Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Casa Dorinda during CMS and state inspections, most recent first.
Food safety and temperature monitoring were not followed when leftover cooked rice and pasta were stored in the kitchen walk-in refrigerator instead of being discarded, cold tuna salad was found at 50 degrees F during trayline prep, and dietary staff handled food without beard restraints. Pantry refrigerator logs also listed an incorrect acceptable range of 36 to 46 degrees F even though the facility policy required 33 to 41 degrees F, and nursing staff documented a 44-degree reading without recognizing it as out of range.
Staff administered medications to residents without using two identifiers, relying instead on the door name, MAR photo, or familiarity with the resident. In addition, nebulizer equipment was left uncovered instead of being stored per policy, and an oxygen-dependent resident had no oxygen-in-use/no-smoking sign posted outside the room. The DON acknowledged the facility did not use wristbands and that identifying residents by the door name was probably not appropriate.
Expired medications and supplies were found in medication carts and medication rooms, including Oxivir Tb Wipes, Biotene oral rinse, bisacodyl suppositories, Glucerna Therapeutic Nutrition, and Premier protein supplements. An LPN confirmed the expired items should have been removed from stock and discarded. The facility’s Supply Rotation Policy stated medical supplies must be kept current and outdated items discarded during weekly inspections.
Food Service Staff Lacked Required Competency and Qualifications: The NSM gave inconsistent answers about refrigerated storage times for raw chicken, raw fish, and MightyShakes, and his responses did not align with the facility’s food storage guide, the facility policy, or manufacturer instructions. He also stated he did not meet the education pathways required to serve as a dietary services supervisor or the qualifications for daily management of the SNF foodservice operation. The contracted RD visited weekly, but there was no formal schedule or documentation showing frequent consultation for oversight of food safety and sanitation.
Meals were not consistently served at an appetizing, palatable, and preferable temperature for several residents. A Nutrition Services Manager found waffle fries at 115 degrees F after lunch trays were served, and staff acknowledged ongoing complaints that food was arriving cold. Residents reported bland, tough, and unappetizing food, and resident council minutes documented repeated concerns about poor meat quality and cold meals.
Failure to Submit PBJ Staffing Data: The facility failed to run PBJ reports 1700D, 1702D, and 1702S to ensure staffing data was received by CMS. Review of the PBJ staffing report showed a One Star staffing rating, no RN hours, and no licensed nursing coverage 24 hours/day. The DON stated she forgot to send the PBJ report, and the facility policy stated the DON checks the data for accuracy and submits it through the CMS portal.
A facility failed to implement EBP for residents with indwelling devices, including a PICC line, suprapubic catheter, and feeding tube, and staff were unfamiliar with EBP, stating they only used TBP and gloves for certain tasks. A nurse was observed changing bed linens without PPE for a resident with a feeding tube, and the resident’s nebulizer mask and tubing were left uncovered on the nightstand/dresser instead of being stored in a labeled bag at bedside. Soiled linen bags were also found on the floor in two SLRs, despite staff acknowledging they should have been placed in the bins.
A resident with a history of falls and cognitive impairment was not provided adequate supervision when staff failed to activate the required bed alarm after care was provided. Despite care plan and physician orders mandating the use of a bed alarm due to high fall risk, staff could not confirm the alarm was turned on, and documentation showed the alarm check was missed for the shift. The resident was later found on the floor with a displaced right hip fracture, with no alarm or call light activated, indicating a lapse in following fall prevention protocols.
The facility did not run necessary reports to verify that PBJ data was submitted to CMS, resulting in missing RN hours and licensed nursing coverage data for June 2024. The DON was unaware of the need to run these reports, despite the facility's policy requiring verification of data submission.
The facility failed to follow food safety protocols, with mislabeled food containers lacking preparation and use-by dates, and sanitizing solutions not meeting recommended concentrations. A dietary aide and sous chef acknowledged these discrepancies, which could lead to inadequate food safety and sanitation.
A facility failed to document a resident's inappropriate behavior as required by the care plan. The resident, diagnosed with Alzheimer's and major depressive disorder, had multiple episodes recorded in the MAR, but no specific documentation was found in the progress notes. A nurse confirmed the lack of detailed notes, which could hinder intervention planning.
