Villa Maria Post Acute
For profit - Limited Liability company
81 Beds
THE ENSIGN GROUP
Data: November 2025
Trust Grade
83/100
#262 of 1155 in CA
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Villa Maria Post Acute in Santa Maria, California, has a Trust Grade of B+, which indicates it is above average and recommended for families considering care options. It ranks #262 out of 1155 facilities in California, placing it in the top half, but #10 out of 14 in Santa Barbara County suggests there are a few better local options. The facility shows an improving trend, with the number of issues decreasing from 12 in 2024 to 4 in 2025. Staffing is relatively strong with a rating of 4 out of 5 stars and a turnover rate of 30%, which is better than the California average. One positive aspect is that the facility has not incurred any fines, indicating good compliance, and it generally provides more RN coverage than many others, which helps catch potential health issues. However, there are some concerns, including a failure to ensure proper food safety standards, as uncovered cheese was found in the refrigerator and pasteurized eggs were not cooked thoroughly. Additionally, there was a lack of documented activity participation for residents and issues with medication management that resulted in a 10% error rate, which could lead to complications for residents. Overall, while there are strengths in staffing and compliance, families should weigh these against the identified weaknesses in food safety and care practices.
- Trust Score
- B+
- In California
- #262/1155
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 30% annual turnover. Excellent stability, 18 points below California's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 25 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
83/100
Top 22%
No red flags
12 → 4 violations
★★★★★
5.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★★
5.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 4 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (30%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (30%)
18 points below California average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
Chain: THE ENSIGN GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 25 deficiencies on record
Jul 2025
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 83) had a qualified l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 83) had a qualified licensed nurse perform their initial comprehensive nursing assessment.This failure had the potential for Resident 83 to not have a complete initial comprehensive nursing assessment and not have all their needs met.During a review of Resident 83's admission Record (AR), dated 7/25/25, the AR indicated, Resident 83 was a [AGE] year old, admitted [DATE] with diagnoses including, heart failure (the heart not able to pump enough blood to meet the body's needs), atrial flutter (uncoordinated beating of the heart), diabetes (the body is not able to turn food into energy), and cognitive communication deficit (problems with communication).During a review of Resident 83's Initial admission Record ([IAR] a comprehensive assessment,) dated 4/25/25, the IAR indicated, Neuro/Mental [brain function assessment].EENT [eye, ear, nose, mouth assessment]. Oral Assessment. Cardiovascular System [heart assessment]. Pulmonary System [breathing assessment]. Bowel and Bladder. Gastrointestinal System [digestive system]. Musculoskeletal System [muscle and bone system]. Current Infections. Behavior, were all signed by a LPN [licensed vocational nurse (LVN)]. Review of the California Association of Long-Term Care Medicine (CALTCM) website indicated, The RN is to perform the nursing process, which includes a clinical assessment. Similarly, the LVN has the authority to conduct basic patient assessments. The limitation is that, in California, the LVN is not allowed to conduct comprehensive health assessments.During a review of the facility's policy and procedure (P&P) titled, Admission, dated 2/2023, the P&P indicated, Licensed Nurse Procedure. Do a complete assessment of body systems and complete admission assessment form and nursing notes.During an interview on 7/24/25 at 4:42 p.m. with the Assistant Director of Nursing (ADON), the ADON stated there wasn't any evidence of the RN oversight during the admission assessment and there should have been.During a review of Barclays Official California Code of Regulations website indicated, The licensed vocational nurse performs services requiring technical and manual skills which include. Uses and practices basic assessment (data collection) . Performs basic nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of one sample residents (Resident 83), had a nursing note recorded in their medical record following the completion of the compr...
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Based on interview and record review, the facility failed to ensure one of one sample residents (Resident 83), had a nursing note recorded in their medical record following the completion of the comprehensive assessment on admission to the facility.This failure resulted in an incomplete record of Resident 83's nursing home stay and had the potential to hinder communication among Resident 83's interdisciplinary team ([IDT], a group of healthcare professionals who work together to achieve resident comprehensive goals).During a review of the facility's policy and procedure (P&P) titled, Admission, dated 2/2023, the P&P indicated, Purpose. Obtain information about the resident to establish baseline data for the MDS and provide the basis for interdisciplinary assessment, care planning, and rehabilitation of each Resident. Licensed Nurses Procedure . Do a complete assessment of body systems and complete admission form and nursing notes.During a review of Resident 83's electronic medical record (eMR), no admission nursing note was found.During an on 7/24/25 at 4:42 p.m. with the Assistant Director of Nursing (ADON), the ADON stated he was aware there was no admission nursing note. ADON also stated there should have been one.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 6) had an appropriately sized waste bin for safely discarding used personal pr...
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Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 6) had an appropriately sized waste bin for safely discarding used personal protective equipment (PPE), a gown worn over clothing for protecting the wearer from infection.This failure had the potential to result in the increased risk of spreading infection to residents, staff, and visitors.During an observation on 7/23/25 at 2:28 p.m. in Resident 6's room, there was a small, beige, uncovered, waste bin overflowing onto the floor with a discarded yellow PPE gown. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 1/2025, the P&P indicated, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals. The facility will use effective methods for the safe storage, transport and disposal of garbage, refuse and infectious waste.During a concurrent observation and interview on 7/23/25 at 2:30 p.m. with a certified nursing assistant (CNA 1) in Resident 6's room, the waste bin with the discarded yellow PPE gown hanging out it and onto the floor was observed. CNA 1 stated Resident 6 was on enhanced transmission precautions (ETP) wearing of PPE gown and gloves to reduce the spread of multi-drug-resistant germs) and the gown should have been discarded into a larger trash can with a lid. During an interview on 7/23/25 at 2:35 p.m. with the Administrator (ADM), the ADM stated he was aware of the PPE gown hanging out of the waste bin because CNA 1 had informed him. ADM further stated the waste bin should have a lid on it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure two of two sampled residents (Residents 72 and 49) had a comfortable environment when foul smelling dirty linen was left in the linen ...
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Based on observation and interview, the facility failed to ensure two of two sampled residents (Residents 72 and 49) had a comfortable environment when foul smelling dirty linen was left in the linen cart in the hallway. This failure resulted in an uncomfortable living environment. During a review of the facility's policy and procedure (P&P) titled, Environmental Conditions / Environmental Rounds, dated 1/2025, the P&P indicated, It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.During an interview on 7/23/25 at 10:15 a.m. with Resident 72, Resident 72 stated the smell out in the hallway gets really bad when staff put dirtied linen in the hamper and leave it there. Resident 72 further stated the staff should at least take it down to the end of the hallway.During a concurrent observation and interview on 7/23/25 at 10:56 a.m. with a licensed nurse (LN 1), LN 1 stated there was a bad smell in the hallway. LN 1 pointed towards the blue linen collection bins, waved her hand and stated, It's probably coming from this area. LN1 confirmed the bad smell was coming from the dirty linen cart. During an interview on 7/23/25 at 11:10 a.m. with the Assistant Administrator (AADM), the AADM stated one of the residents had a bad stomach and the smell was probably from cleaning up the resident. AADM stated the dirty linen cart should have been removed from the resident area. During an interview on 7/24/25 at 9:04 a.m. with Resident 49, Resident 49 stated, The smell in the hallway gets to be too much at times. During a review of the facility's P&P titled, Laundry Services, dated 1/2025, the P&P indicated, Soiled linen should be removed from resident-care areas at least daily and may need to be removed more frequently.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sam...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1), when documentation of interventions for a change in condition were not accounted for.
This failure had the potential to result in Resident 1 not receiving proper treatment during a change of condition.
Findings:
During a review of Resident 1's Medical Records (MR), MR indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses: palliative care (medical care to improve the quality of life for people with a serious illness), amyotrophic lateral sclerosis (progressive, fatal disease that affects nerve cells in the brain and spinal cord), dysphagia (difficulty swallowing), dysarthria (speech disorder that makes it hard to form and pronounce words due to muscle problems) and anarthria (complete loss of speech), cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs), gastrostomy tube ([g-tube] a tube used to provide an alternative route for delivering nutrition, fluids, and medications directly to the stomach), muscle weakness, and need for assistance with personal care. Review of Resident 1's Minimum Data Set (MDS) (a standardized assessment tool to evaluate the health and functional abilities of residents in nursing homes), dated 10/4/2024, indicated, short term and long term memory problem, and cognitive skills for daily decision making severely impaired. Review of Resident 1's History and Physical (H&P), dated 3/1/2024, indicated, Resident 1 is able to make own decisions.
