Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Santa Maria Post Acute during CMS and state inspections, most recent first.
A resident with multiple diabetes-related diagnoses had a blood glucose reading of 369 mg/dL, exceeding the physician order to notify the provider for levels above 351 mg/dL. The LPN did not notify the physician, and the record contained no nursing assessment, provider notification, response, follow-up intervention, or clinical monitoring related to the elevated glucose; the DON confirmed the nurse acknowledged the omission.
Two residents were involved in an altercation with no reported injuries, and an SOC 341 abuse report and progress notes documented that an investigation was initiated. However, when surveyors later requested the completed five‑day follow‑up investigation report, the ADM could not provide it and acknowledged that the investigation had not been completed within the required five working days, contrary to facility policy requiring the ADM to submit a follow‑up abuse investigation report within five business days of an incident.
Two residents with documented histories of polysubstance and stimulant dependence were admitted from the hospital with discharge diagnoses including amphetamine and psychostimulant dependence, opioid abuse, and homelessness, yet their admission screenings recorded no information on tobacco, alcohol, or drug use. Their care plans identified polysubstance use "in remission" and focused only on monitoring for withdrawal and notifying providers, without interventions to address ongoing SUD, prevent access to drugs, or meet behavioral health needs. On one occasion, the two residents went outside in wheelchairs without staff supervision, later returned to their shared room, and one reported finding and sharing a rice grain–like substance and providing a cigarette to the other. Both were subsequently found in their room with signs consistent with overdose, including unresponsiveness, shallow breathing, and eyes rolling back, requiring emergency services, naloxone administration, and hospital transfer with diagnoses of opioid overdose.
A resident with muscle weakness, history of falls, right-sided hemiplegia, and moderate cognitive impairment had a care plan for wandering/elopement that included identifying triggers, patterns, purposes, de-escalation behaviors, and engaging the resident in purposeful activity, with the goal that the resident would not leave unattended. Despite multiple prior elopement attempts, staff did not document identified triggers, patterns, or de-escalation strategies, and no admission elopement risk assessment was available; the only elopement evaluation was completed after a successful elopement in which the resident left the building unnoticed and was later found at a nearby bus stop with a wheelchair, purse, and coat. This lack of implementation and documentation conflicted with facility policy requiring care plan strategies and interventions for residents at risk of wandering or elopement.
A resident did not receive their routine Alprazolam medication due to a failure in the facility's medication ordering process. The admitting nurse was unaware of the requirement to fax orders for controlled substances, leading to the medication not being delivered. The nursing staff did not adequately follow up to resolve the issue, resulting in the resident's distress and eventual discharge against medical advice.
A facility failed to follow physician orders for a resident's pain medication, resulting in a delay and incorrect frequency of administration. Hydrocodone was prescribed to be given every 4 hours as needed, but the facility ordered it two days late and recorded it for every 6 hours. This was confirmed by the DON, who noted the order should have been submitted on the specified day.
A resident with dementia and other health issues eloped from a facility due to inadequate supervision and a malfunctioning wander guard system. The resident, who had a wander guard bracelet on their wheelchair, was able to leave the facility unnoticed and was found five blocks away. Testing revealed the wander guard alarm only activated intermittently, and staff were unaware if it sounded during the elopement.
A resident's behavior escalated due to a delay in medication administration, and staff failed to use de-escalation techniques. The resident, upset and cursing, attempted to grab a phone at the nurse's station, resulting in a skin tear. Despite being trained in de-escalation, the LPNs involved did not address the resident's needs promptly, leading to the deficiency.
A facility failed to ensure a functioning call light system for a resident. During an observation, the resident reported that staff did not respond when the call light was pressed. It was found that the call bell was unplugged, resulting in no response or indication outside the room. A CNA confirmed the issue, and the facility's policy requires call lights to be plugged in and functioning.
The facility failed to maintain food safety standards during lunch tray preparation and did not follow the recommended sanitization schedule for its ice machine. A dietary aide/cook did not change gloves or perform hand hygiene while preparing food, potentially contaminating it. Additionally, the ice machine had not been sanitized within the six-month interval recommended by the manufacturer's manual, as confirmed by the maintenance supervisor and Director of Nursing.
The facility failed to provide 24-hour nursing staff, with no RNs assigned on specific dates as per the PBJ report. The Administrator confirmed the absence of RNs, potentially impacting resident care.