A facility failed to update a care plan for a resident with Alzheimer's and major depressive disorder, despite multiple episodes of inappropriate behavior. The care plan, created in August 2022, was not revised to reflect these episodes, contrary to the facility's policy requiring updates as the resident's condition changes. The Minimum Data Set Nurse confirmed the care plan was not updated during the September 2024 review, and interdisciplinary team meetings did not address the behavior.
A resident with Alzheimer's and major depressive disorder requested a psychiatric consultation, which was recommended by the attending physician. However, the consultation was not ordered or documented by the RN, leaving the resident's psychosocial needs potentially unmet.
A facility failed to monitor and assess a resident's development of foot drop, leading to reduced mobility and potential contractures. The resident was observed with flexed feet, and records showed no therapy was provided despite dependency on staff for mobility. Interviews confirmed the foot drop was new and should have been reported for timely intervention.
The facility failed to ensure proper narcotic reconciliation at shift changes, as required by policy. During a medication pass observation, it was found that the narcotic count book for November lacked signatures from both incoming and outgoing nurses on several occasions. This failure to follow procedure was confirmed by a registered nurse, highlighting a lapse in ensuring accurate narcotic counts and preventing drug diversion.
The facility failed to properly store and label medications, including Polyethylene Glycol 3350 Powder and insulin pens, which were found without open dates and included medications of discharged residents. Staff acknowledged the oversight, and no policy was available for handling medications from home or hospital.
A registered nurse failed to follow proper hand hygiene protocols while taking vital signs and administering medications. The nurse did not sanitize the vital signs machine between uses, nor did they sanitize their hands after removing gloves and before preparing medications. These actions were contrary to CDC recommendations and the facility's policies, potentially leading to cross-contamination and infection spread.
A resident sustained third-degree burns on both thighs after spilling hot coffee. The facility failed to include necessary wound measurements and documentation in the care plan to monitor healing progress. Despite the DON's claim of weekly documentation, records showed only one instance of measurement. The ADON confirmed the care plan lacked instructions for weekly documentation, contrary to facility policy.
A resident with third-degree burns on both thighs was not assessed and documented according to the facility's policy and national standards. The initial assessment was conducted, but subsequent weekly documentation was not performed as required. The DON confirmed the oversight and acknowledged the lack of ongoing assessment and documentation.
The facility failed to maintain sanitary conditions in the food and nutrition services. The high temperature dish machine did not reach the required temperatures for effective sanitization, and inaccurate temperature logs were maintained. The three-compartment sink was not used effectively, with improper wash water temperature and sanitizer concentration. Additionally, a sanitizer dispensing tube was found in a hand washing sink, violating infection control policies.
The facility failed to ensure effective oversight in kitchen sanitation, as the RD did not review monitoring logs for the high-temperature dish machine and three-compartment sink. Observations revealed that the dish machine and sink were operating below required temperatures and sanitizer levels, with inaccurate log entries. The RD and DDS/CDM acknowledged the lack of structured oversight, leading to potential foodborne illness risks for residents.
The facility failed to serve the correct portion size for regular diet orders, as a server used a 4-ounce spoon instead of the required 8-ounce portion for Shrimp and Sausage Jambalaya. This affected the nutritional intake of 20 residents on a regular diet with regular portions.