During a concurrent interview and record review on 10/22/2024 at 1 p.m. with the Director of Nursing (DON), Resident 1's medical chart was reviewed. Nursing progress notes (NPN), dated 8/11/24, indicated Sent to ED for further evaluation due to g-tube (gastrostomy tube) being clogged since yesterday. The DON verbalized received a phone call from Licensed Nurse (LN 2) regarding Resident 1's g-tube being clogged and stated, We tried ourselves with milking it, warm water, soda as an acid to try to break it down and were unsuccessful and sent (Resident 1) out the next morning. Further review of the NPN indicated, no documentation of interventions to unclog Resident 1's g-tube. The DON stated, There is no documentation prior to 8/11/24 . I don't know why.
During an interview on 10/22/2024 at 2:53 p.m. with the Administrator (ADMIN) and the DON, ADMIN stated, We received a phone call that night and steps were taken to unclog it, and after many attempts we proceeded to send (resdient) out. The ADMIN was unable to recall the time of the phone call. The DON verbalized there is no documentation of Resident 1's g-tube being clogged and there is no documentation of the phone call. The DON verbalized was not sure of the cause of Resident 1's g-tube becoming clogged.
During a concurrent interview and record review on 10/22/2024 at 2:53 p.m. with the DON and the ADMIN, the facility's policy and procedures (P&P) titled, Care and treatment quality of care, change of condition reporting, revised 11/2023 and P&P titled, Charting and Documentation, revised 11/2023 were reviewed. P&P titled, Care and treatment quality of care, change of condition reporting indicated, 4. All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met. P&P titled, Charting and documentation indicated, Rules for charting: 2. Daily notes are required as the necessary arises . 5. Continuous nurse's notes are required on all residents as the necessary arises. The DON stated, I can ' t say, if the P&Ps were followed. The ADMIN stated, The documentation wasn't as robusk as it should have been.
During a concurrent phone interview and record review on 11/4/2024 at 3:53 p.m. with the DON, Resident 1's Medication Administration Record (MAR), dated August 2024, was reviewed. The MAR indicated, an X on 8/10/2024 on the noc shift (nocturnal night shift between evening and early morning) and an X on 8/11/2024 on the day shift. The DON verbalized the X means they weren ' t able to give Resident 1 the enteral (nutrition) feeding via g-tube, and the noc shift starts at 7 p.m.
Jun 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an informed consent for the use of psychotropic medications ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an informed consent for the use of psychotropic medications (medications which affects mood or behavior) for one of 20 sampled residents (Resident 37).
This failure violated Resident 37's right to make an informed decision regarding the use of psychotropic medications and had the potential to result in resident misinformation regarding its benefits and side effects.
Findings:
During a review of Residen 37's, admission Records, dated 02/28/24, the records indicated Resident 37 was admitted to the facility on [DATE], with admission diagnoses including but not limited to: Other psychotic disorder not due to a substance or known physiological condition, Vascular Dementia (problems with thought processes caused by brain damage from impaired blood flow to your brain), Unspecified severity with agitation, Other specified depressive episodes, and Chronic Post-traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety).
During a review of Resident 37's, Order Summary Report (OSR), dated 02/28/24 the OSR indicated the physician orders, Seroquel (antipsychotic - a medication used to treat certain mental and/or mood disorders) 25 mg (milligram - unit of measure), give 1/2 tablet every 8 hours as needed for agitation/anxiety and Olanzapine (antipsychotic) 5 mg tablet, give 1 tablet at bedtime for PTSD.
During a concurrent interview and record review on 06/05/24 at 11:09 a.m. with the Assistant Director of Nursing (ADON), Resident 37's form, Facility Verification of Resident Informed Consent for Psychotherapeutic Medications, was reviewed and indicated, the informed consents for Seroquel and Olanzapine were not signed by Resident 37 (or the resident's representative) prior to the resident initially receiving the medications. ADON confirmed the informed consents for the medications were not signed and verbalized they should have been signed by the resident (or the resident's representative) prior to initiating the medications.
During a review of the facility's policy and procedures (P&P) titled, Psychotropic Drug Use, dated 11/2023, the P&P indicated in part, Upon initial comprehensive assessment, the Social Services designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physician's orders for psychotropic medications . to ensure: . Informed consent was obtained prior to medication use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and accurately document a Physician Order for Life Sustain...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and accurately document a Physician Order for Life Sustaining Treatment (POLST - care directives during life threatening situations) and Advance Directive (legal documentation consistent with the known requests or desires of the patient's medical preference) for two of 20 sampled residents (Residents 5 and 37).
These failures had the potential to result in the delay of necessary treatment compatible with the legally recognized decision maker wishes during an emergency situation.
Findings:
During a review of Resident 5's, admission Record, dated 04/20/24, the Record indicated in part, Resident 5 was admitted to the facility on [DATE] with admission diagnoses including but not limited to, Urinary Tract Infection (UTI - an infection in the urinary system of the body), generalized muscle weakness, Type 2 Diabetes Mellitus with other skin complication, and Congestive Heart Failure.
During a concurrent interview and record review on 06/04/24 at 12:11 p.m. with licensed nurse (LN 3), Resident 5's Clinical Record was reviewed. Resident 5's record did not include the resident's POLST. LN 3 verbalized the POLST and consent forms were signed today. LN 3 produced the signed POLST form, dated 06/04/24, confirming it was only signed by the resident today.
During an interview on 06/04/24 at 12:45 p.m. with Resident 5, Resident 5 verbalized just signed a bunch of papers that were not previously signed on admission to the facility on [DATE].
During a concurrent interview and record review on 06/05/24 at 3:15 p.m., with with the Assistant Director of Nursing (ADON), Resident 37's clinical record was reviewed. ADON acknowledged Resident 37's POLST form was not signed and noted the resident as having the capacity to make healthcare decisions.
During a concurrent interview and record review on 06/05/24 at 3:15 p.m. with ADON, Resident 37's Physician Orders were reviewed. A Physician Order dated 02/28/24 at 11:20 a.m. indicated, DNR (Do Not Resuscitate - restrictions to perform life-saving treatment if a patients stops breathing or heart stops beating). An order dated 02/28/24 at 2:41 p.m. indicated, Full Code (perform all life saving measures if a patient stops breathing or heart stops beating). Review of Resident 37's Advanced Directive dated 03/27/24 indicated, Patient 37 wished to have restrictions on end-of-life treatment (DNR). ADON acknowledged the change in physician orders from DNR to Full Code and the POLST form should have been updated to reflect the wishes of the resident.
During a review of the facility's policies and procedures (P&P) titled, Advanced Directives, POLST, dated 11/2023, the P&P indicated, Prior to, upon, or immediately after admission, Social Services or Licensed Nursing Staff will ask residents, and/or their family members, about the existence of any advance directive . resident or surrogate decision maker will be offered and assisted by facility staff (usually SSD [Social Services Department] or Licensed Nursing Staff) to complete a POLST (Physician's Orders for Life Sustaining Treatment) document to formulate decisions regarding Life Sustaining Treatment. A copy of this document will be in the Medical Record of resident . The facility will also notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented in the resident's medical record and plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
This is the incorrect tag
Based on observation, interview, and record review, the facility failed to follow their policy and procedure regarding loss or theft of resident property.
Findings:
During an...
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This is the incorrect tag
Based on observation, interview, and record review, the facility failed to follow their policy and procedure regarding loss or theft of resident property.
Findings:
During an observation on 6/3/24 at 2:10 p.m., a brown wallet containing a driver's license, social security card and military identification was observed in medication cart number one, located in a locked medication drawer.
During a concurrent interview and record review on 6/3/24 at 2:15 p.m. with licensed nurse (LN 2), discharged residents in Point Click Care (PCC) (point click care is a cloud-based software platform used by some health care providers to monitor and track patient care) were reviewed. PCC indicated, Resident was discharged AMA (against medical advice) on 9/8/23. LN 2 verbalized, they did not know if the former resident has been contacted, the wallet should not have been kept in the medication cart. LN 2 further verbalized, the wallet should have been taken to social services.
During a review of the facility's policy and procedure (P&P) titled, Theft and Loss Policy, dated 10/22, The P&P indicated, Loss or theft of resident property worth $25 or more will be documented and reported to the administrator (or designee) for investigation, police reporting or other appropriate action. Documentation of the lost or stolen residence property with a value of $25 or more shall include:
A. Description of the lost or stolen article.
B. Estimated value.
C. Date and time the loss or theft was discovered.
D. If determinable, the date and time the lost or theft occurred.
E. Action taken.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a significant change in status was comprehensively assessed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a significant change in status was comprehensively assessed for one of four sampled residents (Resident 15) using the CMS (Centers for Medicare and Medicaid Services) specified Resident Assessment Instrument (RAI - Resident Assessment Instrument [a standardized tool used to evaluate and document clients in long term care {LTC} settings] process).