A facility failed to obtain informed consent for Xanax administration for a resident. During a review, it was found that the physician's order for Xanax lacked documentation of informed consent, and the DON could not locate a consent form in the resident's chart. The facility's policy requires healthcare practitioners to obtain and document informed consent for psychotherapeutic medications, which was not adhered to in this case.
The facility did not make the most recent recertification survey results from August 2022 available to residents, family members, and legal representatives. The survey binder at the entrance check-in counter was missing these results, and the DON was unaware of the survey. The ADM confirmed the results were in his office, not in the accessible binder, contrary to the facility's policy.
The facility failed to develop comprehensive care plans for two residents regarding their medication use. A resident prescribed Xanax for anxiety and another on Apixaban for anticoagulation did not have care plans addressing these medications. The DON confirmed the absence of these care plans, which is against the facility's policy requiring comprehensive, person-centered care plans.
A resident with a pronounced foot drop was non-compliant with wearing bilateral splints, and this non-compliance was not documented or communicated beyond the Rehab Director. The care plan was not updated to reflect the resident's current condition, including the need for off-loading heels to prevent pressure ulcers. Additionally, the resident received inconsistent RNA therapy, with no documentation explaining the discrepancies. The facility's policy required comprehensive care plans, but the resident's plan did not meet these standards.
A facility failed to administer medications on time for a resident with CHF, did not carry out a physician's order for lab tests for a resident with multiple health issues, and neglected to complete post-dialysis assessments for a resident with end-stage renal disease. These deficiencies were confirmed by the DON and involved registry nurses and other staff.
The facility failed to administer medications correctly for three residents. A resident received an incorrect dose of Acetaminophen, another was given Levothyroxine after breakfast instead of on an empty stomach, and a third resident did not receive Magnesium Oxide and Acamprosate as prescribed, with discrepancies noted between the nurse's documentation and the resident's account.
A facility failed to conduct a Medication Regimen Review (MRR) for Xanax for a resident, as required by their policy. The resident had a physician's order for Xanax, but the MRR did not include a review for its continued use beyond 14 days. The Director of Nursing confirmed the absence of a pharmacist review, which is a requirement under the facility's policy for Consultant Pharmacist Services.
A facility failed to ensure a practitioner's justification for the continued use of Xanax beyond 14 days for a resident. During a review with the DON, it was found that the resident had an order for Xanax 0.25 mg every 8 hours as needed for anxiety and panic, but there was no documentation justifying its use beyond 14 days. The facility's policy requires documentation for extending PRN orders for psychotropic medications beyond 14 days, which was not followed in this case.
The facility had a medication error rate of 14.81%, exceeding the acceptable limit. A nurse administered incorrect dosages and timing of medications to three residents. One resident received less Acetaminophen than prescribed, another was given Levothyroxine after eating, and a third did not receive Magnesium Oxide and Acamprosate as ordered, despite the resident's willingness to take them.
The facility failed to properly label and store medications and biologicals, including an opened Sodium Chloride solution without a date label, out-of-range refrigerator temperatures without corrective actions, and improper storage of lemon glycerin swab sticks in a freezer. Additionally, medications were found in a sink, and glucometer strips lacked an open date label, all confirmed by LNs during interviews.
The facility failed to implement a water management program to prevent Legionella and other waterborne pathogens. The Administrator and DON admitted there was no system to test and track these pathogens, and the facility's assessment did not address a water management program. Despite having policies indicating the need for such a program, it was not in place, potentially exposing residents to harmful pathogens.
The facility failed to maintain a safe and functional environment for two residents. One resident's bed was not working, hindering their ability to feed themselves, and the issue was not addressed despite being reported. Another resident had a frayed bed control wire and an extension cord near their head. The facility's policies require routine inspections to ensure equipment safety.
A resident with a history of a right heel DTI and other medical conditions was admitted with a brace on the right lower extremity, which caused additional pressure injuries. Despite an email allowing modification of the immobilizer, the facility did not act promptly, leading to the worsening of the initial DTI and the development of three additional wounds. The facility's failure to follow its policy and procedure for pressure injuries resulted in increased pain and an additional hospital stay for the resident.