Food safety and temperature monitoring failures
Penalty
Summary
Food safety requirements were not followed in the kitchen when leftover cooked white rice and cooked pasta were found stored in the SNF kitchen walk-in refrigerator. During a concurrent observation and interview, the Nutrition Service Manager observed the rice in a transparent container with a preparation date of 3/2/26 and the pasta in a transparent container with a preparation date of 2/24/26. The Nutrition Service Manager stated the facility did not have a cool down log for the PHF leftover cooked rice and pasta and stated the facility did not store leftover foods. A cook later stated he was the one who placed the leftover rice and pasta in the walk-in refrigerator and confirmed there was no cool down log for safe food handling. The facility policy stated that it maintained a policy of not keeping, storing, or reusing leftover foods and that all cooked foods must be properly discarded at the conclusion of each meal period. Food temperatures were not monitored to ensure cold foods remained at safe temperatures before service. During observation, the Nutrition Service Manager measured cold tuna salad at 50 degrees F and stated it was intended to be served cold and should have been 41 degrees F or less. The Nutrition Service Manager also stated the facility was not checking prepared cold food temperatures for trayline service to ensure cold foods left the kitchen at 41 degrees F or less before being served to residents. The facility's policy for food delivery to the SNF stated that all food must be measured with a calibrated thermometer before being loaded for delivery and upon arrival, and that cold foods must be maintained at 41 degrees F or lower. Food handling and refrigerator monitoring practices were also deficient. Two dietary staff were observed handling clean meal trays and preparing food while wearing beards without beard restraints, and one stated there were no beard restraints available next to the hairnets. In addition, pantry refrigerator temperature logs listed an acceptable range of 36 to 46 degrees, while the facility's refrigerator temperature policy required temperatures between 33 degrees F and 41 degrees F. Nursing staff documented a pantry refrigerator temperature of 44 degrees F and stated there was nothing wrong with the log, while the DON stated the inaccurate guidance on the log prevented staff from identifying out-of-range temperatures for prompt reporting. The DDS acknowledged that the pantry refrigerators should maintain temperatures at or below 41 degrees F.
Failure to Verify Resident Identity and Follow Equipment and Oxygen Safety Policies
Penalty
Summary
Staff failed to verify resident identity using two identifiers before administering medications to three residents. During observations, an LN prepared and administered oral medications to each resident without asking them to state their name and date of birth. When interviewed, the nurses said they identified residents by the name on the door, the picture in the MAR, or because they knew the residents well. The DON also stated residents do not wear wristbands and acknowledged that identifying residents by the name on the door was probably not appropriate. The facility policy titled Resident Identification Prior Medication/Treatments Administration, dated 12/4/2024, required staff to verify identity using at least two identifiers, including the resident stating full name and date of birth or a resident photograph in the eMAR. The facility’s nursing textbook section on medication administration also stated that the right patient must be followed consistently to prevent medication errors. The observations showed that this process was not followed during medication administration for the sampled residents. The facility also failed to store nebulizer equipment properly for a resident admitted with pneumonitis and gastrostomy status. The resident’s nebulizer canula mask and tubing were observed uncovered on the nightstand on two separate observations, and the ADON acknowledged the equipment was on the dresser and not stored per policy. In addition, another resident admitted with pleural effusion, heart failure, and UTI was observed on oxygen via nasal canula with no oxygen-in-use/no-smoking sign posted outside or inside the room, and the ADON acknowledged the required signage was not posted.
Expired medications and supplies found in medication storage areas
Penalty
Summary
The facility failed to ensure its medical supply rotation policy was implemented when expired medications and supplies were found in medication carts and medication rooms. During an observation of the medication room on the first floor behind the nursing station, surveyors found 1 container of Oxivir Tb Wipes with an expiration date of 12/28/2023 and 1 bottle of Biotene dry mouth oral rinse with an expiration date of 2/24/2026. During an interview, LN1 confirmed the items were expired and stated they should have been removed from stock and disposed. During an observation of medication cart 2 on the second floor at the nursing station, 10 bisacodyl 10 mg suppositories with an expiration date of 2/28/26 were noted. During an observation of the medication room on the second floor behind the nursing station, surveyors found 2 cartons of Glucerna Therapeutic Nutrition with an expiration date of 10/25 and 3 bottles of Premier protein supplement with an expiration date of 2/14/26. The facility policy titled Supply Rotation Policy stated medical supplies will be sufficiently stocked and maintained current, and the medical supply room will be inspected weekly by Unit Managers and outdated items will be discarded.
