Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Villa Maria Post Acute during CMS and state inspections, most recent first.
A resident with complex medical conditions was admitted and received an initial comprehensive nursing assessment completed solely by an LPN, without RN oversight, contrary to state regulations and facility policy requiring an RN to perform comprehensive assessments.
A resident did not have a nursing note recorded in their medical record following the completion of a comprehensive admission assessment, as required by facility policy. Review of the electronic medical record confirmed the absence of this documentation, and the ADON acknowledged that the note should have been completed.
A resident on enhanced transmission precautions had a small, uncovered waste bin in their room that was overflowing, with a used PPE gown hanging out and onto the floor. Facility policy requires effective disposal of infectious waste, and staff confirmed the bin should have been larger and covered.
Staff failed to promptly remove foul-smelling soiled linen from a hallway linen cart, resulting in an uncomfortable environment for two residents. Both residents and an LPN confirmed the persistent odor, and the Assistant Administrator acknowledged the cart should have been removed. Facility policy requires soiled linen to be removed from resident-care areas at least daily or more often as needed.
A resident with a gastrostomy tube experienced a clogged tube, and the facility failed to document the interventions attempted to address the issue. The resident was sent to the emergency department, but there was no prior documentation of the actions taken or the communication regarding the problem. The facility's policies required documentation of nursing actions, but this was not followed, as acknowledged by the DON and Administrator.
The facility failed to use pasteurized eggs for undercooked preparations, improperly stored food items, and did not monitor refrigerator temperatures as required. Additionally, inappropriate drainage piping was used for the ice machine, lacking the necessary air gap to prevent contamination.
A facility failed to obtain informed consent for psychotropic medications for a resident with multiple mental health diagnoses, including PTSD and vascular dementia. The resident was prescribed Seroquel and Olanzapine, but the consent forms were not signed before administration, violating the facility's policy and the resident's rights.
The facility failed to properly document POLST and Advance Directives for two residents. One resident's POLST was not signed until after admission, and another resident's records showed conflicting DNR and Full Code orders, not reflecting their documented wishes. These lapses could delay necessary treatment aligned with residents' preferences.
The facility did not follow its policy on handling resident property loss. A wallet with personal identification was found in a medication cart, belonging to a resident discharged months earlier. The policy requires documentation and reporting of lost or stolen property, which was not done.
A facility failed to conduct a comprehensive assessment for a significant change in condition for a resident who was readmitted from the hospital and had been taken off antipsychotic medications, leading to increased disorganization. The facility did not initiate the required assessment, and the DON and MDS nurses acknowledged this oversight.
The facility failed to complete PASRR Level II evaluations for three residents, leading to potential deficiencies in care. A resident experienced a significant mental health decline after hospital readmission, but the facility did not initiate a PASRR screening. Two other residents had positive Level I screenings requiring Level II evaluations, which were not completed due to oversight and procedural issues.
A facility failed to notify the State mental health authority after a resident experienced a significant decline in mental health following the discontinuation of anti-psychotic medication. Despite documenting the change for 72 hours, the facility did not conduct a PASSAR screening to evaluate the resident's condition. The DON and MDS nurses confirmed the oversight, which was against the facility's policy requiring a comprehensive care plan update.
The facility failed to discard expired Povidone-Iodine prep pads, date an opened vial of PPD solution, and date an open container of glucose test strips. Additionally, Barium Sulfate stored in the medication refrigerator lacked a documented physician order for specific resident use. These failures could lead to residents receiving expired, ineffective, and unprescribed medications and treatments.
The facility failed to store Schedule II drugs under double lock and did not sign a controlled drug count sheet post-administration, violating its P&P. Additionally, refrigerator logs showed out-of-range temperatures for medication storage, risking drug efficacy.
A facility failed to implement transmission-based precautions for a resident with a Multidrug Resistant Organism (MDRO), specifically ESBL. Despite the resident's history indicating the need for contact isolation, the resident was not placed on Enhanced Barrier Precautions (EBP) upon admission. Interviews with staff confirmed the oversight, which was contrary to the facility's infection control policy.