The facility failed to report a resident's unwitnessed fall from a wheelchair in the dining room, which resulted in injuries requiring EMS and an ER visit. The Administrator stated that no report was filed because the resident did not return from the hospital. This was against the facility's policy requiring such incidents to be reported within 24 hours and a written report within 48 hours.
The facility failed to provide an environment free from restraints when all four side rails of a resident's bed were raised without consent. Despite the facility's policy against using bedrails as restraints, a CNA raised the side rails to prevent the resident from getting out of bed due to a history of falls. Both the DON and Administrator confirmed that this practice is considered a restraint and should not have occurred.
Failure to Notify Physician of Elevated Blood Glucose
Penalty
Summary
The facility failed to follow a physician order requiring notification for blood glucose levels greater than 351 mg/dL for one resident with Type 2 diabetes mellitus, diabetic retinopathy with macular edema, diabetic neuropathy, diabetic dermatitis, COPD, and essential hypertension. The resident’s comprehensive care plan included interventions for diabetes management, such as monitoring and documenting signs and symptoms of hyperglycemia, monitoring blood glucose abnormalities, administering diabetic medications as ordered, and monitoring for diabetic complications. On 4/13/26, the resident’s MAR documented a blood glucose level of 369 mg/dL during the 9:00 p.m. insulin administration pass, but the physician was not notified. Review of the medical record found no documented nursing assessment, physician notification, physician response, follow-up intervention, or clinical monitoring related to the elevated blood glucose level. The facility’s secure cell phone communication log also showed no documented communication from the responsible nurse to the physician regarding the 369 mg/dL result, and the DON confirmed the nurse acknowledged she did not notify the physician despite the order.
Failure to Complete and Submit Required Five‑Day Abuse Investigation Report
Penalty
Summary
The facility failed to complete and submit the required five‑day follow‑up investigation report to the Department after an altercation between two residents. On 4/1/26, the abuse coordinator was notified of an altercation between Resident 1 and Resident 2, with documentation on an SOC 341 form dated 4/2/26 indicating there were no injuries. Resident 1’s progress notes dated 4/2/26 showed that an investigation into the incident had been initiated. However, when the surveyor requested the completed five‑day investigation report multiple times on 4/14/26, the Administrator was unable to provide documentation that the investigation had been completed and reported within the required timeframe. During an interview on 4/14/26 with the Administrator and DON, the Administrator confirmed that the investigation related to the altercation between Resident 1 and Resident 2 had not been completed within the required five working days and acknowledged personal responsibility for the delay. Review of the facility’s policy titled “Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,” revised September 2022, showed that the policy requires the Administrator to provide a follow‑up investigation report within five business days of the incident, which was not done in this case.
Failure to Implement Substance Use Disorder Policy and Care Planning Resulting in Overdose
Penalty
Summary
The deficiency involves the facility’s failure to implement its Substance Use Disorder (SUD) policy and procedures for two residents with known histories of polysubstance abuse. For both residents, the Nursing Admission Screening/History documented “unable to respond/no response” or “unable to determine/no response” for tobacco, alcohol, and drug use, despite hospital discharge summaries listing diagnoses such as amphetamine and psychostimulant dependence, opioid abuse, polysubstance abuse, and homelessness. The facility’s SUD policy required that a resident’s history of SUD and risk for using substances that could lead to overdose while in the facility be identified and documented in the medical record, but this was not done accurately for either resident. Both residents had care plans that identified a history of polysubstance use “in remission,” with goals focused on remaining free from withdrawal symptoms during the SNF stay. Interventions were limited to monitoring for withdrawal symptoms, notifying the provider of concerning symptoms, and providing support or social services consults. The care plans did not include interventions or approaches addressing the residents’ specific conditions of amphetamine and psychostimulant dependence, nor did they include measures to prevent or minimize access to drugs while in the facility or address behavioral health care needs related to SUD. The DON confirmed that there were no interventions in the care plans to prevent the residents from obtaining any form of drugs while in remission. On the day of the incident, both residents, who shared a room, were outside in front of the facility in wheelchairs without staff present. They later returned to their room, where one resident reported finding a rice grain–like substance in clothing, breaking it in half, consuming half, and giving the other half to the roommate. One resident also reported being given a cigarette by the roommate outside and smoking it. Shortly thereafter, staff found one resident unresponsive with eyes rolled back and cyanotic lips, and the other resident lethargic and later unresponsive with shallow breathing and eyes rolling back. Emergency services were called, naloxone was administered, and both residents were transferred to the hospital, where diagnoses included opioid overdose. The facility’s ADM and DON stated that no staff member was present with the residents when they were outside at the time of the incident.