Food Service Staff Lacked Required Competency and Qualifications
Penalty
Summary
The facility failed to ensure sufficient and qualified staff with the appropriate competencies and skill sets were available to carry out food and nutrition services, including a qualified dietitian. During observation and interview in the SNF kitchen walk-in refrigerator, the Nutritional Services Manager (NSM) gave inconsistent answers about refrigerated storage times for uncooked chicken, raw fish, and MightyShakes. Uncooked chicken was observed labeled with a preparation date, and the NSM first stated it could be stored for three to four days, then later stated the posted Food Storage Guide showed only one to two days. Raw salmon and red [NAME] were also observed labeled with a preparation date, and the NSM stated they could be stored for three to four days before cooking, despite the facility policy indicating fresh poultry/fish should be stored for a maximum of one to two days. The NSM also demonstrated a lack of understanding of the storage requirements for MightyShakes. The cartons were observed labeled with a date when they were removed from the freezer and placed in the refrigerator, and the NSM stated they had three days to use them. He then pointed to the manufacturer date printed on the cartons and stated they could also be stored unopened in the refrigerator until that date. The manufacturer instructions reviewed by surveyors stated the product should be stored frozen, thawed at or below 40 degrees F, and used within 14 days after thawing while kept refrigerated. The NSM further stated he had not met any of the education pathways required under H&SC 1265.4(b) and Title 22 72035 to serve as a dietary services supervisor, and he also stated he did not meet the qualifications listed in federal regulation F801 to be responsible for daily management of the SNF foodservice operation. The Director of Dining Services stated he was responsible for the entire CCRC food and nutrition services, including the main kitchen and other campus operations, and was not full-time specifically to the SNF kitchen. The contracted Registered Dietitian stated she visited once weekly, and the NSM and DDS stated there was no formal schedule or documentation showing frequent consultation by the RD for oversight of food safety and sanitation, and the RD was not part of the routine food safety and sanitation audits.
Meals Served at Improper Temperature and Poor Quality
Penalty
Summary
Food and drink were not consistently served at an appetizing, palatable, and preferable temperature for five sampled residents, including Resident 1, Resident 16, Resident 23, Resident 25, and Resident 34. During a concurrent observation and interview, the Nutrition Services Manager used a calibrated thermometer to check waffle fries from a test tray after the last lunch trays had been served and found them to be 115 degrees Fahrenheit, stating they were not at an acceptable temperature for service and acknowledging that the facility had received resident complaints about meals being served cold. Resident interviews and record review showed ongoing concerns about food quality. Resident 25 stated the food had no flavor and consumed less than 50% of the meal. Resident 16 stated the food was not good and that meals often arrived cold. Resident 1 stated lunch and dinner were not good. Resident 23 stated the food seemed institutional, the meat was too tough to chew, and a regular knife would not cut it. Resident council minutes from multiple meetings documented complaints that tray line food needed improvement, steak was tough and tasteless, meat quality was poor and difficult to cut, and food continued to be served cold during various meals. The Director of Dining Services acknowledged that cold food had been an ongoing issue in the facility.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to run PBJ reports 1700D (employee report), 1702D (individual daily staffing report), and 1702S (staffing summary report) to ensure payroll-based journal staffing data was received by CMS. During review of PBJ Staffing Data Report 1705D for Quarter 4 2025, the report showed a One Star Staffing Rating, no RN hours, and failed to have licensed nursing coverage 24 hours per day for September 2025. During interview, the DON, Administrator, and Assistant DON stated that the DON forgot to send the PBJ report for September. Review of the facility policy and procedure titled, "The DON checks the data for accuracy and submits the data through the CMS portal," was also completed.
Failure to Use EBP, Store Nebulizer Equipment Properly, and Handle Soiled Linen Correctly
Penalty
Summary
Infection prevention and control practices were not implemented for residents with indwelling medical devices. During concurrent observation and interview, Enhanced Barrier Precautions (EBP) signage was not posted and PPE was not available at the point of care for a resident with a PICC line, a resident with a suprapubic catheter, and a resident with a feeding tube. The resident with the PICC line had a history and physical noting treatment for infectious endocarditis with prolonged IV antibiotics, and the resident with the suprapubic catheter had an order for daily site care. The resident with the feeding tube had an order for enteral feeding tube site care. Staff interviews showed the facility was not using EBP and staff were unfamiliar with it. The Infection Prevention Nurse stated the facility did not implement EBP because it was viewed as a recommendation rather than a CMS requirement, and stated the facility used only transmission-based precautions for airborne, contact, and droplet precautions. Licensed nurses confirmed there were no residents on transmission-based precautions, stated gloves were the only PPE used for catheter care, and explained that masks, face shields, or gowns were used only if a resident was on contact precautions. One licensed nurse was observed changing the resident’s bed linens without any PPE and stated gloves were only required if linens were contaminated. The resident with the feeding tube also had nebulizer equipment observed uncovered on the nightstand and dresser rather than stored in a labeled bag at the bedside as required by the facility’s nebulizer policy. In addition, soiled linen bags were observed on the floor in two soiled linen rooms beside the linen bins. The Assistant Director of Nursing acknowledged one bag should not have been on the floor, housekeeping stated the bag should not be on the floor and moved it into the bin, and a licensed nurse stated the bags are supposed to be placed in the bins but some staff do not do it. The facility’s written policy for soiled linen stated soiled linen should be bagged in yellow bags and placed in the green cart in the soiled linen room, while the facility also had a sign directing blue striped bags to be placed on the floor, which the linen company later said was not its policy.