This failure had the potential to result in compromised quality of care for Resident 15.
Findings:
During a review of Resident 15's Medical Record, the Medical Record indicated, Resident 15 was re-admitted to the facility on [DATE] from the hospital. The psychologist's progress note dated 4/16/24, indicated, Pt. (patient) was taken off his anti-psych medications recently (when d/c'd [discharged ] from hospital) & he's become increasingly disorganized since then. Physician: please re-start Pt. on his previous level of Seroquel [an antipsychotic medication] that had been working very well. Further record review revealed the facility failed to initiate a comprehensive assessment after a significant change of condition.
During an interview on 6/6/24 at 11 a.m. in the DON's (Director of Nursing) office, with the DON, MDS1 (Minimum Data Set - nurses responsible for collecting and submitting assessment data for nursing home patients) and MDS2 nurses. The DON and MDS's 1 and 2 concurred the significant change in status assessment was not done for Resident 15 following a significant change of condition.
During a review of the facility's policy and procedure (P&P) titled, Change of Condition - Assessment and Reporting, dated 11/2021, the P&P indicated, PURPOSE: To clearly define guidelines for a timely notification of a change in resident condition, and, Follow-up #3. Resident Assessment Instrument/Comprehensive Care Plan completed/modified as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.a. During a review of Resident 37's form titled, Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 0...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.a. During a review of Resident 37's form titled, Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 02/26/24, the PASRR indicated, a Positive (resident with a mental disorder condition) result.
During a concurrent interview and record review on 06/05/24 at 11:26 a.m. with Assistant Director of Nursing (ADON), Resident 37's Clinical Documents, was reviewed. The Documents indicated, a letter from the Department of Health Care Services, dated 02/26/24, Re: Positive Level I Screening Indicates a Level II Mental Health Evaluation is Required. ADON acknowledged that a PASRR II evaluation was overlooked and should have been completed and not done.
2.b. During a review of Resident 66's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 4/01/2024, the PASRR indicated, Resident 66 had a positive Level I screening, due to suspected mental illness (MI).
During a review of Resident 66's Positive Level I Screening Indicates a Level II Mental Health Evaluation is Required, dated 04/01/2024, and addressed to Resident 66 the Level I Screening indicated, Resident 66 was positive for suspected mental Illness (MI).
During a review of Resident 66's, letter of correspondence from the PASSR Section of the Department of Health Care Services (DCHS), dated 4/2/24, the letter indicated in part, Unable to Complete Level II Evaluation . the individual currently has a duplicate PASRR on file . The case is now closed. To reopen, please submit a new Level I Screening.
During an Interview on 06/06/2024 at 9 a.m. with ADON, ADON stated, The PASRR Level I is the only one the facility has on file, and there is no other PASRR II or duplicate available.
During an Interview on 06/06/2024 at 9:25 a.m. with DON, Nursing Consultant (NC), and Executive Director (ED), ED and DON stated the facility does not currently have a copy of the duplicate PASRR, and have had this issue in the past with other residents PASRR.
During an interview on 06/06/2024 at 11:04 a.m. with the facility's PASSR Consultant (PC), PC verbalized that ([NAME] Medical Center) conducted the PASSR Level I and II evaluations for Resident 66 and was told that the resident's expected hospital stay would be less than 15 days. PC explained that if the resident's hospital stay was less than 15 days, the facility would have no obligation to resubmit a new Level I screening. PC further verbalized that since the resident stayed in the hospital more than 15 days, the facility did in fact have an obligation to resubmit a new Level I PASRR screening.
Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - a federally mandated process to help ensure that individuals are evaluated for a mental illness and/or intellectual disability and are not inappropriately placed in nursing homes for long term care) Level II evaluations (a person-centered evaluation that is completed for anyone identified by the Level I screening as having, or suspected of having serious mental illness, intellectual disability, developmental disability, or related condition) were completed for three of 20 sampled residents (Residents 15, 37 and 66) when:
1. A significant decline in Resident 15's mental health condition was assessed.
2. A positive PASRR Level I (a preliminary assessment for individuals to identify serious mental illness, intellectual disability, developmental disability, or related condition prior to admission to a nursing facility) evaluation was indicated for Residents 37 and 66.
These failures in screening for mental health illesses and/or disabilities had the potential to result in these residents not receiving appropriate care and treatment.
Findings:
1. During a review of Resident 15's medical record, the medical record indicated Resident 15 was re-admitted to the facility, on 4/4/24 from the hospital. The psychologist's progress note dated 4/16/24, indicated, Pt. (patient) was taken off his anti-psych medications recently (when d/c'd from hospital) & he's become increasingly disorganized since then. Physician: please re-start Pt. on his previous level of Seroquel [an antipsychotic medication] that had been working very well. Further record review revealed, the facility failed to initiate a PASRR screening and comprehensive assessment after the significant mental change/change of condition was noted by the psychologist. Admitting diagnoses included in part, Psychosis (mental disorder characterized by a disconnection from reality) and Depression (mental state of low mood and aversion to activity).
During an interview on 6/6/24 at 11 a.m. in the DON's (Director of Nursing) office, with the DON, MDS1 (Minimum Data Set - nurses responsible for collecting and submitting assessment data for nursing home patients) and MDS2 nurses. The DON and MDS's 1 and 2 concurred the PASRR screening of Resident 15 for the significant mental change of condition on 4/16/24, as noted by the psychologist, was not done by the facility.
During a review of the facility's policies and procedures (P&P) titled, PASRR, dated 11/2023,the P&P indicated, POLICY: It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State, and, PROCEDURES: #3. a. If a resident temporarily went somewhere outside the NF, a new PASRR would not be required unless upon return, there was a significant change in the resident's physical or mental condition. If this happens, then the NF initiates the RR process by submitting a Level 1 Screening, and if needed, arrange for a Level 2 Evaluation to be performed by the state approved contractor to help ensure the individual receives services in the most integrated setting.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0646
(Tag F0646)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the State mental health authority was notified after a significant decline in the mental health condition of one of four sampled res...
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Based on record review and interview, the facility failed to ensure the State mental health authority was notified after a significant decline in the mental health condition of one of four sampled residents (Resident 15) was assessed.
This failure had the potential to result in Resident 15 not receiving the necessary mental health care and services which had the potential to affect Resident 15's quality of life and resulted in the mental significant change of condition not having been properly screened/evaluated and reported to the state mental authority.
Findings:
During record review of Resident 15's Psychologist Progress Notes, dated 4/16/24, the Progress Note indicated, Pt. was taken off his anti-psych medication (when d/c'd from hospital) & he's become increasingly disorganized since then. Physician: please re-start Pt. on his previous level of Seroquel that had been working very well. Admitting diagnoses included in part, Psychoses (mental disorder characterized by a disconnection from reality) and Depression (mental state of low mood and aversion to activity).
The facility documented the change of condition for 72 hours, as reflected in the reviewed nursing documentation. However, the facility failed to initiate a PASSAR screening, to accurately screen/evaluate Resident 15's mental health status.
During an interview on 6/5/24, at 11 a.m., in the DON's office, with the DON, MDS1 nurse, and MDS2 nurse (Minimum Data Set [nurses assigned to collect and assess information for the health and well-being of residents in Medicare and Medicaid certified nursing homes]). The DON and both MDS nurses concurred the PASSAR screening of Resident 15 for the significant mental change of condition on 4/16/24, as noted by the psychologist, was not done by the facility.
During a review of the facility's policy and procedure titled, Change of Condition - Assessment and Reporting, dated 11/2021, the facility's policy and procedure indicated, PROCEDURES: Follow-up #3. Resident Assessment Instrument/Comprehensive Care Plan completed/modified as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure:
1. A box of expired Povidone-Iodine prep pads...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure:
1. A box of expired Povidone-Iodine prep pads. (antiseptic pads saturated with povidone iodine solution to help control bacteria and minimize infection) was discarded.
2. An opened vial of purified protein derivative (PPD - solution used in a skin test to help diagnose tuberculosis [a serious lung infection caused by bacteria]) solution was dated.
