harmful, clarification from the physician is necessary.
During a review of Resident 9's, admission Record (AR), dated 07/20/21, the AR indicated, diagnoses
including, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and
eventually the ability to carry out daily activities) with late onset and major depressive disorder.
During record review of Resident 9's social services notes (SSN), dated 10/13/22, the SSN indicated
Resident requested to see a psychiatrist and upon clarification stated he sometimes feels depressed.
During record review of Resident 9's physician notes, dated 10/17/2022 at 9:08 PM, the note indicated .OA
Depression .Depression and feelings of De JaVu (a feeling of having already experienced the present
situation). Psych consult.
During record review of the nurses' notes, dated 10/17/22 at 10:41 PM, the note indicated, Seen by
[attending physician] this pm, new orders received. Medical Doctor (MD) rec psych MD per resident's
request for c/o Déjà [NAME].
During record review of Resident 9's medical record, no progress notes, consultation notes, or medical
notes indicating Resident 9 was seen by a psychiatrist was located.
During an interview on 12/04/24 at 03:24 PM with Registered Nurse (RN3) and Director of Nursing (DON),
RN3 acknowledged Resident 9 requested a psychiatric consultation. RN3 said she forgot to order the
psychiatric request (failed to put in an MD order). RN3 stated, I forgot to document it (referring to the
resident requesting to see a psychiatrist).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555023
If continuation sheet
Page 3 of 10
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
12/05/2024
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, and interview, the facility failed to ensure one of four sampled residents
(Resident 15) development of a foot drop was monitored and assessed for appropriate intervention to
prevent further decline in range of motion.
This failure resulted in reduced mobility of the foot with potential for contractures ( hardening and stiffening
of muscle /bones).
Findings:
During an observation on 12/3/24, at 2:26 p.m., in room [ROOM NUMBER], Resident 15 was observed on
bed, in a supine position (facing upwards) with feet on a pillow. The toes of both feet were noted to be
flexed or extending, pointing towards the foot of the bed (outward) instead of upward (towards the ceiling).
During a review of Resident 15's Physical Therapy Evaluation & Plan & Treatment, dated 2/11/22, under
Musculoskeletal System Assessment, the AROM (Active Range of Motion) - (R) Ankle Dorsiflexion (upward
or backward bending of a body part, often referring to a hand or foot) = WNL (Within Normal Limits); Plantar
(sole of the foot/feet) Flexion (bending) = WNL. The AROM - (L) Ankle Dorsiflexion = WNL; Plantar Flexion
= WNL. The Physical Therapy evaluation indicated Resident 15 had no extension or flexed feet on 2/11/22. (
admission /initial assessment).
During a review of Resident 15's Annual MDS (Minimum Data Set [process that provides a comprehensive
assessment of resident's functional capabilities and helps nursing home staff identify health problems]),
dated 4/10/24, indicated Resident 15 did not receive any kind of therapies from the Rehabilitation
Department (OT (Occupational Therapy)/PT (Physical Therapy)/ST (Speech Therapy).
During a review of Resident 15's Quarterly MDS, dated [DATE], Section GG indicated Resident is
dependent on staff for mobility while Section O indicated Resident 15 did not receive any kind of therapies
from the Rehabilitation Department (OT/PT/ST).
During an interview with the assistant director of nursing (ADON), on 12/3/24, at 2:59 p.m., in the ADON's
office, regarding the observed foot drop of Resident 15, the ADON reviewed the electronic rehabilitation
records dated 2/11/22 and concurred the noted footdrop was new. The ADON indicated, the footdrop cause
might be attributed to how the resident was positioned. The ADON added , I will call the doctor to get an
order to have rehab evaluate the resident.
During an interview with the Director of Rehabilitation (ReD), on 12/5/24, at 10:18 a.m., in the rehab room,
the ReD concurred with the finding regarding Resident 15's footdrop, and that it should be reported to
rehab for assessment and timely intervention.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555023
If continuation sheet
Page 4 of 10
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
12/05/2024
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on record review, observation, and interview, the facility failed to ensure the change of shift narcotics
reconciliation count was properly counted and signed by two licensed nurses to ensure accuracy of the
narcotic/controlled medications.
This failure had the potential to result in an inaccurate count and drug diversion (the illegal distribution or
abuse of controlled prescription drugs) of controlled medications.
Findings:
During a medication pass observation, on 12/3/24, at 7:53 a.m., in the East Wing, first floor of the facility,
the narcotic count book/log (a book/log recording the systemic monitoring, counting, and documentation of
controlled medications/substances every start and end of each shift) for the month of November, was
observed to be missing several signatures from both the incoming and outgoing licensed nurses.
During record review, the following were noted.
On November 21, 2024, the incoming 3-11 shift nurse failed to sign at the start and at the end of the shift.
On November 21, 2024, the incoming 11-7 shift nurse failed to sign at the start of the shift and at the end of
the shift on November 22, 2024, at 7 a.m.