Failure to Ensure Bed Alarm Activation Results in Resident Fall and Hip Fracture
Penalty
Summary
The facility failed to follow its policy and procedure regarding fall prevention interventions for a resident with a significant history of falls and cognitive impairment. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, major depressive disorder, recurrent mild muscle weakness, gait abnormalities, and a history of falls, was assessed as high risk for falls and had a care plan and physician order requiring a bed alarm to be activated whenever in bed. Despite these interventions, the bed alarm was not activated after the resident was changed in bed during a shift change. Interviews with the DON, ADON, licensed nurses, and a CNA revealed that staff could not recall if the bed alarm was turned back on after providing care, and documentation confirmed that the required alarm check was not completed for the evening shift. The facility's policy required alarms to be tested at the start of each shift and after resident care, but this was not consistently followed. The resident was found on the floor after calling for help, with no bed alarm or call light activated, and subsequently sustained a displaced right hip fracture. Record reviews, including care plans, physician orders, and progress notes, confirmed that the bed alarm was a required intervention for this resident due to poor safety awareness and a high fall risk. The failure to ensure the bed alarm was activated directly resulted in the resident being able to exit the bed unassisted, leading to a fall and serious injury. Staff interviews and documentation indicated lapses in following established protocols for alarm use and shift checks.
Failure to Verify PBJ Data Submission to CMS
Penalty
Summary
The facility failed to run necessary reports to ensure that payroll-based journal (PBJ) data was accurately submitted to the Centers for Medicare and Medicaid Services (CMS). Specifically, the facility did not generate reports 1700D (employee report), 1702D (individual daily staffing report), and 1702S (staffing summary report) to verify that the data was received by CMS. As a result, CMS did not receive registered nurse (RN) hours and licensed nursing coverage data for June 2024. During an interview, the Director of Nursing (DON) acknowledged responsibility for sending staffing information to CMS but was unaware of the need to run these reports to confirm data submission. The facility's policy and procedure, dated January 15, 2024, indicated that after data submission, the DON should generate a report from CASPER to verify submission, which was not done.
Food Safety and Sanitization Deficiencies
Penalty
Summary
The facility failed to adhere to food safety requirements, as evidenced by the improper labeling of prepared food containers and inadequate sanitizing solutions. During an inspection, three stainless steel containers in the kitchen freezer were found mislabeled with a future date, lacking both a preparation date and a use-by date. This discrepancy was acknowledged by a dietary aide, who attributed the error to a possible oversight by weekend staff. The facility's policy mandates that all prepared foods not in their original containers must be covered, labeled, and dated, with leftovers used within 72 hours or discarded. Additionally, the facility did not maintain the recommended concentration of sanitizing solutions used for cleaning kitchen surfaces. Testing of three red buckets revealed varying concentrations, with one bucket below the recommended range. The sous chef suggested that the solution might have been diluted or not changed as required, leading to inadequate disinfection. The facility's policy requires regular testing of sanitizing solutions to ensure they maintain the proper strength for food contact surfaces, with a recommended concentration between 200 ppm and 400 ppm.
