Casa Dorinda

Inspectors wroteBased on observation, interview and Policy and Procedure (P/P) the facility failed to ensure food safety requirements was followed and implemented whenFailed to discard leftover in the itchen's walk-in-refrigerator. Take temperature of cold foods for lunch meal service to maintain potentially hazardous food and Time/ Temperature Control for Safety PHF/TCS foods at safe temperatures. Ensure kitchen staff during food preparation for meals served to residents wear appropriate beard restraints. Ensure safe food storage when documenting temperatures on the temperature monitoring log exceed 41 degrees Fahrenheit (F) and went unnoticed due to incorrect guidelines listed on the log.1. During a concurrent observation and interview on 3/3/26 at 11:00 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and all services are provided according to accepted standards of clinical practice for 5 of 12 sampled resident ( (Resident 40, 47 4, 1, and 34) when: Resident 40's nebulizer equipment (tubing and nasal canula) was not stored per facility policy. Resident 47 on oxygen had no signage posted indicating no smoking/oxygen in use. Ensure staff consistently used the unique identifiers to verify resident identity prior to medication administration These facility failures creates a potential for compromised resident outcomes and safety During an observation on 3/4/26 at 7:20 a.m., Licensed Nurse 3 (LN) 3, LN 3 was observed preparing medications for Resident 4. LN 3 entered the resident's room and administered five oral medications to the resident sitting in the chair. [...]

Inspectors wroteBased on observation, interview, and facility Policy and Procedure (P/P), the facility failed to ensure the medical supply rotation policy was implemented when expired medications were found in the medication carts and medication roomsThis facility failure has the potential for medciation error. During an observation of medication room [ROOM NUMBER] on 3/4/26 at 10:10 a.m. located on the first floor behind nursing station, 1 container, Oxivir Tb Wipes, (ready-to-use, hospital-grade disinfectant) with expiration date of 12/28/2023 and 1 bottle of Biotene dry mouth oral rinse, with expiration date of 2/24/2026 was noted. During an interview on 3/4/26 at 10:20 a.m. with licensed nurse (LN1). LN 1 confirmed items were expired and indicated, they should have been removed from stock and disposed. During an observation of medication number 2 3/4/26 at 10:40 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there is sufficient and qualified staff with the appropriate competencies and skills sets to carry out food and nutrition services when:1. The Nutritional Services Manager (NSM) was competent on the facility's refrigerated food storage guidelines for food safety.2. The NSM responsible for day-to-day food service for the residents at the Medical Center Skilled Nursing Facility (SNF) was qualified in accordance with federal and state regulations (Health and Safety Code (H&SC)1265.4(b) and Title 22 72035), as required per federal regulation.3. The Registered Dietitian (RD) provided frequently scheduled consultation to the NSM to include overseeing food safety and sanitation. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food were prepared by methods that conserve nutritive value, flavor, and appearance for five of twelve sampled residents (Resident 1,16, 23,25, and 34) when meals were not consistently served at an appetizing, palatable and preferable temperature as determined by the residents. This failure had the potential to cause weightloss. During a concurrent observation and interview on 3/3/26 at 12:20 p.m., with Nutrition Services Manager (NSM). NSM was observed using a calibrated thermometer to check the internal temperature of waffle fries from a test tray after the last lunch meal tray was served to residents and was noted to be 115 degrees Fahrenheit (F). [...]

Inspectors wroteBased 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 September 2025.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were implemented when: Enhanced barrier precautions (EBP - Infection control measures the involves wearing personal protective equipment [PPE - protective gear such as gloves, gowns, masks, and eye protection] for specific high-contact tasks such as bathing, transfers, and wound care for at-risk residents to stop germ spread) were not implemented for three of three residents (Resident 3, Resident 4, Resident 40) with indwelling medical devices (instruments placed inside the body to assist with diagnostic, monitoring, or therapeutic functions) A nebulizer mask (a medical device worn over the nose and mouth to deliver liquid medication directly into the airways as a fine mist) used for breathing treatments for Resident 40 was not stored in a manner to maintain hygiene and prevent [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure and implement interventions of a fall care plan to ensure a bed alarm was turned on for one of three sampled residents (Resident 1) while Resident 1 was in bed. This facility failure resulted in Resident 1 getting out of bed, falling to the floor and sustaining an acute displaced right hip fracture (broken hip bone that moved so much a gap formed around the fracture). During a review of Resident 1's Face sheet, [undated], the Face sheet indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow food safety requirements when: 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.

Inspectors wroteBased 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. This failure had the potential to inadequately identify what behavior needed to be monitored /planning of intervention to address the resident's inappropriate behavior.

Inspectors wroteBased 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.

Inspectors wroteBased 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). 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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). This failure had the potential to result in cross contamination and spread of infections to residents , compromising their wellbeing.

Inspectors wroteF656 Develop/Implement Comprehensive Care Plan §483.21(b) Comprehensive Care Plans §483.21(b)(1) Based on interview and record review, the facility failed to ensure Resident 1 ' s burn wound care plan included wound measurements and documentation requirements to monitor wound progression towards healing. This failure resulted in resident ' s burn wounds not being measured and documentation performed as required.