3. An open container of glucose test strips (used in a device to measure the amount of sugar in the blood) was dated.
4. Barium Sulfate (a contrast agent used to diagnose disorders of the esophagus, stomach and intestines) stored in the medication refrigerator had a documented physician order for specific resident use.
These failures had the potential for the residents to receive expired, ineffective and unprescribed medications and treatments.
Findings:
During an inspection on [DATE] at 9:30 a.m. of the medication storage area, the following were observed:
1. One box of expired Povidone-Iodine prep pads with an expiration date 4/24.
2. One vial of PPD was opened and not dated.
During a review of the facility's policy and procedures (P&P) titled, Storage of Medications, dated 2023, The P&P indicated in part, Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock disposed of according to procedures for medication disposal. The P&P further indicated, All PPD bottles are to be dated when opened and discarded after 30 days of opening.
3. One container of diabetic glucose test strips that was opened and undated.
During a review of the facility's P&P titled, Infection Control, Glucometer Cleaning and Decontamination, dated 12/23, the P&P indicated in part, Test strips will be used according to manufacturer's guidelines.
During a review of manufacturer's guidelines for diabetic glucose test strips, the guidelines indicated, Use within three months of opening the vial.
4. Barium Sulfate, stored in the facility's medication refrigerator had no physician order for specific resident use.
During a review of the facility's P&P titled, Resident Assessment, Physician Orders, dated 11/2023, the P&P indicated in part, It is the policy of this facility that drugs or biologicals shall be administered only upon written order of a person duly licensed and authorized to prescribe such drugs . Drugs and biologicals orders must be recorded on the physicians order sheet in the resident chart.
During a concurrent interview and record review on [DATE] at 1:05 p.m. with the Director of Nursing (DON), physician orders for all residents were reviewed. After a thorough review of all resident physician orders, DON verbalized that no orders were found in the facility's electronic or paper charting system for Barium Sulfate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and record review, the facility failed to:
1.Store Schedule II Drugs (schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use p...
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Based on observation and record review, the facility failed to:
1.Store Schedule II Drugs (schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) under double lock per facility's policy and procedure (P&P).
2.Sign the drug count sheet after administering medication per facility P&P.
3.Maintain refrigerator temperatures.
These failures had the potential to result in (1) schedule II drugs being available to residents and visitors; (2) for drug diversion; and (3) medications to not be effective.
Findings:
During an inspection on 6/3/24 at 9:30 a.m. of the medication storage area, the following were observed:
1.Schedule II Drugs were not stored under double lock.
During a review of the facility's P&P titled, Medication Administration, dated 11/2023, the P&P indicated, Medications listed in schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications.
2.One controlled drug count sheet had not been signed after medication was administered as directed by the facility's P&P.
Further review of the facility's P&P titled, Medication Administration, dated 11/2023, the P&P indicated, When a controlled medication (a controlled medication is a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) is administered the licensed nurse administering the medication immediately enters all of the following information on the accountability record:
*Date and time of administration
*Amount administered.
*Signature of the nurse administering the dose, completed after the medication is administered.
3. The facility refrigerator log listed out of range temperatures, for April, May and June of 2024 resulting in multiple episodes of the refrigerator being out of range for optimal medication storage.
During a review of the facility's P&P titled, Storage of Medications, dated 2023, the P&P indicated, Medications requiring refrigeration or temperatures between 2°C (36°F) and 8°C (46°F) are kept in a refrigerator with a thermometer to allow temperature monitoring.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to implement transmission-based precautions (infection control measures specific to how an infection is spread) for one of 20 sa...
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Based on observation, interview, and record review, the facility failed to implement transmission-based precautions (infection control measures specific to how an infection is spread) for one of 20 sampled residents (Resident 5) when the resident was diagnosed with a known Multidrug Resistant Organism (MDRO - a germ that is resistant to many antibiotics).
These failures had the potential to result in the spread of harmful microorganisms to staff, residents and visitors.
Findings:
During a concurrent interview and record review on 06/05/24 at 10:00 a.m. clinical record with Assistant Director of Nursing (ADON), Resident 5's History and Physical (H&P), dated 04/20/24, was reviewed. Resident 5's H&P indicated, . Patient was found to have UTI [urinary tract infection] with history of ESBL ., .continue with contact isolation . ADON acknowledged Resident 5 was colonized (presence of bacteria without causing an active infection but can be spread to others) with Extended-spectrum beta-lactamases (ESBL - enzymes (special proteins) that are made from bacteria that are resistant to antibiotics) on admission and should have been placed on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of MDROs in nursing homes, https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html).
During an interview on 06/05/24 at 10:09 a.m. with Licensed Nurse (LN 2), LN 2 verbalized Resident 5 is not on any isolation including, EBP. LN 2 verbalized Resident 5 had completed treatment for an ESBL infection.
During an interview with Infection Preventionist (IP) on 06/05/24 at 10:35 a.m. IP acknowledged that Resident 5 is not on contact isolation and not on EBP. IP acknowledged that ESBL is a condition that is considered colonized (germs on or in the body but do not have symptoms of infection) and resident should have been placed on EBP on admission.
During a review of facilities policy and procedure titled, IPCP Standard and Transmission-Based Precautions, dated 04/2024 indicates, . 3. Enhanced Barrier Protection (EPB): used in conjunction with standard precautions [precautions required to achieve a basic level of infection control used for all residents] and expand the use of PPE [personal protective equipment] through the use of gown, and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff ., a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply . ii. MDRO infection or colonization. The policy states, b. Multi-drug Resistant Organisms (MDRO) - the MDROs for which the use of EBP applies are based on local epidemiology. At a minimum, they should include resistant organisms targeted by CDC . ESBL - producing Enterbacterales .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure:
1. Pasteurized eggs were used for egg prepera...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure:
1. Pasteurized eggs were used for egg preperations not cooked through completely according to the facility's policy and procedures (P&P).
2. Food was stored properly in accordance with professional standards of food service safety when an uncovered and undated bag of shredded mozzarella cheese was found in the refrigerator and an opened staff personal water bottle was stored in the freezer.
3. Resident food refrigerator temperatures located in the nursing station were monitored daily and corrective actions implemented for out-of-range temperature readings by the food and nutrition representative according to the facility's P&P on foods brought by family or visitor.
4. An appropriate drainage piping material was used to drain the ice machine and an appropriate air gap was maintained between the ice machine and floor drains to prevent contaminated water from backing up into the ice machine should drainage problems arise.
These failures had the potential to place the residents at an increased risk for contracting foodborne illness (any illness caused by consuming food or beverages contaminated with harmful pathogens - such as bacteria, viruses and fungi - or their toxins).
Findings:
1. During a concurrent observation and interview on 06/04/24 at 09:05 a.m. with the Dietary Supervisor (DS) and Registered Dietician (RD), the inside of refrigerator #2 was observed. There was an open box of unpasteurized eggs. RD acknowledged the eggs were not pasteurized and there were no fresh pasteurized eggs in the facility.
During an interview on 06/04/24 at 10 a.m. with RD and Morning [NAME] (AMC), RD verbalized the facility only cooks fried eggs cooked through. AMC verbalized if a resident requests an over easy (fried egg with under cooked yolk) egg or other egg not fully cooked he will cook it on their request. RD acknowledge that they stopped buying pasteurized eggs because of expense.
During a concurrent interview and record review on 06/04/24 at 5:15 p.m. with RD, the P&P titled, Procedure For Refrigerated Storage was reviewed. The P&P indicated, 11. Raw eggs shall be obtained pasteurized . RD verbalized and acknowledged the facility P&P was not followed.
2. During a concurrent observation and interview on 06/03/24 at 09:57 a.m. with the RD in the kitchen, inside the kitchen refrigerator #5 was an open bag of mozzarella cheese stored uncovered and in Freezer #8 an opened bottle of water was found on the floor of the freezer. RD acknowledged that the cheese found in refrigerator #5 should not be opened stating, should be rolled with a clasp and labeled. RD acknowledged that the open bottle of water found in freezer was half full and was a staff members personal water and should not be in the freezer.
During a review of the facility's P&P titled, Procedure for Refrigerated Storage, dated 2023, the P&P indicated, . Food should be covered and stored loosely .
3. During a concurrent interview and record review on 06/04/24 at 4:00 p.m. with Assistant Director of Nursing (ADON), resident refrigerator temperature logs were reviewed. ADON verbalized the resident refrigerator is kept on Nurses Station 1 and it is the responsibility of the nurses every a.m. and p.m. shifts to check temperatures in both refrigerators and the freezer. The ADON acknowledged the refrigerator logs have been checked but only on PM shift from January 2024 through June 2024.