Failure to Document Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to ensure that specific inappropriate behaviors of a resident were documented as required by the care plan. The care plan for the resident, who had diagnoses including Alzheimer's disease with late onset and major depressive disorder, required monitoring and documentation of inappropriate behavior episodes towards staff members three times a day. However, a review of the resident's progress notes from January 1, 2024, to December 4, 2024, revealed that there was no specific documentation of these behaviors, despite multiple episodes being recorded in the Medication Administration Record (MAR) during the same period. During an interview, a registered nurse acknowledged the resident had incidents of inappropriate behavior on multiple occasions throughout the year but confirmed that there were no progress notes detailing the specifics of these episodes. This lack of documentation as instructed in the care plan had the potential to inadequately identify what behavior needed to be monitored and hindered the planning of interventions to address the resident's inappropriate behavior.
Failure to Update Care Plan for Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to update the care plan for a resident with inappropriate behavior, as required by their policy and procedure. The resident, who has Alzheimer's disease with late onset and major depressive disorder, experienced multiple episodes of inappropriate behavior over several months. Despite these occurrences, the care plan, which was initially created in August 2022, was not revised to reflect these episodes or to implement effective interventions. The facility's policy mandates that care plans be revised as changes in the resident's condition dictate and reviewed at least quarterly, but this was not adhered to in this case. The Minimum Data Set Nurse confirmed that the care plan for monitoring the resident's inappropriate behavior was not updated during the quarterly review in September 2024. Additionally, the interdisciplinary team meetings did not address the monitoring of the resident's behavior, as noted in the meeting reports from October 2023 to October 2024. This oversight in updating the care plan and addressing the resident's behavior in team meetings highlights a lapse in the facility's adherence to its own policies and procedures.
Failure to Implement Psychiatric Consultation for Resident
Penalty
Summary
The facility failed to ensure that a doctor's recommendation for a psychiatric consultation was followed for a resident diagnosed with Alzheimer's disease and major depressive disorder. The resident had expressed feelings of depression and requested to see a psychiatrist, which was noted in the social services notes. The attending physician also documented the need for a psychiatric consultation in the physician notes. However, there was no evidence in the medical records that the resident was seen by a psychiatrist. During an interview, a registered nurse and the Director of Nursing acknowledged the resident's request for a psychiatric consultation. The registered nurse admitted to forgetting to order the psychiatric consultation and failing to document the resident's request. This oversight resulted in the resident's psychosocial health care needs potentially being unattended, as there were no progress notes or consultation notes indicating that the psychiatric consultation was carried out.
Failure to Monitor and Assess Resident's Foot Drop
Penalty
Summary
The facility failed to monitor and assess the development of foot drop in one of the residents, leading to a deficiency in maintaining or improving the resident's range of motion. During an observation, the resident was found in a supine position with their feet on a pillow, and the toes of both feet were flexed outward instead of upward. A review of the resident's physical therapy evaluation from February 2022 indicated that the resident's ankle dorsiflexion and plantar flexion were within normal limits at that time, with no extension or flexed feet noted. However, the resident's annual MDS from April 2024 and a subsequent quarterly MDS indicated that the resident did not receive any therapies from the rehabilitation department, despite being dependent on staff for mobility. Interviews with the assistant director of nursing and the director of rehabilitation confirmed the presence of the foot drop and acknowledged that it was a new development. The assistant director of nursing suggested that the foot drop might be due to the resident's positioning and mentioned the need to contact the doctor for a rehabilitation evaluation. The director of rehabilitation agreed with the findings and noted that the foot drop should have been reported for assessment and timely intervention. This lack of monitoring and intervention resulted in reduced mobility of the resident's foot, with the potential for contractures.
Failure in Narcotic Reconciliation Count
Penalty
Summary
The facility failed to ensure that the change of shift narcotics reconciliation count was properly conducted and documented by two licensed nurses, as required by their policy. During a medication pass observation, it was noted that the narcotic count book for November was missing several signatures from both incoming and outgoing licensed nurses. Specifically, on multiple occasions, nurses failed to sign at the start and end of their shifts, which is a critical step in ensuring the accuracy of the narcotic count and preventing drug diversion. The facility's policy, revised in October 2023, mandates that narcotics be counted daily at shift change by two licensed nurses, with both the incoming and outgoing nurses required to sign the narcotic count log. However, the record review revealed that on several dates in November, this procedure was not followed, as evidenced by the missing signatures. During an interview, a registered nurse confirmed the absence of signatures in the narcotic count book, acknowledging the oversight.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that biologicals and medications were properly stored and labeled, as observed during a medication pass on the East Wing, first floor. Five plastic containers of Polyethylene Glycol 3350 Powder for Solution, a laxative, were found with room numbers labeled on the caps but missing open dates. Additionally, one of these containers belonged to a discharged resident and had not been removed from the medication cart. The registered nurse acknowledged the oversight, noting the absence of open dates and the presence of the discharged resident's medication. Further observations at the first-floor nursing station medication room revealed three used insulin pens belonging to a discharged resident stored in the medication refrigerator. These insulin pens, including NovoLOG Flex Pen, Insulin Glargine (LANTUS), and insulin aspart (NovoLOG), were used but lacked open dates. The licensed vocational nurse could not explain why these medications remained in the refrigerator. The facility's policy required staff to label medications with open dates, but no policy was available for handling medications brought from home or hospital or for discontinued medications.
