Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 | — | 4 | 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 | — | 1 | 0 |
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