Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Valley Oaks Post Acute during CMS and state inspections, most recent first.
Medication administration did not follow prescriber orders for three residents. One resident received a beta blocker when SBP was below the ordered hold parameter, another did not receive PRN Hydralazine for elevated BP and also received PRN opioid doses when pain was below the ordered threshold, and a third resident received scheduled opioid doses when pain scores were above the ordered range. The DON verified the discrepancies during record review.
A resident's patient identification sticker was observed left unattended on top of a locked medication cart. The Charge Nurse stated the label should not have been left unattended, and facility policy addressed confidentiality and safeguarding PHI.
Failure to develop timely care plans for medication and wound needs: one resident had Trazodone HCL ordered without an initial care plan started when the medication was first prescribed, and another resident had an unstageable sacrococcyx pressure injury assessed and treated without a corresponding care plan. The DON and MDSC acknowledged the missing care plan entries.
Improper medication storage was found in two med carts when surveyors observed two unlabeled tablets, open syringes, and an open container of pudding in the drawers. Surveyors also found Enoxaparin syringes with different expiration dates stored together in the same bag, and the Charge Nurse stated the items were not supposed to be there and meds should remain in the original bag when expiration dates differ.
A resident's Medication Administration Record (MAR) inaccurately showed that medication was administered within the facility on two occasions, when in fact the resident had left the facility and received the medication from an outside provider. The DON confirmed the discrepancy, resulting in inaccurate medical records.
A resident experiencing coffee ground emesis, indicative of upper GI bleeding, was transferred to the ED without a comprehensive nursing assessment being documented beforehand. Review of nursing progress notes and interview with the DON confirmed the absence of required assessment documentation prior to the transfer.
A resident with complex medical needs, including a stage 4 sacral pressure ulcer and deep tissue injury to the heel, did not receive or have documented daily wound care treatments as ordered by the physician for two consecutive days. The DON confirmed that the absence of documentation indicated the treatments were not performed, despite facility policy requiring assessment and documentation of pressure ulcers and their care.
A resident with multiple complex medical conditions experienced a fall and developed a bloodshot eye, but staff failed to complete required change in condition assessments, post-fall risk evaluations, and timely documentation. Family notification was not performed as per policy, and the IDT meeting to review the resident's status was delayed beyond the required timeframe. These actions resulted in incomplete records and communication regarding the resident's care.
A resident with Type 2 Diabetes and multiple other diagnoses was admitted to a facility without an insulin sliding scale order. Despite consistently high blood sugar levels, the facility failed to manage the resident's diabetes effectively. The resident's condition worsened, leading to hospitalization with diabetic ketoacidosis and subsequent death. The facility's inadequate response and lack of timely medical intervention contributed to the resident's critical condition.
The facility failed to ensure dishware was air-dried before stacking, as observed by surveyors. A dietary aide was seen stacking wet dishes, contrary to facility policy and FDA guidelines, potentially affecting all 51 residents. Interviews confirmed improper drying practices, posing a risk of bacterial growth and foodborne illness.
Two residents in an LTC facility experienced falls without proper evaluation or documentation, leading to deficiencies in fall prevention. One resident with severe cognitive impairment fell from bed, and another with Alzheimer's disease had multiple falls. The facility failed to update care plans or document incidents, resulting in a lack of communication and intervention.
The facility failed to ensure proper documentation and follow-up for falls experienced by two residents. One resident rolled off the bed during care, and another experienced multiple falls, but the incidents were not properly documented or discussed by the interdisciplinary team (IDT). The facility's processes for evaluating and addressing falls were not effectively implemented, leading to a lack of follow-up and intervention.
A facility failed to ensure staff adhered to contact isolation precautions for a resident with Clostridium difficile (C. diff). Observations revealed that staff, including a housekeeper and CNAs, entered the resident's room without wearing the required gown and gloves, despite the presence of a sign indicating contact precautions. The resident had severe cognitive impairment and a history of recurrent enterocolitis due to C. diff. Interviews with the Infection Preventionist and DON confirmed the expectations for PPE use and hand hygiene, which were not consistently followed, leading to the deficiency.