During a concurrent interview and record review on 06/06/24 at 11:55 a.m. with the Assistant Administrator (AADM) AADM, resident refrigerator temperature logs and facility P&P titled, Foods [NAME] by Family or Visitor, were reviewed. AADM acknowledged that according to this policy, the temperature logs for the resident refrigerator should be checked daily by nursing staff and verified by a dietary representative. AADM acknowledged that any out of range temperatures should be reported to maintenance for corrective action and documented on the log. AADM acknowledged that the refrigerator temperature on 1/24/24 was 46 degrees Farenheit (F) and on 1/25/24 the temperature was 44 degrees F and no documentation of correction actions were noted on log. AADM acknowledged there was no documentation of corrective action for out of range temperatures on these dates.
A review of the facility's P&P titled, Food Brought by Family or Visitor, dated 05/09/2018, the P&P indicated, 9. The temperature of the refrigerator and freezer will be monitored and logged by Station 3 Nursing staff no less than once a day and verified by a food and nutrition representative once daily in accordance with the facility professional food safety standards. Any deviations from the correct temperature's standards will be reported to the Maintenance Department and / or the DSS (Department Staff Services) for guidance and correction.
4. During an observation on 06/03/24 at 10:45 a.m., in a separate locked closet outside of the kitchen. [NAME] plastic pipe [PVC - Polyvinyl chloride] drain from ice machine draining into floor drain black plastic pipe with black funnel attached to the black pipe in floor drain was observed. The white drainage pipe appeared to be approximately 1 inch below the flood level rim of floor drain.
During a review of an email communication on 06/04/24 at 11:33 a.m. with the Department of Health Care Access and Information (HCAI), the e-mail indicated, PVC and ABS [Acrylonitrile Butadiene Styrene - type of drainage pipe] are both prohibited.
During a concurrent observation and interview on 06/05/24 at 10:01 a.m. with the Director of Maintenance (DM),the ice machine was observed. DM acknowledged the air gap from the ice machine should be one inch above the top of the floor drain. DM also acknowledged the drainage pipe is below the top of the floor drain and there is not an appropriate air gap. DM verbalized the plastic PVC pipe to drain the ice machine was appropriate material to drain the ice machine.
During a review of an email communication on 06/06/24 at 08:20 a.m. from HCAI to surveyor, the email indicated, ABS and PVC drainage fittings which is a code violation per CPC 701.2(2)(b) [California Plumbing Code].
During a concurrent interview and record review on 06/06/24 at 09:45 a.m. with DM, the CPC 701.2(2)(b) code was reviewed. DM acknowledged the CPC code 701.2(2)(b) is the plumbing regulation to be followed and that per PCP 701.2(2)(b) PVC pipe should not be used to drain ice machine.
During a review of the Food and Drug Administration Food Code (FDAFC), dated 2022, the FDAFC indicated, 5202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUEPMENT, or non FOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25mm (1 inch).
During a review of the Food and Drug Administration Food Code Annex (FDAFCA), dated 2022, the FDAFCA indicated, Backflow Prevention, Air Gap . Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow.
During a review of CPC 2022, Chapter 7, 701.2 Drainage Piping, the CPC indicated, Materials for drainage piping shall be in accordance with one of the referenced standards in Table 701.2 except that: . (2) ABS and PVC DWV piping installations shall be installed in accordance with applicable standards referenced in Table 701.2 and the firestop protection requirements in the California Building Code. (b) [OSHPD 1,2,3,4 & 5] ABS and PVC installations are not allowed.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to notify the resident representative (RR - person designated as being responsible for another person's medical and/or financial decisions) o...
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Based on interviews and record review, the facility failed to notify the resident representative (RR - person designated as being responsible for another person's medical and/or financial decisions) of one of two sampled resident (Resident 1) after a change of condition (CoC) when Resident 1 underwent debridement (removal of damaged tissue) on the sacrum (buttocks).
This facility failure resulted in Resident 1's resident representative not being informed of their CoC or of the risks and benefits of the treatment options available to them.
Findings:
During a review of the facility's policy and procedure (P&P) titled, Change of Condition Reporting, dated 11/22, the P&P indicated, Purpose: To clearly define guidelines for timely notification of a change in resident condition . Licensed nurse will inform family of change of condition and document notification.
During a review of Resident 1's Minimum Data Set ((MDS) an assessment tool for a resident), dated 11/23, the MDS indicated, Resident 1 had a Brief Interview for Mental Status BIMS of 6 (a system that measures mental status in a nursing home, 0-7 suggests severe impairment, 8-12 suggests moderately impaired, and 13 -15 suggests cognitively intact).
During a review of Resident 1's Progress Note (PN), dated 10/28/23, the PN indicated, Deep tissue pressure injury (localized areas of tissue damage), debrided (removed damaged tissue) by (named doctor).
During an interview on 11/27/23 at 5:00 p.m. with Director of Nursing (DON), DON stated a CoC was not documented after the debridement. DON further stated there should have been documentation.
During an interview on 1/2/23 at 2:15 P.M. with treatment nurse (LN 1), LN 1 stated he did not notify the family after the DTI debridement.
During an interview on 1/2/23 at 2:30 PM. with Assistant Director of Nursing (ADON), ADON stated he did not notify because expected the treatment nurse to notify the family RR.
Jun 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to develop, and implement a person-centered activity care plan for one of 18 sampled residents (Resident 59).
This failure had ...
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Based on observation, interview, and record review, the facility failed to develop, and implement a person-centered activity care plan for one of 18 sampled residents (Resident 59).
This failure had the potential for isolation, psychosocial and physical decline for Resident 59.
Findings:
During a review of the facility policy and procedure (P&P) titled, Care and Treatment, Care Planning, revised 11/2021, the P&P indicated, POLICY: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive Person-Centered Care Plan for each resident based on resident's needs to attain or maintain his or her highest practicable physical, mental, and psychological well-being. PROCEDURES: 4. To the extent possible, the resident, the resident's family and/or responsible party should participate in the development of the care plan.
During a review of the facility's P&P titled, Activity Assessment, revised 01/2021, the P&P indicated, POLICY: It is the policy of this facility to provide ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities based on the comprehensive assessment and care plan and the preferences of each resident. PROCEDURES: 4. A quarterly and annual assessment shall be conducted using the Activity - Quarterly or Annual Evaluation UDA (User Defined Assessment consists of questions compiled together under various headings to create questionnaires that may be completed within the software) to include: a. Activity Pursuit Patterns and b. Activity Attendance/Participation Summary.
During a review of Resident 59's admission Record, dated 6/22/23, the admission record indicated, Resident 59 was 92-years-old with diagnoses including, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), muscle weakness, difficulty in walking, major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life) and need for assistance with personal care.
During a review of Resident 59's Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents), dated 10/8/22, the cognitive section indicated, Resident 59's Brief Interview for Mental Status (BIMS -a cognitive assessment tool -a resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the resident cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment) was a score of 6. Resident 59 required supervision to moderate assist with most activities of daily living (ADL-The tasks of everyday life. Basic ADLs include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). In addition, the Preferences for Customary Routine and Activities section indicated, it is very important to resident to have books/newspapers to read, do favorite activities, and go outside to get fresh air.
During a review of Resident 59's Activities Care Plan, undated, the care plan indicated, Focus - (Resident 59's name) potential alteration in diversional activities r/t (related to) Prefers to initiate activities of choice independently. (Resident 59's name) likes to independently read the daily chronicle, watch TV, do word search puzzles, and receive visits from her son and other family members when able. (Resident 59's name) favorite activities include getting her nails done, reminiscing, and being outdoors at times. Goal - Will choose and participate in his/her preferred leisure activities daily over the next 90 days as evidenced by activity attendance logs/progress notes/assessments. Interventions/Tasks - Communicate his/her interests to health care team.
During a review of Resident 59's Care Plan, undated, the care plan indicated,(Resident 59 name) is at risk for impaired cognitive function/dementia or impaired thought processes . undated, indicated, /needs supervision/assistance with all decision-making undated Son is POA (Power of Attorney).
During an observation and interview on 06/19/23 at 3:46 p.m. in Resident 59's room, Resident 59 was observed in bed, awake. The TV was not on and resident was not observed in any activity. Resident 59 stated used to be very active in her church and greeted people all the time at the church. Resident began to cry and stated, Not one person has come to visit, not the pastor, no one, and that hurts. It was the Seventh Day Adventist Church.