Failure to Implement and Document Elopement Risk Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and document care plan interventions for a resident with a known history of elopement attempts. The resident was admitted with diagnoses including muscle weakness, history of falling, and hemiplegia/hemiparesis following cerebral infarction affecting the right dominant side, and had a BIMS score of 8, indicating moderate cognitive impairment. The resident’s care plan for Risk for Wandering/Elopement, initiated with the goal that the resident would not leave the facility unattended and that safety would be maintained, listed interventions such as engaging the resident in purposeful activity, identifying triggers, patterns, and purposes of wandering/elopement, and identifying de-escalation behaviors and times of day when attempts occurred. However, there was no evidence that these interventions were carried out or documented. On one occasion, nursing notes documented that oncoming staff observed the resident at a bus stop outside the facility with a wheelchair, purse, and coat, confirming the resident had exited the building without staff awareness. During interviews, the DON and a licensed nurse confirmed the resident had multiple prior elopement attempts before this successful elopement. Record review with the DON revealed no documentation identifying the resident’s triggers for wandering/eloping, no identified pattern or purpose of wandering, and no identified de-escalation behaviors, and the DON was unable to produce an elopement risk assessment completed upon admission. The only elopement evaluation available was dated after the successful elopement. This was inconsistent with the facility’s Wandering and Elopements policy, which required that residents identified at risk for wandering or elopement have care plan strategies and interventions to maintain safety.
Failure to Provide Routine Medication
Penalty
Summary
The facility failed to ensure that a routine medication, Alprazolam 2 mg, was available for a resident, resulting in the resident not receiving the scheduled medication and experiencing distress. The deficiency occurred when the admitting nurse sent the medication list electronically to the pharmacy but was unaware that a fax was required for controlled medications like Alprazolam. The pharmacist confirmed that controlled medications need to be faxed unless the order is sent directly by the prescriber. The resident was admitted in the evening, and the medication was missing from the delivery, which was not immediately addressed. The nursing staff did not follow up adequately to resolve the issue. The nursing progress notes indicated that the medication did not arrive, and there was no documentation of further attempts to contact the physician for an alternative medication until the following day. The resident's representative was upset and signed the resident out of the facility against medical advice. The facility's policy required special procedures for ordering controlled substances, which were not followed, leading to the deficiency.
Failure to Follow Physician Orders for Pain Medication
Penalty
Summary
The facility failed to adhere to physician orders for a resident, resulting in a delay and incorrect administration of pain medication. Specifically, Hydrocodone was prescribed for the resident's back pain to be administered every 4 hours as needed, according to the discharge medication list from the hospital. However, the facility did not order the medication until two days after the physician's orders were given, and the medication was recorded with an incorrect frequency of every 6 hours as needed. This discrepancy was confirmed during a review with the Director of Nursing, who acknowledged that the order should have been submitted to the pharmacy on the day the physician specified. The facility's policy requires that drug orders be recorded on the physician's order sheet in the resident's chart, which was not followed in this instance.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Faulty Wander Guard System
Penalty
Summary
The facility failed to ensure adequate supervision for a resident identified as being at risk for elopement, resulting in the resident eloping from the facility without staff knowledge. The resident, who had a history of unspecified dementia, hypertension, osteoporosis, major depressive disorder, and adjustment disorder, was admitted to the facility with a physician's order for a wander guard due to increased confusion and poor judgment. Despite the implementation of a wander guard system, the resident was able to leave the facility unaccompanied and was found five blocks away. The facility's wander guard system was not functioning reliably, as observed during an interview and test conducted with the Director of Nursing and the administrator. The wander guard door alarm, which was supposed to sound every time a resident with a wander guard bracelet passed through, only activated three out of six times during a test. Additionally, the resident's wander guard was found on the wheelchair rather than on the resident's wrist or leg, which may have contributed to the failure of the alarm system to detect the resident's exit. Interviews with staff revealed that the resident had expressed intentions to leave the facility to watch a game, indicating a potential risk for elopement. However, there was no documentation of regular testing of the wander guard system, and staff were unaware if the alarm had sounded during the resident's elopement. The lack of reliable alarm function and inadequate supervision allowed the resident to leave the facility unnoticed, posing a potential risk for harm.
