Santa Maria Post Acute

Inspectors wroteBased on record review and interview, the facility failed to ensure staff provided resident care and services in accordance with professional standards of nursing practice when physician orders to monitor Wander Guard ( a wander management device that alarms) for proper placement and functioning for one of three residents (Resident 1) who was identified as an elopement risk. This facility failure compromised Resident 1's elopement prevention plan, placing the resident at an increased risk for unauthorized departure from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent elopement for one of three sampled residents (Resident 1) when Resident 1, who was assessed as an elopement risk and provided with a Wander Guard (device that alarms), left the facility unmonitored. This facility failure compromised Resident 1's elopement prevention plan, placing the resident at an increased risk for accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician order as reflected in the care plan was followed for one of three sampled residents (Resident 1) when Licensed Nurse (LN1) failed to notify the physician of Resident 1's elevated blood glucose level of 369 mg/dL (milligrams per deciliter; a unit of measurement used to describe the concentration of glucose in the blood) with physician order to notify for blood glucose levels greater than 351 mg/dL. This failure placed Resident 1 at risk for possible effects of high blood glucose level with delayed medical evaluation and treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the five day follow-up investigation report regarding two of two residents (Resident 1 and 2) altercation incident was completed and forwarded to the DepartmentThis failure is a violation of reporting requirements. During a record review of facility SOC 341 dated 4/2/26 (Form use to report of suspected dependent adult/elder abuse) indicated that on 4/1/26 the abuse coordinator was made aware of Resident 1 and Resident 2 altercations with no injuries. During a record review of Resident 1's Progress Notes (PN), dated 4/2/26 indicated that an investigation was initiated. On 4/14/26 at 11:58 a.m., 12:32 p.m., 12:45 p.m., and 12:50 p.m., the surveyor requested the complete five day investigation report related to the incident involving Resident 1 and Resident 2 from the Administrator (ADM). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, the facility's policy and procedures on Substance Use Disorder was implemented for two of two sampled residents (Residents 1 and 2) when the:Nursing Screening Assessment for substance abuse for two sampled residents (Residents 1 and 2) did not reflect the use of tobacco, alcohol, and drug use. Care plan for substance abuse for two of two sampled residents (Resident 1 and 2), did not include approaches, interventions, and addressing risks which could lead to an overdose while in the facility. These failures resulted in Residents 1 and 2 being found unresponsive secondary to drug overdose, requiring emergency medical interventions and hospitalization with potential for harm. [...]

Inspectors wroteBased on record review, observation, interview, the facility failed to implement care plan interventions to monitor a resident with a known history of elopement attempts for one of three sampled residents (Resident 1). These failures resulted in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death. During a review of Resident 1's admission Record (AR), AR indicated Resident 1 was admitted to facility on 6/11/24 with diagnoses that includes muscle weakness (reduced muscle strength), history of falling and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis or weakness on the right side of the body caused by a stroke). During a review of Resident 1's Brief Interview for Mental Status (BIMS) score (13-15: Cognitively Intact, 8-12: Moderate Impairment, 0-7: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a routine medication was available for one of three sampled residents (Resident 1). This failure resulted in Resident 1 not receiving scheduled medication and caused the resident distress.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one of two sampled residents (Resident 1), when pain medication was not ordered until two days post orders and incorrect frequency of medication recorded. This failure had the potential for Resident 1 to suffer unnecessary physical discomfort.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure adequate supervision for one of three sampled residents (Resident 1), to prevent elopement. The facility identified Resident 1 to be at risk for elopement and implemented a wander guard system (a wander management system that uses wearable bracelets, sensors, and a technology platform to help keep residents safe) but failed to provide adequate supervision and Resident 1 eloped on 12/30/24. Resident 1 was found five blocks away from the facility, unaccompanied. This failure resulted in Resident 1 eloping from the facility without staff knowledge, posing a potential risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 1) was treated with dignity when the resident's behavior was escalating, and de-escalation techniques were not utilized. This failure had the potential to cause psychosocial harm to Resident 1