On November 22, 2024, the incoming 3-11 shift nurse failed to sign at the start of the shift.
On November 31, 2024, the incoming 3-11 shift nurse failed to sign at the start and at the end of the shift.
On November 31, 2024, the incoming 11-7 shift nurse failed to sign at the start of the shift.
During an interview with RN 2, at 8 a.m., in the East Wing hallway, RN 2 reviewed the document and
concurred with the finding. RN 2 stated, Yes, there are missing signatures in the narcotic count book.
During a review of the facility's policy and procedure titled, Narcotic Medication Control, dated 4/7/17 and
revised 10/22/23, indicated in part, 2. Narcotics will be counted daily at shift change by two licensed nurses
., b. On coming shift will count the narcotics and sign Narcotic Count Log under Nurse On column ., c.
Outgoing shift will call out number of remaining medication as indicated on the individual medication count
log and sign Narcotic Count Sheet under Nurse Off) column.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555023
If continuation sheet
Page 5 of 10
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
12/05/2024
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 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.
Based on observation, interview, and record review, the facility failed to ensure biologicals were properly
stored and labeled and the medications of discharged residents were properly stored, discarded , labeled
per policy and procedure .
This failure had the potential for biologicals, medications, medication items to be diverted.
Findings:
During a concurrent medication pass observation and interview, on 12/3/24, at 9:50 a.m., in the East Wing,
first floor of the facility, with Registered nurse (RN 2), the following were noted in the 1 East medication cart
(EMC).
Five plastic containers of Polyethylene Glycol 3350 Powder for Solution (a laxative used to prevent
constipation) had the respective room numbers written/labeled on the caps but were missing the open
dates.
One of the plastic bottles of Polyethylene Glycol 3350 Powder for Solution belonging to a discharged
resident .
RN 2 inspected the 5 plastic bottles of Polyethylene Glycol 3350 Powder for Solution and stated, The open
dates were not labeled, and the bottle of the discharged resident should have been removed from the
medication cart.
During another concurrent observation and interview, on 12/3/24, at 10 a.m., at the first-floor nursing station
medication room, with LVN 2, the following were noted.
Three used insulin pens (a medication/hormone that lowers the level of glucose in the blood of diabetics)
belonging to one discharged resident were in the medication refrigerator. The three insulin pens were
NovoLOG Flex Pen 100 UNIT/1ML insulin pen, Insulin Glargine (LANTUS) 100 units/1 ml., and insulin
aspart (NovoLOG) 100 units/1 ml. All three insulin pens were used but missing open dates.
LVN 2 indicated the three insulin pens were for a resident who was transferred out/discharged to the
hospital , and as to why it were still in the medication refrigerator at the nursing medication room , LN 2 had
no response /explanation .
During a review of the facility's policy and procedure titled, General Dose Preparation and Medication
Administration, dated 12/1/07 and revised 4/30/24, indicated in part, 2.10 Facility staff should enter the date
opened on the label of medications with shortened expiration dates (e.g., insulin, irrigation solutions, etc.).
2.10.1 Facility staff may enter the expiration date based on date opened on the label of medications with
shortened expiration dates.
No policy and procedure for medications brought from home or hospital or on discontinued medications
was presented upon request .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555023
If continuation sheet
Page 6 of 10
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
12/05/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to follow food safety requirements when:
Residents Affected - Some
1. Three (3) containers of prepared food were mislabeled as to date prepared of expiry date and is
ante-dated (written date is one day after date of inspection)
2. One (1) of three (3) red buckets tested was below the recommended concentration of sanitizing solution.
These failures has the potential for food borne illnesses affecting residents when safe refrigerated food are
mislabelled, food has no use-by date, and sanitizing solutions are not safe when preparing foods.
Findings:
1. During an observation on 12/02/24 at 11:36 a.m. at the kitchen freezer section, three stainless steel
containers were identified. Two (2) containers with precut vegetables, and one (1) container with potatoes
with spices, covered in clean [NAME] wrap and is labelled as 12/3/24. There is no evidence to indicate a
date prepared or use by date.
During an interview on 12/3/24 at 11:36 a.m. with Dietary Aide (DA1), DA verbalized that the staff who had
previously worked on the weekend may have made a mistake and not checked on the date. DA 1 validates
that there was no date prepared and use by date.
During a review of Policy and Procedure (P&P) Titled: Storage of Food Supplies dated 11/04/24, the
Storage of Food Supplies indicated in part . It is the policy of this facility to properly store dining service
supplies in clean, appropriate containers at the proper temperature in the location and manner as
prescribed by law . The following procedures are the responsibility of the dining services director:
11. Check foods in refrigerator to make sure they are properly covered. All prepared foods not in original
containers must be covered, labelled, and dated.
13. Leftovers shall be tightly covered, stored appropriately and clearly labelled and dated. Leftovers shall be
used within 72 hours and if not used within this time, will be properly discarded.