Failure to Utilize De-escalation Techniques for Resident
Penalty
Summary
The facility failed to ensure a resident was treated with dignity when their behavior escalated, and de-escalation techniques were not utilized. The incident involved a resident who was upset due to a delay in receiving their medication. The resident was observed cursing and reaching over the nurse's station to grab the phone while a licensed nurse (LN 1) was on a call. LN 1 did not employ any de-escalation techniques and continued with the call, resulting in the resident sustaining a skin tear on their left arm. Another licensed nurse (LN 2) was also involved, as she continued with her medication pass without addressing the resident's escalating behavior or providing the medication sooner. Interviews with the staff revealed that the resident was alert and oriented but difficult to please at times. The Director of Nursing (DON) acknowledged that de-escalation techniques should have been utilized by both LN 1 and LN 2, as staff are trained in these techniques. The facility's policy emphasizes a commitment to compassion and caring, particularly for residents with behavioral issues, which was not adhered to in this situation. The failure to employ de-escalation techniques and address the resident's needs in a timely manner led to the deficiency.
Failure to Ensure Functioning Call Light System
Penalty
Summary
The facility failed to ensure a functioning call light system for a resident, which was identified during an observation and interview. The resident reported that staff did not respond when the call light was pressed, and upon testing, it was found that there was no response, no ringing sound, and the light outside the room was not illuminated. The call bell was observed to be unplugged from the wall. A certified nursing assistant confirmed the call light was not functioning and stated it should always be plugged in. The facility's policy, reviewed with the administrator, indicated that call lights should be plugged in and functioning at all times.
Food Safety and Ice Machine Sanitization Deficiencies
Penalty
Summary
The facility failed to adhere to food safety standards during lunch tray preparation and ice machine sanitization. A dietary aide/cook (DAC) was observed not following proper hygiene and sanitary practices while preparing lunch trays. The DAC measured food temperatures with gloved hands and continued to handle various kitchen items without changing gloves or performing hand hygiene. Additionally, the DAC rested a plate against her body, allowing her apron and ID badge to touch the edge of the plate, potentially contaminating the food. The certified dietary manager (CDM) confirmed these practices were inappropriate and acknowledged the need for frequent glove changes and hand hygiene to prevent food contamination. The facility also failed to follow the recommended sanitization schedule for its ice machine. The ice machine's sanitization was last performed on 3/18/24, which was not within the six-month interval recommended by the manufacturer's manual. The maintenance supervisor (MS) confirmed the lapse in the sanitization schedule and could not provide any service records or invoices indicating sanitization after the last recorded date. The Director of Nursing (DON) also confirmed the ice machine had not been sanitized within the recommended timeframe, which could lead to potential contamination as per the FDA Food Code.
Failure to Provide 24-Hour Nursing Staff
Penalty
Summary
The facility failed to provide nursing staff on a 24-hour basis to meet the needs of residents, as evidenced by the absence of assigned Registered Nurses (RNs) on specific dates. During a review of the Payroll Based Journal (PBJ) report for Quarter 1, 2024, and Quarter 2, 2024, it was found that there were no RNs assigned on several infraction dates, including Sundays and other weekdays. This lack of staffing was confirmed during an interview with the facility Administrator, who acknowledged the absence of assigned RNs on the specified dates. This deficiency had the potential to result in residents not receiving necessary care.
Lack of Informed Consent for Xanax Administration
Penalty
Summary
The facility failed to ensure informed consent was obtained for the use of the medication Xanax for a resident. During an interview and record review with the Director of Nursing (DON), it was found that the physician's order for Xanax, prescribed as 0.25 mg every 8 hours as needed for anxiety and panic, lacked documentation of informed consent. The DON was unable to locate any consent form in the resident's chart that indicated the resident or their representative had been educated on the risks and benefits of Xanax. The facility's policy and procedures on informed consent for psychotherapeutic medications require the healthcare practitioner ordering such medication to obtain and document informed consent. However, this procedure was not followed, leading to the potential for the resident to be administered Xanax without being informed of its risks and benefits.