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was functioning for one of two sampled residents (Resident 2). This failure had the potential to result in Resident 2 not having their needs met and sustain complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety standards were followed when: 1. A dietary aide/cook (DAC) was observed not following proper hygiene and sanitary practices during lunch tray preparation. 2. The frequency of the facility's ice machine sanitization schedule was not followed according to manufacturer's recommendations. These failures had the potential to cause food-borne illness to vulnerable residents currently residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide nursing staff on a 24-hour basis to care for the residents' needs. This failure had the potential to result in residents not receiving necessary care.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was an informed consent for the use of medication Xanax (drug that helps to control anxiety and panic attacks) in one of two sampled residents (Resident 44). This failure had the potential for Resident 44 to be on Xanax without being informed of the risk and benefits of the drug.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the most recent recertification survey results available to residents, family members and legal representatives of residents. This facility failure denied the opportunity for residents, family members, and legal representatives of residents to be aware of the facility's survey results.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of four sampled residents (Residents 44 and 17) when: 1. No care plan was developed for Resident 44 for the use of the medication Xanax (medication that helps control anxiety and panic attacks). 2. No care plan was developed for Resident 17 for the use of the anticoagulant medication Apixaban (a medication that helps prevent blood clots). These failures had the potential to result in misidentifying potential unneccessary use and abnormal bleeding complications for these residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the timely revision/update of a comprehensive care plan for one of four sampled residents (Resident 12), to reflect changes in Resident 12's choices and change in condition. This failure resulted in an inaccurate care plan and had the potential to result in placing the resident at risk of not receiving the appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed professional standards to provide quality care for three of seven sampled residents (Residents 403, 50, and 34) when: 1. A medication for Resident 403 was not administered per doctors' order. 2. A physician order was not carried out for Resident 50. 3. Post dialysis (treatment for kidney failure where blood is cleaned through an artificial filter) assessments were not completed for Resident 34. These failures had the potential to inappropriately identify and manage resident's health issues that may lead to serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Acetaminophen (treat minor aches and pains, and reduces fever) was given as ordered for one of four sampled residents (Resident 403) 2. Levothyroxine (to treat an underactive thyroid gland [hypothyroidism]) was given before breakfast for one of four sampled residents (Resident 404) 3. Acamprosate (a medication used to help overcome alcohol dependence), and Magnesium Oxide (a supplement) were administered as prescribed to one of four sampled residents (Resident 202) These failures had the potential for the residents to not receive the maximum benefit from the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a Medication Regimen Review for Xanax (drug that helps to control anxiety and panic attacks) for one of two sampled residents (Resident 44). This failure had the potential for Resident 44 to have complications from the medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a practitioner's (physician) justification for the continued use of Xanax (drug that helps to control anxiety and panic attacks) beyond 14 days for one of two sampled residents (Resident 44). This failure had the potential for Resident 44 to receive an unnecessary medication and have complications due to the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. During medication administration for three of five residents (Residents 403, 404 and 202) four medication errors were observed out of 27 opportunities which resulted in an error rate of 14.81 percent. This failure had the potential for the residents to not receive the maximum benefit from the medications and sustain complications and side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were safely labeled and stored in the medication storage room when: 1. An opened one-liter bottle of 0.9% Sodium Chloride solution (a solution used for wound cleaning) was found without an open date label. 2. Temperature logs for three sampled months for the two refrigerators used to store medications had days when temperature readings were out-of-range. The log did not have a section to indicate if adjustment was done when temperature readings were out-of-range. 3. A box of lemon glycerin swab sticks (cotton swabs used to soothe dry mouth) was found in the freezer. 4. Two plastic bags containing multiple labeled and unlabeled medications were found in the medication storage room sink. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure measures/system were in place to prevent the growth of Legionella (a bacteria found in water systems such as air conditioners, shower, sinks, and water fountains) and other opportunistic waterborne (a disease/infection from infected water) pathogens in their water system. This failure resulted in not having a water management program/system which had the potential to expose the residents of the facility to Legionella and other harmful waterborne pathogens.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to provide a safe, functional, sanitary, and comfortable environment for two of four sampled residents (Residents 6 and 12). This failure resulted in compromising the comfort and safety of the residents and had the potential to result in adversely affecting the resident's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) Deep Tissue Injury (DTI) did not worsen and the resident did not develop further wounds. This failure resulted in the DTI becoming worse and the development of three additional pressure injuries, an additional hospital stay, and increased pain for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to comply with the state requirement of unusual occurrence by not reporting to the Department (State Agency) a fall with injury for one of two sampled residents (Resident 1). This deficient practice resulted in a delayed investigation by the Department for Resident 1's fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from restraints for one of two sampled residents (Resident 1) when the facility raised all four side rails. This failure had the potential to negatively affect the Resident 1's physical mobility and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), was provided a written Bed Hold notice. This failure resulted in Resident 1 being denied readmission to the facility, after hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess the skin status for one resident (Resident 1) upon admission. This failure had the potential for Resident 1 to not receive needed care.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented with measurable objectives and individualized interventions for four of 13 residents in the sample. (Residents 40, 45, 41 and 14). As a result of this deficient practice, the residents had a potential to be at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being and, had a potential negative impact on the resident's quality of life, as well as quality of care and services received.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure the facility is free of a medication error rate of 5% or more as evidenced by 4 medication errors out of 42 medication administration opportunities or an error rate of 9.52%. when: 1. Resident 22 received 37.5 mg of metoprolol tartrate (a medication to lower blood pressure) instead of 50 mg. 2. Resident 21 received 1 patch of 4% lidocaine (a numbing agent) instead of 2 patches applied to the lower back. 3. Resident 21 received 2 drops of Dorzolamide HCL 2% (eye drops used to treat residents increased eye pressure) to both eyes immediately followed by 2 drops of Tears Naturale (a viscous solution that acts as an artificial tear). There should be a 3-5-minute interval between the two medications. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling and sanitation were implemented when: 1. Food items were unlabeled and/or undated in the utility refrigerator adjacent to the nursing station. 2. Staff could not demonstrate competency during chemical testing of the kitchen sanitizing solution. These failures had the potential to cause foodborne illness to the highly susceptible residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices when the contact time (time product should stay wet) of a disinfectant/cleaner could not be verbalized by staff. This facility failure had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for residents in an already compromised condition.