2. During a concurrent observation and interview on 12/03/24 at 10:13 a.m., testing of sanitizing solution
used to clean surfaces of the kitchen in 3 Red Buckets were conducted with DA 2 with the following results:
Bucket 1 400 ppm (unit of measure); Bucket 2 100 ppm; Bucket 3: 200 ppm. DA 2 states that the solution
was changed early in the morning, cannot explain the discrepancy or difference in the test results.
During an interview 12/03/24 at 2:30 p.m. with Sous Chef (SC), SC verbalized that the person in charge
may have forgotten to change the solution or that the solution was diluted and that the sanitizing liquid may
have lowered its potency. SC validates that disinfection process may be inadequate.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555023
If continuation sheet
Page 7 of 10
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
12/05/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
During a review of P&P titled Red Sanitation Bucket Policy undated, the P&P indicated in part: Test
solutions with test strips regularly to ensure they are maintaining the proper strength of sanitizer for food
contact surfaces. There are three factors that influence the effectiveness of chemical sanitizers. 1.
Concentration, recommended is from 200 ppm - 400 ppm.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555023
If continuation sheet
Page 8 of 10
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
12/05/2024
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 0851
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and
other verifiable and auditable data.
Based on interview and record review, the facility failed to run reports 1700D (employee report), 1702D
(individual daily staffing report) and 1702S (staffing summary report) to ensure payroll-based journal (PBJ)
data (a system for facilities to submit staffing information on a regular and frequent basis, ensuring
accuracy) was received by the Center for Medicare and Medicaid (CMS).
This failure resulted in CMS not receiving registered nurse (RN) hours and licensed nursing coverage data
for the month of June 2024.
Findings:
During a review of PBJ Staffing Data Report CASPER (Certification And Survey Provider Enhanced
Reports) Report 1705D, Quarter 3 2024 (April 1 - June 30) run 11/25/2024 indicated, One Star Staffing
Rating, No RN hours, and failure to have licensed nursing coverage 24 hours/day.
During an interview on 12/4/24 at 10:30 a.m. with the Director of Nursing (DON), DON verbalized they are
responsible for sending staffing information to CMS, also verbalizing they were not aware of the reports to
run to ensure CMS received data sent.
During a review of the facility's policy and procedure (P&P) titled, PBJ Process dated 1/15/24, the P&P
indicated, After the data is submitted the DON generates a report from CASPER to verify that the data has
been submitted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555023
If continuation sheet
Page 9 of 10
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
12/05/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure proper handwashing was observed in
between vital signs taking and medication pass by one of one nurse (RN 2).
Residents Affected - Few
This failure had the potential to result in cross contamination and spread of infections to residents ,
compromising their wellbeing.
Findings:
During an observation on 12/3/24, at 9:18 a.m., with RN 2, in Unit 1 East, RN 2 was observed using a hand
sanitizer on the wall, sanitized his hands and donned surgical gloves, before knocking and entering room
[ROOM NUMBER]A with the vital sign machine on wheels. RN 2 failed to sanitize the vital signs machine
which was observed previously used on another resident. RN 2 then proceeded to take the resident's vital
signs. Subsequently, RN 2 completed the task of obtaining the residents vital signs and proceeded to wheel
the vital signs machine out of the room. RN 2 once again, failed to sanitize the vital signs machine after
use. RN 2 doffed and disposed of the surgical gloves, failed to hand sanitize and proceeded to prepare the
residents medications. RN 2 took the prepared medications, re-entered room [ROOM NUMBER]A without
hand sanitizing to administer the prepared medications. RN 2 exited the room and failed to hand sanitize
before touching medication cart and proceeding to the next resident.
During an observation on 12/3/24, at 9:45 a.m., RN 2 failed to observe hand hygiene etiquette before
entering room [ROOM NUMBER]A to administer medications and after exiting room [ROOM NUMBER]A.
The CDC (Centers for Disease Control and Prevention) article titled Clinical Safety: Hand Hygiene for
Healthcare Workers, dated 2/27/24, indicated, CDC provides the following recommendations for hand
hygiene in healthcare settings. 1) Immediately before touching a patient. 2) After touching a patient or
patient's surroundings. 3) Immediately after glove removal.
During a review of the facility's policy and procedure titled, Hand Hygiene, dated 2/27/17 and revised on
10/30/23, indicated in part, C. Decontaminate hands: 1. Before direct contact with residents .3. After contact
with a residents intact skin.
During a review of the facility's policy and procedure titled, General Dose Preparation and Medication
Administration, dated 12/1/07 and revised 4/30/24, indicated in part, 1.1 Appropriate hand hygiene should
be performed before and after direct resident contact.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555023
If continuation sheet
Page 10 of 10
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Back to topCitations
9 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
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.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F851 - Mandatory submission of staffing information based on payroll data in a
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FAQ · About this visit
Common questions about this visit
What happened during the December 5, 2024 survey of Casa Dorinda?
This was a inspection survey of Casa Dorinda on December 5, 2024. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Casa Dorinda on December 5, 2024?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure services provided by the nursing facility meet professional standards of quality."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.