A resident was unable to access their personal funds on a weekend due to the facility's practice of limiting access to funds outside of weekday hours. Despite the facility's policy and regulatory requirements, the resident was told to wait until Monday unless it was an emergency. The resident had intact cognition and a medical history including type 2 diabetes mellitus.
The facility did not submit the findings of an alleged abuse investigation involving two residents to the State Survey Agency within the required timeframe. The incident involved a physical altercation between two residents, and although the investigation was completed, the results were not reported as per the facility's policy.
A resident with dementia and Alzheimer's exhibited aggressive behavior, which was documented in Nursing Progress Notes but inaccurately reflected in the MDS assessment. The facility's DON acknowledged the discrepancy, which could lead to unmet care needs.
A resident with dementia and Alzheimer's exhibited aggressive behavior, including kicking another resident, but their care plan was not revised as required by facility policy. The care plan had not been updated since a previous revision, despite documented changes in the resident's condition.
Medication orders and pain/BP parameters not followed
Penalty
Summary
The facility failed to ensure staff followed physician medication orders for three sampled residents when administering medications and checking required parameters. Resident 13, who had COPD, paroxysmal atrial fibrillation, a pacemaker, and HTN, had an order for Metoprolol Succinate 25 mg with instructions to hold the dose if SBP was less than 110 or HR was less than 60. Staff administered the medication when the resident’s SBP was 108 on two occasions, and the DON verified the discrepancies during record review. Resident 6, who had type 2 DM with diabetic CKD, HTN, and was receiving surgical aftercare following circulatory system surgery, had orders to monitor BP with SBP goals of 100-160 and to give Hydralazine 25 mg every 6 hours as needed for SBP over 160. Staff did not administer Hydralazine when the resident had elevated BP readings of 177/66, 202/90, and 176/71. Resident 6 also had an order for Hydrocodone-Acetaminophen 5-325 mg every 8 hours as needed for severe pain 7-10/10, but the medication was given on multiple occasions when the resident reported pain at 6/10. The DON confirmed the discrepancies and stated staff should have thoroughly checked and followed physician orders. Resident 3, who had a nondisplaced fracture of the right second metatarsal bone, a stage 4 pressure ulcer of the right buttock, and post-traumatic osteoarthritis of the right ankle and foot, had an order for Hydrocodone-Acetaminophen 10-325 mg every 4 hours for pain 1-6/10 and every 8 hours as needed for breakthrough pain related to the pressure ulcer. Staff administered the medication on multiple dates when the resident’s reported pain was 7/10 to 9/10, rather than reassessing pain before giving the medication. The DON confirmed staff did not follow the order instructions and acknowledged this could have resulted in ineffective pain management. The facility policy stated medications are to be administered in accordance with prescriber orders, and the nursing reference cited that nurses are obligated to follow physician orders unless they believe the orders are in error or would harm clients.
Failure to Secure Resident PHI
Penalty
Summary
The facility failed to ensure identifiable information was secured and kept confidential when a patient identification sticker for Resident 51 was left unattended on top of a locked medication cart. During observation on 2/10/26 at 6:18 a.m., one patient identification label was seen left unattended on top of the medication cart. During an interview on 2/10/26 at 7:14 a.m., the Charge Nurse stated that the patient identification label should not be left unattended on the cart. Facility policies titled HIPPAA Compliance and Protected Health Information (PHI), Safeguarding Electronic, were reviewed and indicated the facility's procedures for maintaining confidentiality and safeguarding PHI.