Inspectors wroteF658 Services Provided Meet Professional Standards §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. Based on interview and record review, the facility failed to implement standards of practice when Resident 1 ' s burn wounds were not assessed and documented according to standards of practice and its policy. This failure resulted in resident ' s burn wounds only being assessed and documented only one time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when: 1. The high temperature dish machine was not reaching proper wash, rinse and final rinse temperatures in order to effectively sanitize in accordance with the manufacturer's guidelines. 2. The three compartment sink used to wash pots and pans was not implemented in an effective manner to properly wash and sanitize the foodservice equipment. 3. The tube to dispense sanitizer was located in the hand washing sink. These failures had the potential to result in cross contamination and food borne illness in a highly susceptible resident population in which the majority of residents were on oral diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the director of dining services (DDS/CDM; certified dietary manager) received sufficient frequently scheduled consultations from the facility's Registered Dietitian (RD) to include oversight over sanitation of the main kitchen when: 1. RD had not reviewed the monitoring logs for the main kitchen's high temperature dish machine that resulted in not identifying and addressing sanitation concerns, in a timely manner, related to meal service for the health and safety of residents residing in the skilled nursing facility. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the correct portion size for the regular diet orders, with regular portion sizes (i.e.; meaning not a small portion or large portion) was served following the planned menu. This facility failure had the potential to not meet the resident's nutritional needs for 20 residents who were prescribed a regular diet, with regular portions, per the facility's Resident Diet Information, dated 3/14/24, provided by the Registered Dietitian (RD). (Resident's 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20).

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services when: 1. The dishwasher was unable to accurately record dish machine wash water and sanitizing (final rinse) temperatures. The dishwasher was not competent to know when to report a problem to ensure properly washed and sanitized dishes were used for residents. 2. A pot washer was not competent on the correct concentration of sanitizer for the 3-compartment sink to ensure the pots and pans were effectively sanitized. 3. A cook was not competent on thermometer calibration to ensure temperatures obtained were accurate to promote food safety for the residents. These failures placed residents at risk of cross contamination and acquiring foodborne illness. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an interdisciplinary team (IDT- team members from different discipline with common purpose, to set goals, share responsibilities and make decisions together) meeting was conducted for the self-administration of medication for one of 12 sampled residents (Resident 8). This failure had the potential for Resident 8 to unsafely self-administered a medication, without IDT's approval for self-administration.

Inspectors wroteBased on record review and interview the facility failed to update the medical records with current wishes for life sustaining treatment (POLST-Physician Order for Life Sustaining Treatment) for one of three sampled residents (Resident 8). This failure had the potential to prevent facility staff and emergency personnel from providing life sustaining treatment to Resident 8 in case of emergency.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an accurate system for monitoring parameters of nutritional status for one of 2 sampled residents (Resident 16), when: 1. An inaccurate nursing weekly assessment failed to identify a significant weight loss which resulted in a missed referral to the Registered Dietitian (RD). 2. An inaccurate weight goal was documented on the interdisciplinary team (IDT) nutrition care plan that had not been assessed by the RD or involved the decision making of the participant or responsible party (RP). 3. The facility lacked monitoring of a nutrition intervention, such as a high protein shake, when delivered with the meal trays. 4. The IDT nutrition care plan was not updated and revised to reflect changes the RD made to the intervention for weekly weights. [...]

Inspectors wroteBased on observation, interview and record, review, the facility failed to follow it's policy and procedures (P&P) (set of rules for employees to follow in an organization) for disposition (process for destroying unused medications) of expired and controlled medications (medications that are potential for abuse), and to reconcile (record keeping) accounting for controlled medications brought from home to the facility by family members for one unsampled resident (Resident 229) when the following was observed on [DATE], during a facility tour: 1. Eight packets of 4 vials each, 0.9% sodium chloride inhalation (nebulazer solution), expiration date 1/17, located at second floor Medication Room. 2. A small biohazard sharps container with narcotic medication as reported by the licensed staffs, located at first floor west station medication cart narcotic drawer. 3. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure one of 12 sampled residents (Resident 23) had been assessed for the use of antipsychotic (medicine for mental disorders) while having a diagnosis of dementia (a condition of the brain affecting ability to remember, think or make decisions with doing everyday activities), as outlined in the manufacturer's black box warning. This failure resulted in Resident 23, taking this medication and placed Resident 23, at increased risk of death as outlined by the black box warning and making this as inappropriate drug for Resident 23.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a cook followed the puree recipe for a puree egg omelet as a method to ensure nutritive value. As a result, the resident was provided a puree egg omelet with less nutritive value than planned.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Registered Dietitian provided care within the scope of practice guidelines of the California Business and Professions Code 2586 (a)(1) when the facility approved order writing privileges to the RD related to writing orders for nutritional supplements and therapeutic diets. As a result, the RD was performing services outside of RD scope of practice per State law.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling when: 1. Expired, leftover lentil soup that had not been cooled down safely was available for use in the walk-in refrigerator, and 2. The ice machine dispenser located in a kitchenette was not clean. As a result, residents were placed at risk for developing a food borne illness.