Failure to Provide Access to Recent Survey Results
Penalty
Summary
The facility failed to provide the most recent recertification survey results to residents, family members, and legal representatives. During an observation at the entrance check-in counter, it was found that the survey binder was missing the recertification survey results and plan of correction from the survey conducted in August 2022. The Director of Nursing (DON) was unaware of the August 2022 survey and confirmed that the most recent survey results in the binder were from July 2021. The Administrator (ADM) acknowledged that the August 2022 survey results were in his office and not in the survey binder accessible to residents. The facility's policy and procedure, dated April 2007, requires that the most recent survey results and plans of correction be maintained in a binder located in an area frequented by residents.
Failure to Develop Comprehensive Care Plans for Medications
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which was identified during a survey. For Resident 44, there was no care plan addressing the use of Xanax, a medication prescribed to control anxiety and panic attacks. During an interview and record review with the Director of Nursing (DON), it was confirmed that the care plan for behavior monitoring and continuous use of Xanax was missing from Resident 44's records. Similarly, Resident 17, who has a medical history of anemia and atrial fibrillation, was prescribed Apixaban, an anticoagulant medication. However, the facility did not develop a care plan for the use of this medication. During a review of Resident 17's clinical records, it was found that there was no documented care plan for the use of Apixaban, which was acknowledged by the DON. The facility's policy and procedures require the interdisciplinary team to develop comprehensive, person-centered care plans, but this was not adhered to in these cases.
Failure to Update Care Plan for Non-Compliant Resident
Penalty
Summary
The facility failed to ensure the timely revision and update of a comprehensive care plan for a resident, which resulted in an inaccurate care plan. The resident was observed with a pronounced foot drop and was non-compliant with the use of bilateral lower extremities splints, as they would remove and discard them. Despite this non-compliance, there was no documentation of the resident's refusal or non-compliance, and the information was only verbally communicated to the Rehab Director, who did not report it further. The care plan did not reflect the resident's current condition, including the need for off-loading the heels to prevent pressure ulcers, and the foot drop was not documented as a change of condition. The resident was supposed to receive 30 minutes of restorative nursing assistant (RNA) therapy, but records showed inconsistent therapy times, with several instances of reduced or no therapy provided. There was no documentation explaining the discrepancies in therapy duration or the resident's refusal. The facility's policy required comprehensive, person-centered care plans with measurable objectives, but the care plan for this resident was not updated to reflect their current needs and non-compliance, leading to a potential risk of inadequate care.
Medication Administration and Assessment Failures
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards for Resident 403. The resident had a doctor's order for Furosemide, a medication used to manage congestive heart failure, to be given twice daily at specific times. However, the medication was consistently administered late on multiple occasions throughout November 2024, with delays ranging from over an hour to more than five hours. There was no documentation explaining the reasons for these delays, and the Director of Nursing confirmed that the nurses involved were registry nurses. The facility's policy required medications to be administered within 60 minutes of the scheduled time, which was not adhered to. For Resident 50, the facility did not carry out a physician's order for laboratory tests. The resident, who had multiple diagnoses including hypertensive heart disease and chronic kidney disease, was supposed to have a CBC and CMP conducted due to symptoms of a swollen abdomen with tenderness. Despite a verbal order being received and documented, the tests were not performed, and no lab results were found. Both the Minimum Data Set coordinator and a licensed nurse confirmed the absence of lab results and the failure to execute the physician's order. Resident 34, who required regular dialysis due to end-stage renal disease, did not receive proper post-dialysis assessments. The facility's policy required vital signs and assessments of dialysis access sites to be completed after each dialysis session. However, records showed that these assessments were incomplete on several occasions. The Director of Nursing confirmed that the nursing staff did not fulfill the expected documentation requirements for post-dialysis care, leaving critical health assessments unrecorded.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper administration of medications for three residents, leading to potential deficiencies in pharmaceutical services. For one resident, Acetaminophen was administered incorrectly, with only 325 mg given instead of the prescribed 650 mg. This discrepancy was observed during a medication administration session. Another resident received Levothyroxine after breakfast, contrary to the recommended administration on an empty stomach, as per the drug reference handbook used by the facility. Additionally, a third resident did not receive Magnesium Oxide and Acamprosate as prescribed. The licensed nurse documented these medications as refused, citing reasons such as stomach upset and the resident's desire to discontinue Acamprosate. However, upon interview, the resident denied experiencing stomach issues or refusing the medications, indicating a discrepancy between the nurse's documentation and the resident's account.