Failure to Follow Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by a registered nurse (RN 2) during the process of taking vital signs and administering medications. On December 3, 2024, RN 2 was observed using a hand sanitizer and donning surgical gloves before entering a resident's room with a vital sign machine. However, RN 2 did not sanitize the vital signs machine, which had been used on another resident, before or after taking the resident's vital signs. After completing the task, RN 2 removed the gloves but did not sanitize his hands before preparing medications for the resident. RN 2 continued to neglect hand hygiene by failing to sanitize hands before re-entering the resident's room to administer medications and after exiting the room. This was observed again later the same day when RN 2 did not perform hand hygiene before entering and after exiting the resident's room to administer medications. These actions were in violation of both the CDC's hand hygiene recommendations and the facility's own policies, which require hand hygiene before and after direct resident contact and after glove removal.
Failure to Document and Measure Burn Wounds Weekly
Penalty
Summary
The facility failed to ensure that a comprehensive care plan for a resident's burn wound included necessary wound measurements and documentation to monitor healing progress. The incident occurred when a Licensed Vocational Nurse (LVN) accidentally caused a resident to spill hot coffee on their lap, resulting in third-degree burns on both thighs. Although the Director of Nursing (DON) reported that weekly measurements and documentation were performed, the medical record showed that the burn wounds were only measured and documented once, the day after the incident. The Assistant Director of Nursing (ADON) confirmed that the care plan did not specify the need for weekly measurements and documentation, which was contrary to the facility's policy requiring weekly documentation of skin conditions until resolved.
Failure to Document and Assess Burn Wounds
Penalty
Summary
The facility failed to adhere to professional standards of quality in the assessment and documentation of a resident's burn wounds. The resident sustained third-degree burns on both thighs, which were initially assessed and documented the day after the injury. However, the facility did not continue to assess and document the wounds as required by their policy and national standards. The facility's policy mandates weekly documentation of wounds expected to take 14 days or longer to resolve, but this was not followed for the resident's burn wounds. During an interview, the Director of Nursing (DON) confirmed that the resident's burn wounds were only documented once and acknowledged the lack of ongoing assessment and documentation. The DON explained that their electronic health record system includes a template for documenting skin integrity observations, which was not utilized for this resident. The failure to initiate and maintain the required weekly observation and documentation for the resident's burn wounds led to the deficiency identified in the report.
Sanitary Conditions Not Maintained in Food and Nutrition Services
Penalty
Summary
The facility failed to maintain sanitary conditions in the food and nutrition services, as evidenced by multiple deficiencies observed during a survey. Firstly, the high temperature dish machine was not reaching the proper wash, rinse, and final rinse temperatures required to effectively sanitize dishes according to the manufacturer's guidelines. Despite the dish machine's final rinse temperature needing to reach 180 degrees Fahrenheit, it was observed to be significantly lower. The issue was compounded by inaccurate temperature logs and a lack of reporting by the dishwashing staff to supervisory personnel. The Director of Dining Services confirmed that the dish machine was not meeting the required temperatures and required a heating element replacement after an external service assessment. The facility's policy and procedure for high-temperature machine ware washing were not adhered to, leading to potential cross-contamination and foodborne illness risks for residents on oral diets. The FDA Food Code Annex also emphasizes the importance of adhering to the manufacturer's guidelines to ensure effective sanitization, which was not followed in this case. Secondly, the three-compartment sink used for washing pots and pans was not implemented effectively to properly wash and sanitize foodservice equipment. Observations revealed that large food storage bins and lids were only partially immersed in the sanitizing solution, leaving parts of the equipment unsanitized. The wash water temperature in the first compartment was also found to be below the required 110 degrees Fahrenheit, and the sanitizer concentration in the third compartment was below the necessary 200 parts per million. The facility's policy and procedure for using the three-compartment sink were not followed, leading to improper sanitization of foodservice equipment. Lastly, a tube used to dispense sanitizer was found in the hand washing sink, which is designated solely for hand washing. This was confirmed by both the lead diet aide and the Executive Chef, who acknowledged that the tube should not have been in the hand washing sink due to infection control concerns. The facility's hand washing policy clearly states that hand sinks should only be used for hand washing and not for any other purposes. These deficiencies collectively indicate a failure to maintain sanitary conditions in the food and nutrition services, posing a risk of cross-contamination and foodborne illness to the residents.