Inspectors wroteBased on interview and record review, the facility failed to follow its Mitigation Plan for the prevention and containment of COVID-19 when testing for two of three sampled staff were not conducted according to the recommended frequency. This deficient practice had the potential to contribute to the transmission and spread of infectious diseases, such as COVID-19, to residents, staff, and visitors in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was initiated within forty-eight hours of admission for one sampled resident (Resident 40). This failure had a potential for the staff to not have proper guidelines to follow to ensure proper care and services for Resident 40 were received.

Inspectors wroteBased on interview, and record review, the facility staff failed to ensure for one resident's (Resident 41) comprehensive care plan pertaining to psychotropic (drugs that affect a person's mental state) use was reviewed, evaluated for effectiveness, and revised. This failure resulted in resident 41's behaviors not being monitored to justify the continued use of the psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were accurately administered to two of 13 sampled residents (Resident 21, Resident 22) when: 1. Resident 22 received 37.5 mg of metoprolol tartrate (a medication to lower blood pressure) instead of 50 mg. 2. Resident 21 received one patch of 4% lidocaine (a numbing agent) instead of two patches applied to the lower back. 3. Resident 21 received two drops of Dorzolamide HCL 2% (eye drops used to treat increased eye pressure) to both eyes and then immediately followed by two drops of Tears Naturale (a solution that act as artificial tears). The three to five minutes interval between the two medications was not observed. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately label and store drugs when: 1. Two (2) boxes of Tylenol/Paracetamol (a medication for pain relief) suppositories were improperly stored in the medication room based on temperature requirements of 20-25 ºC (68-77º F) or in a cool place. 2. One (1) vials of Purified Protein Derivative (PPD also known as Tuberculin, (used to diagnose tuberculosis) was located in the refrigerator in the medication room. The opened date was documented on the box as [DATE]. 3. A medication of hydrocodone acetaminophen (Norco 5-325 a medication for pain relief) found in the north wing medication cart was expired with a an expiration date of 7/22. These failures had the potential for residents to receive expired, ineffective, and contaminated medications.