Failure to Develop Timely Care Plans for Medication and Pressure Injury Needs
Penalty
Summary
Resident 9, an older male admitted with diagnoses including moderate protein-calorie malnutrition, dementia, alcohol dependence, anxiety disorder, and GERD, had an order for Trazodone HCL 50 mg at bedtime with an order date of 11/30/25. Review of the care plan showed that the Trazodone HCL care plan was not initiated on the same date the medication was ordered; instead, it was initiated on 1/28/26 and revised on 2/11/26. During interview and record review, the MDSC and DON acknowledged that the care plan for Trazodone HCL was not started when the medication was ordered. Resident 40, an older male admitted with diagnoses including myelodysplastic syndrome, atrial fibrillation, transient ischemic attack, and megaloblastic anemias, had physician progress notes and a wound assessment identifying wound number three as an unstageable sacrococcyx pressure injury with a service date of 12/17/25. The wound assessment report confirmed the pressure injury was assessed and treated, but the care plan did not include a care plan for the sacrococcyx pressure injury. During interview and record review, the DON acknowledged that a care plan for the unstageable sacrococcyx pressure injury was not created on 12/17/25.
Improper Medication Storage in Medication Carts
Penalty
Summary
Medications and biologicals were not stored in a sanitary manner and were not separated from non-medication and food items in two medication carts. During an observation of the West Cart, surveyors found two unidentified, unlabeled medication tablets in the bottom drawer, an open syringe in the drawer for a room, and an open container of pudding in the top drawer. During an observation of the East Cart, surveyors found an open syringe in a medication drawer and two syringes of Enoxaparin 40 mg/0.4 ml with an expiration date of 03/2028 stored in the same bag as four syringes of the same medication expiring 08/2028. During interview, the Charge Nurse stated the two medications in the bottom drawer were not supposed to be there, there should not have been open syringes or open pudding in the drawers, and medications should be kept in the original bag when they have different expiration dates. Facility policy titled Storage of Medications stated medications and biologicals are to be stored safely, securely, and properly, following manufacturer recommendations or those of the supplier, and that transfer of medications from one container to another is done only by the pharmacy. Facility policy titled Medication Destruction stated tablets, capsules, and liquids are to be disposed of in accordance with the Medical Waste Management Act.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for one resident when the Medication Administration Record (MAR) indicated that medication was administered on two specific dates, despite the resident having left the facility and receiving the medication from an outside provider. Review of the outside provider's Medication Dosing Log confirmed that the medication was administered at their facility on those dates. During an interview, the Director of Nursing confirmed that the resident did not receive the medication in the facility, but rather from the outside provider. This resulted in the MAR reflecting inaccurate documentation of prescribed medication, contrary to accepted professional standards for medication administration and recordkeeping.
Failure to Document Comprehensive Assessment Prior to Hospital Transfer
Penalty
Summary
The facility failed to document a comprehensive nursing assessment for one of two sampled residents who experienced a significant change in condition. Specifically, the nursing progress notes for the resident, who was sent to the Emergency Department for coffee ground emesis (a sign of upper gastrointestinal bleeding), did not contain evidence that a comprehensive assessment was completed prior to transfer. During an interview and record review, the Director of Nursing confirmed that no assessment was documented, despite the expectation that one should have been completed. This lack of documentation was identified through review of nursing progress notes covering the period before the resident's transfer.
Failure to Provide and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
A resident was admitted to the facility with multiple complex medical conditions, including a stage 4 pressure ulcer on the sacral region and deep tissue damage to the left heel. Physician orders were in place for daily wound care treatments for both pressure ulcers, specifying cleansing, application of topical agents, and dressing changes. However, a review of the Treatment Administration Record (TAR) revealed missing documentation for the prescribed treatments on two consecutive days for both wounds. The Director of Nursing confirmed that blank entries on the TAR indicated the treatments were not performed, and acknowledged that the treatments should have been initiated as ordered, even though the resident was a new admission and it was the weekend. The facility's policy required full assessment and documentation of pressure ulcers, including current treatments, which was not reflected in the records for the days in question. The failure to provide and document the ordered wound care treatments constituted a lapse in ensuring that services met professional standards of quality for the resident's pressure ulcers.