Failure to Conduct Medication Regimen Review for Xanax
Penalty
Summary
The facility failed to ensure a Medication Regimen Review (MRR) was conducted for Xanax, a medication prescribed to control anxiety and panic attacks, for one of the sampled residents. The deficiency was identified during an interview and record review with the Director of Nursing (DON), where it was found that the resident had a physician's order for Xanax oral tablet 0.25 mg, dated 10/30/24. However, the MRR dated November 2024 did not include a review for the continued use of Xanax beyond 14 days. The DON confirmed the absence of a pharmacist review for Xanax. The facility's policy and procedure titled 'Consultant Pharmacist Services Provider Requirements' mandates that the medication regimen of each resident be reviewed at least monthly, or more frequently under certain conditions. It also requires communication of potential or actual problems detected, as well as recommendations for changes in medication therapy to the responsible prescriber and facility leadership. The failure to adhere to these guidelines resulted in the deficiency noted in the report.
Lack of Justification for Extended Use of Xanax
Penalty
Summary
The facility failed to ensure there was a practitioner's justification for the continued use of Xanax beyond 14 days for one of the sampled residents. During an interview and record review with the Director of Nursing (DON), it was found that Resident 44 had an order for Xanax 0.25 mg to be taken every 8 hours as needed for anxiety and panic. However, there was no documentation in the physician's progress notes justifying the need for the continuous use of Xanax beyond the 14-day limit. The DON acknowledged the absence of provider justification for the continued use of the drug beyond the specified period. The facility's policy and procedure on psychotropic medication use, dated July 2022, indicated that PRN orders for psychotropic medications are limited to 14 days. If the prescriber or attending physician believes it is appropriate to extend the order beyond 14 days, they must document the rationale for extending its use. This policy was not adhered to in the case of Resident 44, leading to the potential for the resident to receive an unnecessary medication and experience complications due to the medication.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 14.81 percent error rate during medication administration for three residents. For Resident 403, a licensed nurse administered only 325 mg of Acetaminophen instead of the prescribed 650 mg. For Resident 404, Levothyroxine was given after breakfast, contrary to guidelines that it should be taken on an empty stomach. For Resident 202, the nurse did not administer Magnesium Oxide and Acamprosate as ordered, citing the resident's refusal due to stomach upset, which the resident later denied.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed during a survey. An opened one-liter bottle of 0.9% Sodium Chloride solution was found without an open date label, making it impossible to determine when it should be discarded. Additionally, temperature logs for medication refrigerators showed multiple instances of out-of-range temperatures without any documentation of corrective actions taken. A box of lemon glycerin swab sticks was improperly stored in a freezer, despite instructions indicating they should not be frozen. Furthermore, two plastic bags containing both labeled and unlabeled medications were found in the medication storage room sink, with no clear understanding of why they were there or what should be done with them. The survey also revealed an opened container of glucometer strips in a medication cart without an open date label, contrary to instructions that require discarding the strips 60 days after opening. These deficiencies were confirmed through interviews with licensed nurses, who acknowledged the issues but were unsure of the appropriate actions to take. The facility's policies and procedures for medication storage and disposal were reviewed, highlighting the lack of adherence to established guidelines, which could potentially lead to ineffective and unsafe medication administration.
Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement a water management program to prevent the growth of Legionella and other waterborne pathogens in their water system. During an interview and record review, the Administrator and Director of Nursing admitted that the facility did not have a system in place to test and track for Legionella and other harmful pathogens. The facility's assessment did not address a water management program, and the Administrator confirmed that no water testing had been conducted to ensure the absence of Legionella or other pathogens in the water system. The facility's policy and procedure documents, dated September 2022, indicated that a water management program should be part of the infection control program, overseen by a water management team. However, these procedures were not followed, as evidenced by the lack of a water management program or team. The CDC guidelines encourage healthcare facilities to develop comprehensive water management programs to reduce the risk of Legionella growth and transmission, but the facility did not adhere to these guidelines, potentially exposing residents to harmful pathogens.