During an observation and interview on 06/21/23 at 2:49 p.m. in hallway outside of Resident 59's room with a certified nurse assistant (CNA 1), CNA 1 confirmed Resident 59 is lying in bed awake with no activity. CNA 1 confirmed she does not document residents' activities.
During an observation and interview on 06/21/23 at 2:49 p.m. in hallway outside of Resident 59's room with a licensed nurse (LN 2), LN 2 confirmed resident is lying in bed awake with no activities. LN 2 does not know what kind of activities Resident 59 likes and confirmed she does not document activities of residents.
During a review of the Activity-Quarterly Evaluation dated 10/8/22, 4/10/2023, and 10/8/2023 for Resident 59 the Attendance Participation Summary indicated, to refer to attendance records and describe residents participation/responses in activities. There were no attendance records in Resident 59's medical record.
During an interview and concurrent record review on 06/22/23 at 11:40 a.m. with the Activity Director (AD), Resident 59's activities care plan and Activity- Quarterly Evaluations were reviewed. Also reviewed the facility's P&Ps titled, Activity Assessment and Care and Treatment, Care Planning. The AD confirmed does not have any documentation regarding Resident 59's initial activity assessment or interview with POA. The AD confirmed facility staff are not informed of Resident 59's Activities, and no staff are documenting Resident 59's attendance in activities, and stated, To be honest, I used to document but do not anymore. The AD confirmed the facility is not following and implementing the policies and procedures and should be.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure physician orders were followed for one resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure physician orders were followed for one resident (Resident 38) when the resident did not rinse their mouth after receiving a medication via an inhaler.
This failure had the potential to cause a fungal infection in Resident 38's mouth and throat.
Findings:
Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicated, Nurses are obligated to follow physician orders unless they believe the orders are in error or would harm clients.
Review of the facility policy and procedure (P&P) titled, Medication Administration, revised 11/2021, the P&P indicated in part, Accurate and timely administration according to MD order is essential .
According to Breo Ellipta product information accessed at https://www.mybreo.com/ on 6/27/23, BREO can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using BREO to help reduce your chance of getting thrush [fungal infection].
During a medication pass observation on 6/20/23 at 8:10 a.m. licensed nurse 5 (LN 5) was observed administering Resident 38 Ellipta - Fluticasone Furoate (an inhaled medication to treat asthma and chronic obstructive disease) from a handheld powdered medication inhaler. LN 5 did not provide education to Resident 38 of the importance to rinse mouth with water without swallowing after using the inhaler and did not provide water and basin/cup to spit out rinse water before exiting the room.
During a concurrent interview and record review on 6/20/23 8:26 a.m. with LN 5, Resident 38's physician's order dated 12/28/22 was reviewed. The order indicated in part, Breo Ellipta Inhalation Aerosol Powder Breath Activated . (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day for RAD (reactive airway disease) rinse mouth with water after use. LN 5 confirmed, No, I did not educate Resident 38 to rinse out mouth after inhaling powdered Fluticasone Furoate medication; provide water and container to spit out rinse water; and did not witness Resident 38 rinse mouth out and spit out the rinse water. Resident 38 was supposed to do that. It can cause oral fungus if not done.
During an interview on 6/20/23 at 8:27 a.m. with Resident 38, Resident 38 stated, Usually I do rinse and spit, but I didn't today.
During an interview on 6/22/23 at 9:49 a.m. with the director of Nursing (DON), DON indicated, Licensed nurses are supposed to educate the need for rinsing out the mouth after inhaling the fluticasone inhaler and offer residents rinse water and receptacle for spitting out rinse water and remain with resident to ensure procedure accomplished . The policy and procedures were not followed and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 278) receiving the med...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 278) receiving the medication Apixaban (an anticoagulant or medication that prevents the blood from clotting) was monitored for complications and the monitoring documented in the resident's clinical record.
This oversight failure had the potential to result in serious harm to Resident 278.
Findings:
During a review of Resident 278's, admission Record, dated 6/20/23, the record indicated in part, Resident 278 was an [AGE] year-old male admitted to the facility on [DATE], with admission diagnoses including, abscess (a collection of pus within the tissue) of the liver, unspecified atrial fibrillation (fluttering of the heart), and unspecified psychosis (a condition of the mind that results in difficulties determining what is real and what is not real) not due to a substance or known physiological condition.
During a review of Resident 278's, Order Recap Report (ORR), dated 6/1/23 - 6/30/23, the ORR indicated the physician order, dated 6/10/23, Apixaban oral tablet 5 mg (milligram), give one tablet by mouth two times daily for A-Fib (atrial fibrillation).
During a concurrent interview and record review, on 6/21/23 at 2:40 p.m. with a licensed nurse (LN 1), Resident 278's Medication Administration Record (MAR), dated June 2023, was reviewed. LN 1 confirmed that Resident 278 was taking Apixaban 5 mg twice daily as reflected on the MAR. When asked if monitoring for anticoagulant complications such as bleeding/bruising was done and documented, LN 1 verbalized monitoring orders were usually transcribed in the MAR as a reminder for staff so they could sign off on them. LN 1 could not find monitoring documentation for anticoagulant complications transcribed in Resident 278's MAR and acknowledged there should have been one.
During a concurrent interview and record review, on 6/21/23 at 2:48 p.m. with LN 1, Resident 278's, Care Plan (CP), dated 6/10/23, was reviewed. The CP indicated in part, Anticoagulant therapy (Apixaban) r/t (related to) Atrial Fibrillation . at risk for bleeding, bruising, shock. The CP indicated further, Interventions . Monitor/document/report to MD . s/sx (signs/symptoms) of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools LN 1 acknowledged there should have been monitoring for anticoagulant complications documented and signed off by staff in Resident 278's clinical record.
During a review of the facility's, policy and procedures (P&P), titled, Physician Orders, dated 11/21, the P&P indicated in part, Procedures: .7) Medications that require parameters or monitoring for either signs and symptoms, behavior, or side effects (i.e.: antihypertensives, psychotropic medications, anticoagulants, etc.) will have such monitoring reflected in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 278) was properly asse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 278) was properly assessed for the continued use of the medication Quetiapine (brand name: Seroquel - a medication used to treat certain mental or mood conditions such as schizophrenia, bipolar disorder, and depression) as required by its policy and procedures on psychotropic (drugs that affect the brain and behavior) drug use.
This failure resulted in Resident 278 receiving an unnecessary psychotropic medication which had the potential to result in serious complications from prolonged use without proper monitoring.
Findings:
During a review of the facility's policy and procedures (P&P) titled, Psychotropic Drug Use, dated 5/19, the P&P indicated in part, Procedures: 1) Psychotropic medications shall not be administered for the purpose of discipline or convenience. They are to be administered only when required to treat the resident's medical symptoms . 2) On admission, the admitting nurses will review the transfer orders for psychotropic medications. All efforts will be made by the licensed nurses to obtain as much history regarding these medications . Any information obtained will be documented in the resident's clinical record . 3) The licensed nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse side effects prior to verification of admission orders with the attending physician.
During a review of Resident 278's admission Record, dated 6/20/23, the record indicated in part, Resident 278 was an [AGE] year-old male resident admitted to the facility on [DATE], with admission diagnoses including, abscess (a collection of pus within the tissue) of the liver, unspecified atrial fibrillation (fluttering of the heart), and unspecified psychosis (a condition of the mind that results in difficulties determining what is real and what is not real) not due to a substance or known physiological condition.
During a review of Resident 278's Order Recap Report (ORR), dated 6/1/23 - 6/30/23, the ORR indicated the physician order, dated 6/10/23, Quetiapine Fumarate oral tablet 50 mg (milligram) give one tablet by mouth two times a day for psychosis amb (as manifested by) agitation. This order was discontinued on 6/14/23. The ORR indicated further the physician order, dated 6/14/23, Quetiapine Fumarate oral tablet 50 mg give one tablet by mouth two time a day for psychosis with manic sx (symptoms) of agitation related to unspecified psychosis . amb resisting ADL (activities of daily living)/personal care necessary for resident's health and safety. This order was discontinued on 6/15/23.
During a concurrent interview and record review on 6/21/23 at 10:21 a.m. with a licensed nurse (LN 1), Resident 278's, Medication Administration Record (MAR), dated June 2023, was reviewed. The MAR indicated in part, staff administered Quetiapine 50 mg to Resident 278 on the following dates and times: on 6/10/23 at 5 p.m., 6/11/23 through 6/14/23 at 9 a.m. and 5 p.m., and 6/15/23 at 9 a.m. When asked where staff documented Resident 278's observed behavior (i.e., agitation) as an indication of the medication, LN 1 could not provide any documentation.