Lack of Effective Oversight in Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that the director of dining services received sufficient consultations from the facility's Registered Dietitian (RD) to oversee the sanitation of the main kitchen. Specifically, the RD did not review the monitoring logs for the high-temperature dish machine, which resulted in unaddressed sanitation concerns. During an observation, the dish machine was found to be operating below the required temperatures for sanitization, and the monitoring logs contained inaccurate entries. The Sous Chef confirmed that the dish machine was not meeting the manufacturer's guidelines for wash and rinse cycles, and the RD admitted there was no structured schedule for oversight of kitchen sanitation. Additionally, the RD did not review the monitoring log for the main kitchen's three-compartment sink to ensure accurate guidance was available and followed. During an observation, the wash water temperature and sanitizer concentration were found to be below the required levels. The facility's policy and procedures for the three-compartment sink were not being adhered to, and the monitoring log did not provide proper direction to the dishwashing staff. The RD confirmed that there was no formal schedule for kitchen audits and that he was not responsible for providing the monitoring log for the three-compartment sink. The facility's policies and job descriptions for the Director of Dining Services and the Dietitian/Nutritional Services Manager indicated responsibilities for ensuring sanitation and safety standards. However, the lack of effective oversight and routine inspections led to deficiencies in the sanitation of the main kitchen, potentially causing foodborne illness to the residents. The RD and DDS/CDM acknowledged the absence of effective oversight and monitoring related to kitchen sanitation.
Failure to Serve Correct Portion Sizes for Regular Diet Orders
Penalty
Summary
The facility failed to ensure the correct portion size for regular diet orders was served according to the planned menu. During an observation, a server was seen using a 4-ounce serving spoon to plate the main entree of Shrimp and Sausage Jambalaya for residents on a regular diet with regular portion sizes. The Registered Dietitian (RD) pointed out that the planned menu specified an 8-ounce portion for this dish. Despite this, the server continued to use the 4-ounce spoon, serving only one scoop instead of the required two scoops to meet the 8-ounce portion size. This discrepancy was noted after three meal delivery carts had already been distributed to residents, potentially affecting the nutritional intake of 20 residents on a regular diet with regular portions. The facility's policy and procedure on portion control and menu planning were reviewed and indicated that specific portion sizes should be listed on the menu and that food should be served with standard-sized utensils to ensure accurate portion sizes. The policy also emphasized that portions that are too small could result in residents not receiving the necessary nutrients. The RD verified that the facility's Resident Diet Information list indicated 20 residents on a regular diet with regular portions, and the planned lunch menu specified an 8-ounce portion for the Shrimp and Sausage Jambalaya. The facility's job description for the Dietitian/Nutritional Services Manager also included monitoring portion control to ensure food is prepared and presented acceptably.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 56 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Barbara
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Californian | 4.6 mi | ★★★★★ | 0 | 0 |
| Samarkand Skilled Nursing Facility | 5.1 mi | ★★★★★ | 5 | 0 |
| Mission Park Healthcare Center | 5.1 mi | ★★★★★ | 0 | 0 |
| Valle Verde Health Facility | 6.3 mi | ★★★★★ | 7 | 0 |
| Channel Islands Post Acute | 6.3 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Casa Dorinda.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.