Facility Fails to Maintain Safe and Functional Environment for Residents
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for two residents. In one instance, a resident's bed was not in working order, making it difficult for the resident to feed themselves as the head of the bed could not be elevated. The maintenance supervisor was informed of the issue by a night shift CNA four days prior, but the bed had not been repaired, and the resident was not moved to an available functional bed. The maintenance supervisor indicated that the nursing department should have moved the resident to the other bed. In another instance, an extension cord with six sockets was found on a bedside table near a resident's head, and the bed control switch had a frayed wire within easy reach of the resident. Both the director of nursing and the maintenance supervisor confirmed these findings during an observation. The facility's policies and procedures require the maintenance department to ensure that equipment is maintained in a safe and operable manner, including routine inspections of residents' beds and their components for safe operating conditions.
Failure to Prevent Worsening of Pressure Injuries
Penalty
Summary
The facility failed to prevent the worsening of a Deep Tissue Injury (DTI) and the development of additional pressure injuries in a resident. The resident, who had a history of a right heel DTI, a spiral fracture of the right tibia, Type II Diabetes, and hemiplegia, was admitted with a brace on the right lower extremity. The brace, which was not to be modified or removed until a follow-up with an orthopedic surgeon, caused irritation and pressure ulcers on the heel and ankle. Despite an email from Central Coast Orthopedics allowing modification of the immobilizer, the facility did not act promptly, leading to the worsening of the initial DTI and the development of three additional wounds. The resident's wound assessments showed a progression from a single DTI on the right heel to additional wounds on the lateral, posterior, and medial right ankle. The facility's records indicated that the resident experienced significant pain and non-compliance with positioning due to the brace. The brace was eventually removed after it was found to be causing significant pressure and eschar formation on the resident's skin. Despite the worsening condition, the facility continued with the same treatment orders without revising the care plan in a timely manner. The Director of Nursing confirmed that the facility's policy and procedure for pressure injuries were not followed. The facility failed to evaluate the resident's clinical condition and risk factors adequately, implement appropriate interventions, monitor the impact of interventions, or revise interventions as needed. This lack of adherence to policy resulted in the resident's DTI worsening and the development of additional pressure injuries, leading to increased pain and an additional hospital stay.
Failure to Report Resident Fall with Injury
Penalty
Summary
The facility failed to comply with the state requirement of reporting unusual occurrences by not reporting a fall with injury to the Department for one of the sampled residents. The clinical record indicated that the resident sustained an unwitnessed fall from a wheelchair in the dining room, resulting in injuries that required emergency medical services and a transfer to the emergency room. During an interview, the Administrator stated that no report was filed because the former Administrator did not report the fall to the California Department of Public Health, as the patient did not return to the facility from the hospital and therefore was not given a diagnosis. The facility's policy and procedure on Unusual Occurrence Reporting required such incidents to be reported via telephone within twenty-four hours and a written report to be sent within forty-eight hours, which was not followed in this case.
Failure to Provide an Environment Free from Restraints
Penalty
Summary
The facility failed to provide an environment free from restraints for one of the sampled residents when all four side rails of the resident's bed were raised. The facility's policy and procedure on the use of restraints, dated April 2017, explicitly stated that practices preventing resident mobility, such as using bedrails to keep a resident from voluntarily getting out of bed, are considered restraints and are not permitted. Despite this policy, Resident 1's consent form dated July 30, 2019, indicated that the resident did not consent to the use of side rails. However, during an observation on March 21, 2024, Resident 1 was found in bed with all four side rails up. Interviews with facility staff revealed that the Certified Nursing Assistant (CNA) had raised all four side rails to prevent Resident 1 from getting out of bed due to the resident's history of falls. The Director of Nursing (DON) confirmed that staff should not use bed side rails to prevent residents from getting out of bed as they are considered restraints. The Administrator also acknowledged that having all four bed side rails up is considered a restraint and that Resident 1 should not have had the side rails up as the resident did not consent to their use.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 28 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Maria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Maria Post Acute | 1.2 mi | ★★★★★ | 0 | 0 |
| Valley Oaks Post Acute | 1.7 mi | ★★★★★ | 11 | 0 |
| Marian Regional Medical Center D/p Snf | 2.3 mi | ★★★★★ | 5 | 0 |
| Arroyo Grande Care Center | 14 mi | ★★★★★ | 0 | 0 |
| Lompoc Skilled Nursing & Rehabilitation Center | 20.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.