During a review of Resident 278's, Initial admission Record (IAR), dated 6/10/23, a section of the IAR indicated in part, . 7) Other Assessments . Psychotropic Drugs . E) Resident receives psychotropic medication(s). [If yes, a Psychoactive (or psychotropic) Medication Evaluation will be triggered]. The option, NO, was selected for this item which suggested Resident 278 did not receive psychotropic medication(s), hence a Psychoactive Medication Evaluation was not initiated. The IAR indicated further, . 2) Neuro/Mental . Level of Consciousness . B) Agitated . The option, NO, was selected for this item which suggested Resident 278 was not observed with agitation.
During a review of Resident 278's, Verbal Consent for Psychotropic Medications, Physician Order, dated 6/10/23, the Consent indicated, Specific Condition/Behavior Being Treated: psychosis amb agitation.
During a review of Resident 278's admission Drug Regimen Review (ADRR), dated 6/10/23, a section of the ADRR indicated in part, I. Review of Potential/Actual Clinically Significant Medication Issues . 2) Use of medication(s) without evidence of adequate indication for use . The option, NO, was selected for this item.
During a review of the facility's, CMS (Center for Medicare/Medicaid Services) 802 Matrix for Providers (a form used to list all current residents and to note pertinent care categories), dated 6/19/23, a section of the form under Medications failed to indicate Resident 278 was on antipsychotic medication(s).
During a review of Resident 278's, Facility Verification of Informed Consent . Psychotherapeutic Drugs, dated 6/10/23, the consent failed to indicate the physician's name and signature who obtained the consent.
During a concurrent interview and record review, on 6/22/23 at 10:15 a.m., with the Director of Nursing (DON), Resident 278's clinical record was reviewed. DON verbalized Resident 278's Quetiapine order was included in the resident's discharge medication list from the hospital prior to getting transferred to the facility and was considered a home medication. DON also verbalized a review from the interdisciplinary team (IDT) was conducted for new or current resident psychotropic medication orders to ensure appropriateness of the medication based on the resident's diagnosed behavioral issue or condition. An IDT review of Resident 278's Quetiapine use was conducted on 6/15/23, five days after the medication was initiated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure pharmacy services policy and procedure (P&P) for medication disposal was followed when medication pills were observed ...
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Based on observation, interview, and record review, the facility failed to ensure pharmacy services policy and procedure (P&P) for medication disposal was followed when medication pills were observed inside a trash receptacle.
This failure had the potential for misuse of medications and jeopardize residents' health and safety.
Findings:
During an observation and subsequent interview on 6/19/23 at 4:51 p.m. with licensed nurse (LN 6) and the director of nursing (DON), a trash can at nursing station two-three was observed and contained a discarded medication card bubble pack with two unused tablets. Inside of each individual segmented plastic bubble was a single tablet of Amlodipine Besylate (medication to treat high blood pressure) Tab USP (United States Pharmacopeia - quality standards of the United States) 10 mg (milligrams). LN 6 confirmed and acknowledged being responsible for throwing the bubble pack containing two tablets of Amlodipine Besylate Tab USP 10 mg Tab into the trash can and not disposing the medications properly. LN 6 stated, I was disposing of the medications, and I must have missed those. I have my drug buster inside the medication room and the medications should be disposed of in the drug buster. The DON confirmed the medication card bubble pack with 2 unused tablets of Amlodipine Besylate Tab USP 10 mg removed from the nursing station 2-3 trash can and acknowledged, Amlodipine besylate tab USP 10 mg was not disposed of properly into the drug buster.
During a review of the facility's P&P titled, Pharmacy Services, revised 11/2021, indicated in part, PROCEDURES: 4. Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction, Disposal of non-controlled medications 6. Facility should destroy non-controlled medications in the presence of two nurses, in accordance with Facility policy or Applicable Law.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to implement its policy for activities when:
1. One of eighteen sampled residents (Resident 59) was not observed in any activiti...
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Based on observation, interview, and record review, the facility failed to implement its policy for activities when:
1. One of eighteen sampled residents (Resident 59) was not observed in any activities during onsite four-day survey.
2. The activity director was not documenting activity pursuit patterns or activity attendance for any of the 75 residents in the facility.
This failure has the potential for psychosocial and physical harm to all 75 residents.
Findings:
During a review of the facility's policy and procedure (P&P) titled, Activity Assessment, dated 01/2021, the P&P indicated, POLICY: It is the policy of this facility to provide ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities based on the comprehensive assessment and care plan and the preferences of each resident. PROCEDURES: 4. A quarterly and annual assessment shall be conducted using the Activity - Quarterly or Annual Evaluation UDA (User Defined Assessment consists of questions compiled together under various headings to create questionnaires that may be completed within the software) to include: a. Activity Pursuit Patterns and b. Activity Attendance/Participation Summary.
During a review of the facility's P&P titled, Activities Program, dated 11/2021, the P&P indicated, POLICY: It is the policy of this facility to implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being, and independence. It is also the policy of this facility to create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy, and meaning). PROCEDURES: 8. Residents who wish to meet with or participate in social or religious activities, or other community activities, at or away from the facility, is encouraged to do so.
During a review of Resident 59's admission Record, dated 6/22/23, the admission record indicated, Resident 59 was 92-years-old with diagnoses including, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), muscle weakness, difficulty in walking, major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life) and need for assistance with personal care.
During a review of Resident 59's Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents), dated 10/8/22, the cognitive section indicated, Resident 59's Brief Interview for Mental Status (BIMS -a cognitive assessment tool -a resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the resident cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment) was a score of 6. Resident 59 required supervision to moderate assist with most activities of daily living (ADL-The tasks of everyday life. Basic ADLs include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). In addition, the Preferences for Customary Routine and Activities section indicated, it is very important to resident to have books/newspapers to read, do favorite activities, and go outside to get fresh air.
During an observation and interview on 06/19/23 at 3:46 p.m. in Resident 59's room, 59 was observed in bed, awake. The TV was not on and resident was not observed in any activity. Resident 59 stated used to be very active in her church and greeted people all the time at the church. Resident began to cry and stated, Not one person has come to visit, not the pastor, no one, and that hurts. May be a long time ago because I was driving then. It was the Seventh Day Adventist Church.
During an observation and interview on 06/20/23 at 3:42 p.m. with Resident 59's Representative, Resident 59 was observed lying in bed. Representative stated church is very important to Resident 59, she used to be a door greeter and is very upset no one from the church comes to visit. Representative stated has not seen Resident 59 in any activities and would like to.
During observations from 6/19/23 to 6/22/23 from 10 a.m. until 4 p.m., Resident 59 was observed in bed, awake, without any activity being provided. These observations were conducted on 6/19/23 two occasions, 6/20/23 three occasions, and on 6/21/23 eight occasions.
During an observation and interview on 06/21/23 at 2:49 p.m. in hallway outside of Resident 59's room with a certified nurse assistant (CNA 1) and Licensed Nurse (LN 2) CNA 1 confirmed Resident 59 is lying in bed awake with no activity. CNA 1 confirmed she does not document residents' activities. LN 2 does not know what kind of activities Resident 59 likes and confirmed she does not document activities of residents.
During an interview and concurrent record review on 06/21/23 at 3:28 p.m. with the Activity Director (AD), the AD confirmed facility P&P, Activity Assessment, indicated, staff should be documenting residents' activities and are not. The AD confirmed there is no documentation to confirm Resident 59 participating in any activities. The AD stated, To be honest, I used to document but do not anymore.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure its medication error rate was less than five percent when:
1. Licensed Nurse 5 (LN 5) left medications intended for Res...
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Based on observation, interview and record review, the facility failed to ensure its medication error rate was less than five percent when:
1. Licensed Nurse 5 (LN 5) left medications intended for Resident 38 unattended on the medication cart.
2. LN 5 did not educate and provide Resident 38 water to rinse mouth out after inhalation of Ellipta powder medication.
3. LN 5 left Resident 38's medications unattended on bedside table and did not witness medication consumption.
These failures resulted in a 10% medication error rate and had the potential for Resident 38 to have medication complications.
Findings:
Review of the facility's policy and procedures (P&P) titled, 6.0 General Dose Preparation and Medication Administration, revised 1/1/13, the P&P indicated in part, . Facility staff should not leave medications or chemicals unattended . Provide the resident with any necessary instructions (e.g., using an inhaler) . Observe the resident's consumption of the medications(s) .
