Santa Paula Post Acute Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary cleaning of dishes and storage practices in the kitchen when:Clean plastic mugs were stored upside down on a tray, with the rims in contact with standing water. An expired bottle of Cayenne Pepper Hot spice was found on the shelf with an expiration date of 3/10/26. These failures had the potential to allow viruses and bacteria to grow and put the residents at risk of developing food borne illnesses (any illness resulting from eating contaminated/spoiled foods).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Advance Directive (a written document specifying an individual's medical care wishes) process was completed according to the facility's policies and procedures (P&P) when: 1. There was no documented evidence indicating that 11 of 20 sampled residents (Residents 2, 4, 6, 7, 10, 19, 26, 37, 47, 58, and 91) who had not executed an Advance Directive were offered assistance to formulate one and whether such assistance was accepted or declined. 2. There was no documented evidence indicating that two of 20 sampled residents (Residents 42 and 43) were provided with written information of their rights to formulate an Advance Directive upon admission. This deficient practice had the potential to result in residents not having their health care wishes known, honored, or available during emergent medical situations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and medical supplies were properly labeled and stored when:1. Expired medications and medical supplies remained in the active medication storage areas in one of one Medication Room; and2. A resident-owned (Resident 31) medication with an unreadable expiration date was stored in one of four medication carts without physician review and authorization, and an insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pen was stored beyond the manufacturer's recommended in-use (opened) period. These failures had the potential for residents to receive expired, ineffective, or unauthorized medications, which could compromise resident safety.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess one of nine sampled residents (Resident 19) when the Minimum Data Set (MDS - a standardized assessment tool) assessment indicated Resident 19 was using anticoagulants (medications that stop the blood from clotting too easily) but did not have any physician orders for anticoagulant medications. This had the potential for inappropriate plan of care for Resident 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide grooming services to one of nine sampled dependent residents (Resident 84), when Resident 84 was observed with untrimmed and dirty fingernails on both hands. This had the potential for skin problems and infection around the nail bed.

Inspectors wroteBased on interview and record review, the facility failed to provide nutritional care and services for one of two sampled residents (Resident 12) when Resident 12 had a significant weight loss of 10.31% within three months. This had the potential for Resident 12's nutritional needs and goals to be unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure continuous oxygen therapy was administered as ordered for one of one sampled resident (Resident 91). This failure had the potential to place Resident 91 at risk for hypoxemia (low levels of oxygen in the blood) and respiratory compromise (a dangerous state where breathing or gas exchange is impaired) which could lead to other serious health complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled substances (CS - medications with a high potential for abuse and dependence) for one of six randomly selected residents (Resident 23) reviewed for CS accountability. The facility's Controlled Drug Record (CDR - inventory records used to document receipt, use, and count of controlled substances) did not correspond with the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). This failure resulted in inaccurate accountability of a controlled substance and had the potential for diversion (controlled substances used by someone other than the resident for whom the medication was prescribed) or misuse of controlled substances and compromised residents' medication therapy and safety.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician regarding one of three sampled resident's (Resident 10) chest X-ray (a quick, painless imaging test that uses a small dose of radiation to photograph the heart, lungs, airways, blood vessels, and chest bones) result. This failure had the potential to delay other related physician services that may benefit Resident 10's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Infection Prevention and Control Practices when:1. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene after picking up trash from the floor and before assisting with resident care activities, including adjusting the resident's overbed table and obtaining a clean towel. This had the potential to spread microorganisms that can cause healthcare-associated infections.2. Licensed Vocational Nurse (LVN) 3 touched the blood collection tip of a glucose test strip (a disposable plastic or paper strip coated with chemicals that react with the sugar in blood) before obtaining Resident 39's blood specimen and discarded the used blood-contaminated test strip into a regular trash receptable. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a vending machine, located in the resident dining room, in good repair and free from hazard. This facility failure had the potential to place residents at risk of injury. During a concurrent observation, and interview, on 7/29/25, beginning at 12:47 p.m., with the Maintenance Director (MTD 1) and a kitchen staff member (KS 1), the facility's dining room vending machine was inspected. The vending machine had a broken plastic window screen and a note from KS 1 which indicated Please Please Please you have problem's with the machine call me please don't broken window thanks. The MTD 1 verbalized not being aware that the vending machine was broken and verbalized it posed a safety risk to residents, as they could attempt to reach through the broken plastic window and get hurt. [...]