Failure to Assess, Document, and Notify Changes in Resident Condition
Penalty
Summary
The facility failed to ensure proper assessment and notification procedures were followed for a resident who experienced multiple changes in condition. Specifically, when the resident was observed with a bloodshot right eye, there was no documentation of a change in condition (COC) assessment, such as an SBAR, in the medical record. The Director of Nursing (DON) confirmed that neither an assessment nor appropriate documentation was completed, despite facility policy requiring such documentation for changes in a resident's medical or mental condition. Additionally, the facility's policy on charting and documentation mandates that all changes in a resident's condition be recorded in the medical record, which was not done in this instance. Following a fall incident, the facility did not complete a post-fall risk assessment for the resident, as required by both the facility's orientation materials and its policy on assessing falls and their causes. The DON acknowledged that a post-fall assessment was not performed or documented, and that the facility's procedures require such an assessment after a fall. The lack of documentation and assessment meant that the resident's medical record did not accurately reflect the incident or the resident's subsequent risk status. Furthermore, the facility did not notify the resident's family of the changes in condition, including the fall and the bloodshot eye, as required by facility policy. The DON and a licensed nurse both stated that it is standard practice to notify family members after such incidents, but there was no evidence that this occurred. Additionally, the Interdisciplinary Team (IDT) meeting to review the resident's changes in condition was not conducted within the required 72-hour timeframe, with the DON confirming the delay. These failures resulted in incomplete communication and documentation regarding the resident's care and condition.
Failure to Manage Diabetes Leads to Resident's Hospitalization and Death
Penalty
Summary
The facility failed to provide quality care for a resident with Type 2 Diabetes (DM2) who was admitted with multiple diagnoses, including DM2 with neuropathy, COPD, pneumonia, atherosclerotic heart disease, chronic kidney disease, congestive heart failure, high blood pressure, transient ischemic attack, and cerebral infarct. Upon admission, the resident did not have an insulin sliding scale order, and the facility's protocol was to check blood sugar levels daily and notify a doctor if levels exceeded 400 mg/dl. Despite consistently high blood sugar readings, the facility did not adequately manage the resident's diabetes, leading to a critical situation. The resident's blood sugar levels were documented as consistently high, with readings such as 385 mg/dl, 390 mg/dl, and 498 mg/dl over several days. On one occasion, the night shift nurse notified the doctor when the blood sugar was 'HI,' and the doctor ordered 10 units of Lispro insulin, but there was no written or signed order for this. The resident's blood sugar continued to be high, and there was a lack of documentation and follow-up on the resident's glucose levels until the situation worsened. Ultimately, the resident was transferred to the hospital with a diagnosis of diabetic ketoacidosis with coma, acute kidney injury, and ventricular tachycardia. The resident's condition deteriorated, and he passed away the following morning. The facility's failure to manage the resident's diabetes effectively and provide timely medical intervention contributed to the resident's critical condition and subsequent death.
Improper Dish Drying Practices in Facility Kitchen
Penalty
Summary
The facility failed to ensure that dishware was allowed to air dry before being stacked in the kitchen, as observed by surveyors. This practice was contrary to both the facility's policy and the U.S. FDA 2022 Food Code, which require that dishes be air-dried before stacking to prevent microbial growth. During an observation, a dietary aide was seen stacking wet dessert bowls, plate holders, and plate covers without allowing them to air-dry. Interviews with the dietary aide, another staff member, the Food Service Supervisor, and the Administrator confirmed that the dishes were not being dried properly before stacking, which could lead to bacterial growth. The deficiency had the potential to affect all 51 residents who received meals from the facility's kitchen. The Director of Nursing was unaware of the dish drying and storing process, but expected the kitchen staff to follow proper procedures. The Administrator acknowledged the importance of allowing dishes to air-dry to prevent bacterial growth. The facility's failure to adhere to proper dish drying procedures posed a risk of foodborne illness to the residents.