1. During an observation and record review on 6/19/23, at 1:32 p.m., LN 5 entered Resident 38's room with back turned toward the medication cart and left a tablet of Clonidine (medication to control elevated blood pressure) 0.2 mg (milligrams) in a medication cup unattended on the surface of a medication cart outside of Resident 38's room. Record review of Resident 38's Physician's order dated 10/15/22 indicated, cloNIDine HCI tablet 0.2 mg Give 1 tablet by mouth three times a day .
During an interview on 6/19/23 at 1:34 p.m. with LN 5, LN 5 acknowledged leaving Resident 38's medication unattended on the medication cart and stated, Clonidine, yes, I left it unattended on my med (medication) cart. I should not have done that.
2. During a medication pass observation on 6/20/23 at 8:10 a.m. LN 5 was observed administering Resident 38 Ellipta - Fluticasone Furoate (an inhaled medication to treat asthma and chronic obstructive disease) from a handheld powdered medication inhaler. LN 5 did not provide education to Resident 38 of the importance to rinse mouth with water without swallowing after using the inhaler and did not provide water and basin/cup to spit out rinse water before exiting the room.
During a concurrent interview and record review on 6/20/23 8:26 a.m. with LN 5, Resident 38's physician's order dated 12/28/22 was reviewed. The order indicated in part, Breo Ellipta Inhalation Aerosol Powder Breath Activated . (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day for RAD (reactive airway disease) rinse mouth with water after use. LN 5 confirmed, No, I did not educate Resident 38 to rinse out mouth after inhaling powdered Fluticasone Furoate medication; provide water and container to spit out rinse water; and did not witness Resident 38 rinse mouth out and spit out the rinse water. Resident 38 was supposed to do that. It can cause oral fungus if not done.
During an interview on 6/20/23 at 8:27 a.m. with Resident 38, Resident 38 stated, Usually I do rinse and spit, but I didn't today.
3. During the same medication pass observation on 6/20/23, at 8:10 a.m., LN 5 was observed placing Resident 38's Physician ordered medications Carvedilol 3.125 mg tablet (treats high blood pressure), clonidine 0.2 mg tablet (treats high blood pressure), and docusate sodium 100 mg gel cap (prevents and treats constipation) into a medication cup, LN 5 then placed the medication cup with medications onto Resident 38's bedside table, and exited Resident 38's room. LN 5 did not stay to witness Resident 38 consume the medications. When asked if Resident 38's medications were left unattended, LN 5 confirmed and acknowledged, I also left the medications unattended on the bedside table and did not witness the Resident 38 consume his medications before I left the room.
During an interview on 6/22/23 at 9:49 a.m. with the director of Nursing (DON), the DON indicated, Licensed nurses are supposed to educate the need for rinsing out the mouth after inhaling the fluticasone inhaler and offer residents rinse water and receptacle for spitting out rinse water and remain with resident to ensure procedure is accomplished. Licensed nurses are never supposed to leave medication unattended in the resident's rooms and/or unattended on the medication cart. Licensed nurses are supposed to stay and witness the resident consume the medications administered. The policy and procedures were not followed and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to store two boxes containing eggs inside of refrigerator and off the kitchen floor in accordance with professional standards of ...
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Based on observation, interview, and record review the facility failed to store two boxes containing eggs inside of refrigerator and off the kitchen floor in accordance with professional standards of food safety for a total of 72 residents who received food from the kitchen.
These failures had the potential to result in foodborne illnesses among residents.
Findings:
According to the Food Code 2022, Annex 3. Public Health Reasons/Administrative,
2-103.11, page 308 All food must be appropriately stored in a safe and secure manner within the food establishment. For example, time/temperature control for safety foods must be stored within refrigeration units and held at temperatures of 41°F or below. Also, 3-202.11 Temperature, page 376 indicated in part, USDA published a final rule (63 FR 45663, August 27, 1998 Shell Eggs; Refrigeration and Labeling Requirements) to require that shell eggs packed for consumer use be stored and transported at an ambient temperature not to exceed 7.2ºC (45ºF). Additionally, 6-501.12 Cleaning, Frequency and Restrictions, page 504 indicated, Primary cleaning should be done at times when foods are in protected storage .
The facility policy and procedure titled, Dietary Services revised 8/2021, indicated in part, All foods stored in walk-in refrigerators and freezers shall be stored above the floor on shelves, racks, dollies, or other surfaces that facilitate thorough cleaning.
During a concurrent observation and interview on 6/19/23 at 10:50 a.m. with kitchen aide 1 (KA 1) and the acting dietary manager (DM-A), two boxes were observed one on top of the other outside of the refrigerator and directly on the soiled kitchen floor while cleaning refrigerator number three. The boxes contained two varieties of eggs. The box directly on the soiled kitchen floor contained boiled eggs with another opened box on top containing a plastic bag of liquid eggs. KA 1 confirmed the above, made no comment, and did not remove/relocate the unrefrigerated boxes of boiled and liquid eggs stored on the soiled kitchen floor. The DM-A confirmed and acknowledged, Foods should be stored onto kitchen carts not on floor. The DM-A did not acknowledge that refrigerated eggs should remain inside of the refrigerator during cleaning.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure nursing staff notified the attending physician of a significant weight loss for one of three sampled residents (Resident 1).
This fa...
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Based on interview and record review, the facility failed to ensure nursing staff notified the attending physician of a significant weight loss for one of three sampled residents (Resident 1).
This failure resulted in a delay in medical intervention and potential for adverse consequences.
Findings:
During a review of Resident 1's Weights and Vitals Summary, (undated), the Weights and Vitals Summary indicated, Resident 1 had a 7.6 pound weight loss, totaling a 6.6% decrease from 2/21/23 to 3/1/23.
During a review of the facility's policy and procedure (P&P) titled, Nutrition Care Management, revised 7/21/21, the P&P indicated, Significant weight loss is a loss of (5% in one (1) month The P&P further indicated, The physician will be notified by the License Nurse of weight changes (+/-) of 5 pounds. Family member/responsible party and attending physician will be notified by LN (Licensed Nurse).
During a review of the facility's P&P titled, Care and Treatment - Quality of Care, Change of Condition Reporting, revised 11/22, the P&P indicated, Policy: It is the policy of the of this facility that all changers in residents condition will be communicated to the physician .Under Routine Medical Changes, 2. The nurse in charge is responsible for notification of physician prior to end of assigned shift when a significant change in resident's condition is noted.
During a review of Resident 1's Progress Note, IDT Weight Committee, dated 3/7/23, the Progress Note indicated, Resident noted to have a 7lb (pound) weight loss in one week.
During an interview on 4/19/23, at 12:25 p.m., with Director of Nursing (DON), DON stated, the physician wasn't notified of Resident 1's 7.6 pound weight loss from 2/21/23 through 3/1/23 until 3/7/23 and confirmed this caused a delay in weight loss prevention interventions for Resident 1. DON stated, The physician should have been notified right away on 3/1/23.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade B+ (83/100). Above average facility, better than most options in California.
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most California facilities.
- • 30% annual turnover. Excellent stability, 18 points below California's 48% average. Staff who stay learn residents' needs.
Concerns
- • 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Villa Maria Post Acute's CMS Rating?
CMS assigns Villa Maria Post Acute an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Villa Maria Post Acute Staffed?
CMS rates Villa Maria Post Acute's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 30%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Villa Maria Post Acute?
State health inspectors documented 25 deficiencies at Villa Maria Post Acute during 2023 to 2025. These included: 25 with potential for harm.
Who Owns and Operates Villa Maria Post Acute?
Villa Maria Post Acute is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE ENSIGN GROUP, a chain that manages multiple nursing homes. With 81 certified beds and approximately 77 residents (about 95% occupancy), it is a smaller facility located in Santa Maria, California.
How Does Villa Maria Post Acute Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, Villa Maria Post Acute's overall rating (5 stars) is above the state average of 3.2, staff turnover (30%) is significantly lower than the state average of 46%, and health inspection rating (5 stars) is much above the national benchmark.
What Should Families Ask When Visiting Villa Maria Post Acute?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Villa Maria Post Acute Safe?
Based on CMS inspection data, Villa Maria Post Acute has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Villa Maria Post Acute Stick Around?
Staff at Villa Maria Post Acute tend to stick around. With a turnover rate of 30%, the facility is 16 percentage points below the California average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was Villa Maria Post Acute Ever Fined?
Villa Maria Post Acute has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Villa Maria Post Acute on Any Federal Watch List?
Villa Maria Post Acute is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.