Inspectors wroteBased on record review and interview, the facility failed to create a comprehensive dental care plan for one of two sampled Residents (Resident 1). During a concurrent record review and interview, on 7/16/25, at 11:40 a.m., with the Director of Nursing (DON 1), Resident 1's initial dental exam dated 11/6/24, was reviewed. The initial exam form indicated Resident 1 had five missing teeth, and four broken teeth. The DON 1 confirmed Resident 1's dental exam form indicated Resident 1 had five missing teeth and four broken teeth. When asked if the facility had created a care plan to address Resident 1's dental status and concerns, the DON 1 verbalzied no and acknowledged there should have been one. [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain physician orders in a timely manner to ensure proper indwelling catheter care was provided to one of two sampled Residents (Resident 1). This facility failure had the potential to place Resident 1 at a higher risk for infection, and lead to negative outcomes. During a review of Resident 1's admission Record undated, indicated in part, Resident 1 was admitted to the facility on [DATE], with diagnoses including a urinary tract infection (an infection in any part of the urinary system), obstructive and reflex uropathy (conditions in which the flow of urine is blocked), and chronic kidney disease (a condition where the kidneys are damaged and can't filter blood as well as they should, leading to a buildup of waste and fluid in the body). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen and food storage sanitation was maintained when: 1. The sanitizing solution used in the kitchen was not routinely tested for concentration when the solution gets replaced every two hours. 2. The ice machine cleaning and sanitization procedures were not done according to manufacturer guidelines. The facility's failure to implement proper sanitization practices placed vulnerable residents at increased risk of foodborne illnessFindings: 1. During a concurrent observation, interview, and record review on 4/14/25 at 9:50 a.m., inside the facility kitchen with the Interim Dietary Supervisor (IDS), IDS was observed performing a chemical concentration test of the kitchen sanitizing solution found in red containers. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure individual financial records were provided to residents on a quarterly basis. This failure had the potential to violate the residents' rights to be routinely informed of their personal funds account activity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the most current survey results and the plan of correction was posted in a place readily accessible to residents and the public. This failure had the potential for the residents, family and their legal representatives to not be fully informed of the facility's deficient practices and how they were corrected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy curtains were in good condition for one of four sampled residents (Resident 54). This facility failure had the potential for the patient's privacy to be compromised.

Inspectors wroteBased on interview and record review, the facility failed to follow up on positive Level I Preadmission Screening and Resident Reviews (PASRR-mental disability assessment) for two of eight sampled residents (Residents 34 and 43). This failure had the potential to result in the residents not followed up for mental health screening post admission and not being adequately assessed to receive recommended care and treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure turning and repositioning intervention on the care plan (a document that summarizes how a patient's needs will be met, and their care will be managed) was implemented for one of four sampled residents (Resident 56). This facility failure had the potential for Resident 56 to develop a pressure sore (damage to the skin caused by constant pressure.)

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for one of five sampled residents (Resident 13) when there was no justification from the physician for continued use beyond 14 days of the drug Ativan and/or Lorazepam (a medication used to help control anxiety). This failure had the potential for Resident 13 to receive an unnecessary medication and have adverse complications due to the medication.

Inspectors wroteBased on record review and interview the facility failed to ensure nursing staff implemented one of four sampled residents (Resident 1) gastrostomy/Jejunostomy feeding tube (G-tube-surgically placed tube that delivers nutrition, fluids, and medications directly into the stomach, bypassing the mouth and esophagus), care recommendations and Physician's orders regarding flushing of the tube. The facility's failure resulted in Resident's G-tube getting clogged frequently.