Deficiencies in Fall Management and Documentation
Penalty
Summary
The facility failed to ensure proper evaluation and documentation of falls for two residents, leading to deficiencies in fall prevention and management. Resident #36, who had a history of severe cognitive impairment and was at high risk for falls, experienced a fall on 03/01/2024. The fall occurred when the resident rolled off the bed while receiving incontinence care. Despite the incident, no new interventions were added to the resident's care plan, and the fall was not documented in the facility's incident log. Interviews with staff revealed a lack of awareness and documentation regarding the fall, indicating a breakdown in communication and procedural adherence. Resident #25, who had Alzheimer's disease and was at risk for falls, experienced multiple falls between 06/19/2024 and 11/27/2024. Documentation for these falls was incomplete or initiated by staff who were not present at the time of the incidents. The facility's Director of Nursing (DON) and Director of Medical Records were unaware of these falls due to the absence of communication notes, which are necessary for initiating audits and discussions during clinical meetings. This lack of documentation and communication prevented the implementation of specific interventions to prevent further falls. The facility's policies on fall risk assessment and management were not effectively followed, as evidenced by the lack of documentation and failure to implement new interventions after falls occurred. The DON and Administrator expected nurses to complete all required documentation during the shift when incidents occurred, but this expectation was not met. The facility's failure to adhere to its policies and ensure proper communication and documentation contributed to the deficiencies in fall prevention and management for the residents involved.
Deficiency in Fall Documentation and Follow-Up
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to address and identify quality deficiencies related to the evaluation, tracking, and documentation of falls. This deficiency was identified during a survey conducted from December 16 to December 19, 2024, which revealed that the facility did not follow its established processes for discussing falls in morning meetings, conducting root-cause analyses, developing and implementing interventions, and evaluating the effectiveness of interventions for two residents who experienced falls. Resident #36 experienced a fall on March 1, 2024, when they rolled off the bed while receiving incontinence care. The resident was found on their knees beside the bed and complained of knee pain, with an abrasion noted on the right knee. However, there was no evidence in the resident's care plan of any new interventions added after the fall. Additionally, the incident was not included in the facility's Incidents by Incident Type log, and the Director of Nursing (DON) was unable to locate any documentation of an investigation or discussion by the interdisciplinary team (IDT) regarding the fall. Resident #25 experienced multiple falls on June 19, October 4, October 17, and November 27, 2024. Documentation for these falls was incomplete or missing, and the incidents were not captured in the facility's records. Interviews with staff revealed that communication notes and incident reports were not consistently completed, and the IDT did not discuss these falls in their meetings. The facility's processes for follow-up and audits related to falls were not effectively implemented, leading to a lack of documentation and follow-up on the residents' falls.
Failure to Adhere to Contact Isolation Precautions for C. diff Resident
Penalty
Summary
The facility failed to ensure staff adhered to contact isolation precautions and donned the appropriate personal protective equipment (PPE) while performing care or services in the room of a resident with a known communicable disease, Clostridium difficile (C. diff). This deficiency was identified during observations where staff members, including a housekeeper and certified nurse aides (CNAs), entered the resident's room without wearing the required gown and gloves, despite the presence of a sign indicating the need for contact precautions. The resident, who had severe cognitive impairment and a history of recurrent enterocolitis due to C. diff, was on contact precautions, and the failure to adhere to these precautions had the potential to affect other residents in the facility. During the observations, Housekeeper #3 entered the resident's room wearing gloves and a mask but no gown, acknowledging later that she forgot to don the gown. Similarly, CNA #4 entered the room without any PPE, moved the resident's wheelchair, and used hand sanitizer instead of washing hands with soap and water, which is necessary for C. diff. CNA #5 also failed to wear a gown while rearranging the resident's bed linens, which touched her clothing, and did not remove her gloves or wash her hands before exiting the room. These actions were contrary to the facility's policy and CDC guidelines, which require wearing gloves and gowns for all interactions that may involve contact with the resident or potentially contaminated areas. Interviews with the staff, including the Infection Preventionist (IP) and the Director of Nursing (DON), confirmed the expectations for PPE use and hand hygiene when dealing with residents on contact precautions. The IP and DON reiterated that staff should wear gowns and gloves when entering the resident's area, remove PPE before leaving the room, and wash hands with soap and water, especially in cases involving C. diff. Despite these protocols, the staff's failure to consistently follow the guidelines led to the deficiency noted in the report.