Inspectors wroteBased on interview and record review, the facility failed to provide physical therapy (PT) services as ordered to one of 13 sampled residents (Resident 22). This failure prevented Resident 22 from receiving PT services to improve functional mobility and had the potential to promote deterioration of muscle strength.

Inspectors wroteBased on interview and record review the facility failed to document accurately the consent for Pneumococcal (bacterial infection) immunizations for one resident (Resident 40) and provide a Pneumococcal immunization for one resident (Resident 12). This facility failure had the potential to result in residents acquiring complications from Pneumococcal disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when: 1. Expired food items were found in the dry food storage room. 2. Dented can stored in dry food storage room. 3. Food items were stored on the floor in the emergency supply room. 4. Expired food items were found in the emergency supply room. 5. A dietary staff employee was not wearing protective hair covering while in kitchen. These facility failures had the potential for to spread food borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. The appropriate personal protective equipment (PPE) was worn by staff when sorting soiled laundry 2. Hand hygiene was performed in-between patients when passing medications These facility failures had the potential to result in cross contamination of micro-organisms and spread of infectious disease to residents and staff

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility's policy and procedure on medication administration was implemented by one licensed nurse (LN2) during a medication pass observation. The facility failure had the potential to cause medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure results of the most recent survey was posted in a location readily accessible to residents/or responsible parties and the public. This failure had the potential to infringe on the residents right to know the facility's overall rating on resident care issues and the corrected actions being implemented.

Inspectors wroteBased on record review and interview, the facility failed to ensure the presence or non presence of an advance directive (legal statement of the residents life sustaining measures choices ) was determined upon admission in one sampled resident (Resident 41). This failure had the potential to not validate the legal life sustaining choices to be implemented on the resident during a life emergency situation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a tab alarm (alarming device) was in place on the wheelchair for one of two sampled residents (Resident 49) as careplanned as one of the intervention for falls. This failure had the potential for staff to be not alerted when the resident gets up and out of the wheelchair with no assistance which can result to a fall and injury.

Inspectors wroteBased on observation and interview the facility failed ensure a cautionary sign for oxygen usage was posted outside a resident room while oxygen was in use for one of three sampled residents (Resident 5). This failure placed residents and visitors at risk for non knowledge of the cautionary measures to be implemented (like no smoking) when in an environment with oxygen on. The failure can result to fire, explosion, or burns

Inspectors wroteBased on record review and interview, the facility failed to ensure facility staff received the required 5 hours training on dementia care (memory loss) to enable and equipped staff on caring for the needs of residents with mental and or psychosocial disorders. This failure has the potential for residents not to received the needed care to attain or maintain their highest practicable mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the use of the medication Seroquel (antipsychotic medication used to treat certain mental/mood conditions) in one of four sampled residents (Resident 38) with the condition of dementia (memory loss) was evaluated for necessity and effectiveness. This failure had the potential for the unnecessary use of antipsychotic medication with the risks for complications on the resident.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure: 1. A resting hand splint (support device) was in place and worned by Resident 6 as ordered by the physician. This failure had the potential for the resident to developed increased contractures (tightening of bones and muscles). 2. Resident 6 received Range of Motion (ROM) exercises as ordered by the physician. This failure has the potential for the resident to developed muscle weakness which can result to decrease mobility (movement).

Inspectors wroteBased on observation interview and record review the facility failed to accurately document in the treatment record when: 1. Resident 18 refuses to wear arm brace/splint. 2. Resident 51's order for range of motion (ROM) exercises at five times per week (5x/wk) was only implemented at three times per week (3x/wk). These failures had potential for inaccurate documentation which can affect the implementation of the care the resident receives with the potential decline in the residents' medical condition.