Inspectors wroteBased on record review and interview, the facility failed to: 1. Ensure one of four sampled residents (Resident 1) gastrostomy/Jejunostomy feeding tube (G-tube-surgically placed tube that delivers nutrition, fluids, and medications directly into the stomach, bypassing the mouth and esophagus), was managed properly. 2. Ensure licensed nursing staff was educated on the management of G-tube. The facility's failures resulted in Resident 1's G tube having problems for six (6) months without any resolution to the tube problem and staff education regarding G-tube management was not provided to licensed nursing staff.

Inspectors wroteBased on record review and interview, the facility failed to ensure an employee working as a certified nursing assistant (CNA- a healthcare professional who provides basic patient care and support)) at the facility held a valid and up-to-date license. This failure had the potential to result in an unlicensed CNA providing direct care to residents without proper certification and put residents' safety at risk.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident 1's assessments were performed by a registered nurse (RN) to meet professional scope of practice and standards of practice. This facility failure had the potential to place Resident 1 at risk of not being assessed appropriately and potentially resulting in harm to resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for one of three sampled residents (Resident 1), as evidenced by: 1. Oxygen set at a flow rate of 3 liters per minute instead of 2 liters per minute. 2. Missing entries for G-tube (flexible hollow tube that is inserted into the stomach through abdomen used for nutrition and medication administration) 3. Dispensed blood pressure medication outside of the health parameters specifications. This failure had the potential for Resident 1's physical state to decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders and a care planned intervention for supplemental oxygen, for one of two sampled residents (Resident 1). These failures had the potential for Resident 1 to experience resipiratory complications and lack of oxygen throughout the body.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two medication carts were locked, when left unattended. These failures had the potential for residents, staff, visitors, and vendors, to have unauthorized access to medications and the potential for drug diversion.

Inspectors wroteBased on record review and interview the facility failed to ensure nursing staff notified the physician and the responsible party (RP) of Resident 1's change of condition (COC) within 24 hours per their policy and procedure. The facility's failure resulted in the resident's RP and physician not being notified of resident's COC in a timely manner placing the resident at risk of deterioration and causing harm to resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident 1's assessments were performed by a registered nurse (RN) to meet professional scope of practice and standards of practice. The facility's failures place resident at risk of not being assessed appropriately and potentially resulting in harm to resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff monitor Resident 1's intake and output and evaluated resident's hydration status as ordered by the physician. The facility's failure places the resident at risk of dehydration without staff identifying it.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician order, and a care planned intervention, for ensuring a wheelchair tab alarm was in place, for one of two sampled residents (Resident 1). This failure had the potential to lead to negative outcomes for Resident 1.

Inspectors wroteBased on interviews, review of staffing data reports, and facility policy review, the facility failed to ensure staffing data based on payroll data was submitted to the Centers for Medicare and Medicaid Services (CMS) for 1 (fourth quarter) of 4 quarters reviewed for fiscal year (FY) 2023. Additionally, the facility failed to ensure accurate and valid staffing data was submitted to CMS for 1 (first quarter) of 1 quarter reviewed for FY 2024.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR) for 1 (Resident #73) of 2 sampled residents reviewed for PASRR requirements when the resident received new mental illness diagnoses.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1), when Resident 1 with a diagnosis of Dementia (a decline in cognitive ability, including memory loss and thinking difficulties) was asked to sign their own medical record accounting for the personal belongings brought into the facility upon admission. This failure had the potential for medical records being inaccurate as Resident 1 was deemed to not have the capacity to understand, further questioning the accuracy of the document and items brought to facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), documentation was accurate when Resident 1's, Fall Risk Assessments, did not reflect Resident 1's accurate status. This facility failure resulted in Resident 1's medical record not reflecting accurate fall assessments and had the potential for Resident 1 to not receive adequate care.