Failure to Provide Weekend Access to Resident Funds
Penalty
Summary
The facility failed to provide a resident with access to their personal funds on weekends, which is a violation of the resident's rights to manage their financial affairs. According to the facility's policy, residents should have access to funds of fifty dollars or less within twenty-four hours and access to larger amounts within three banking days. The State Operations Manual also requires that resident requests for access to their funds be honored as soon as possible, with specific timeframes for different amounts. However, Resident #20, who had intact cognition and a medical history including type 2 diabetes mellitus, hypothyroidism, and mixed hyperlipidemia, reported being unable to access their funds on a weekend because the Business Office employee was not available, and the Administrator encouraged waiting until Monday unless it was an emergency. Interviews with the Director of Nursing and the Administrator revealed that the facility managed residents' money and expected residents to have access to it after hours and on weekends. However, the Administrator indicated a preference to limit access to residents' funds on weekends, suggesting that non-emergency requests wait until the following Monday. This practice led to Resident #20 being unable to access their funds when needed, despite the facility's policy and regulatory requirements to provide timely access to personal funds.
Failure to Submit Abuse Investigation Findings
Penalty
Summary
The facility failed to submit the findings of an alleged abuse investigation to the State Survey Agency within five working days of the incident, as required by their policy. The incident involved two residents, where one resident was yelling because the other was in his bed, leading to a physical altercation where one resident kicked the other. The incident occurred on 9/29/24, and the facility's administrator confirmed the occurrence and the need for an investigation. However, despite completing the investigation, the results were not submitted to the Department, as confirmed by the administrator during an interview on 11/18/24. The facility's policy, revised in July 2017, mandates that a written report of the investigation findings be provided to the appropriate agencies within five working days, which was not adhered to in this case.
Inaccurate MDS Assessment of Resident's Behavior
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, leading to inaccurate documentation of the resident's behavior. The resident, who was admitted with diagnoses including dementia, Alzheimer's disease, depression, and hypertension, exhibited physical aggression towards others. Despite these behaviors being documented in the Nursing Progress Notes (NPN) on multiple occasions, the MDS assessment inaccurately reported that such behaviors were not exhibited. The discrepancy was acknowledged by the facility's Director of Nursing (DON) during a review of the resident's records. The DON confirmed that the MDS assessment did not accurately reflect the resident's aggressive behavior, as noted in the NPN. This inaccuracy in the MDS assessment had the potential for the resident's care needs to go unmet, as the assessment is a standardized tool used to measure health status and inform care planning.
Failure to Revise Care Plan for Aggressive Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for reviewing and revising a person-centered comprehensive care plan for a resident who exhibited aggressive behavior. Resident 1, who was admitted with diagnoses including dementia, Alzheimer's disease, depression, and hypertension, showed physical and verbal aggression, posing a danger to themselves and others. Despite these changes in condition, the care plan, last revised on July 8, 2024, was not updated to reflect the resident's new behavioral symptoms. The deficiency was highlighted when Resident 1 became aggressive and kicked another resident in the leg. This incident was documented in the nursing progress notes, but the care plan was not revised accordingly. The facility's policy, which mandates ongoing assessments and care plan revisions as residents' conditions change, was not followed. The Director of Nursing confirmed that the care plan was not updated after the resident's change in status, leading to the deficiency noted in the report.
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Illustrative
What surveyors actually found near you
We read the 21 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
A prioritized, do-first checklist
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Illustrative
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 | 0.6 mi | ★★★★★ | 0 | 0 |
| Marian Regional Medical Center D/p Snf | 0.6 mi | ★★★★★ | 5 | 0 |
| Santa Maria Post Acute | 1.7 mi | ★★★★★ | 4 | 0 |
| Arroyo Grande Care Center | 14.8 mi | ★★★★★ | 0 | 0 |
| Lompoc Skilled Nursing & Rehabilitation Center | 21 mi | ★★★★★ | 0 | 0 |
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