Comprehensive Nursing Assessment Not Performed by RN at Admission
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including heart failure, atrial flutter, diabetes, and a cognitive communication deficit, was admitted to the facility. The initial comprehensive nursing assessment for this resident was completed and signed by an LPN, rather than a registered nurse (RN). According to the California Association of Long-Term Care Medicine and state regulations, an LPN is permitted to conduct only basic patient assessments and is not authorized to perform comprehensive health assessments, which are required to be completed by an RN. A review of the facility's policy and procedure for admissions indicated that a licensed nurse should perform a complete assessment of body systems and complete the admission assessment form and nursing notes. However, during an interview, the Assistant Director of Nursing confirmed that there was no evidence of RN oversight during the admission assessment for this resident, and acknowledged that such oversight should have been present.
Failure to Document Admission Nursing Note After Comprehensive Assessment
Penalty
Summary
The facility failed to ensure that a nursing note was recorded in the medical record for one resident following the completion of their comprehensive admission assessment. According to the facility's policy and procedure for admissions, licensed nurses are required to perform a complete assessment of body systems and document their findings in both the admission form and nursing notes. However, a review of the electronic medical record revealed that no admission nursing note was present for the resident. During an interview, the Assistant Director of Nursing acknowledged the absence of the required admission nursing note and confirmed that it should have been completed.
Improper Disposal of PPE Due to Inadequate Waste Bin
Penalty
Summary
The facility failed to provide an appropriately sized and covered waste bin for the safe disposal of used personal protective equipment (PPE) for one resident on enhanced transmission precautions. During observation, a small, uncovered waste bin in the resident's room was found overflowing, with a discarded yellow PPE gown hanging out and onto the floor. The facility's infection prevention and control policy requires effective methods for the safe storage, transport, and disposal of infectious waste. A certified nursing assistant confirmed that the resident was on enhanced transmission precautions and that the gown should have been discarded in a larger, lidded trash can. The administrator acknowledged awareness of the issue after being informed by the CNA and stated that the waste bin should have had a lid.
Failure to Remove Soiled Linen Results in Uncomfortable Environment
Penalty
Summary
Facility staff failed to maintain a comfortable environment for residents by leaving foul-smelling dirty linen in a linen cart in the hallway, as observed and confirmed by both residents and staff. Two residents reported that the odor in the hallway became very unpleasant when soiled linen was left in the hamper, with one resident specifically noting that staff should remove the linen to a different area. A licensed nurse acknowledged the presence of a bad smell coming from the linen collection bins, and the Assistant Administrator confirmed that the dirty linen cart should have been removed from the resident area. Facility policy and procedure documents reviewed indicated that soiled linen should be removed from resident-care areas at least daily, and more frequently if needed, to maintain a safe, functional, sanitary, and comfortable environment.
Failure to Document Interventions for Clogged G-Tube
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident 1, who was admitted with multiple serious health conditions including amyotrophic lateral sclerosis, dysphagia, and a gastrostomy tube (g-tube) for nutrition. The deficiency was identified when there was no documentation of interventions taken for a change in the resident's condition, specifically when the g-tube became clogged. The nursing progress notes indicated that the resident was sent to the emergency department for evaluation due to the clogged g-tube, but there was no prior documentation of the attempts made to unclog the tube or the phone call received by the Director of Nursing (DON) regarding the issue. During interviews, both the DON and the Administrator acknowledged the lack of documentation regarding the interventions attempted to address the clogged g-tube. The facility's policies and procedures required that all nursing actions be documented in the progress notes as soon as possible after resident needs were met, and continuous nurse's notes were required as necessary. However, the DON admitted uncertainty about whether these policies were followed, and the Administrator noted that the documentation was not as robust as it should have been. Additionally, the Medication Administration Record (MAR) indicated that enteral feeding via the g-tube was not administered during the night and day shifts when the issue occurred.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the use of pasteurized eggs for egg preparations that are not fully cooked. During an observation, it was noted that the facility had an open box of unpasteurized eggs, and the Registered Dietician (RD) confirmed that pasteurized eggs were not available due to cost concerns. The RD and a staff member acknowledged that eggs were sometimes cooked undercooked upon resident request, which was against the facility's policy that required the use of pasteurized eggs. Additionally, the facility did not store food in accordance with professional standards. An open and undated bag of shredded mozzarella cheese was found in the refrigerator, and a staff member's personal water bottle was stored in the freezer. The RD acknowledged these storage issues, noting that the cheese should have been covered and labeled, and personal items should not be stored in the freezer. The facility also failed to monitor and document refrigerator temperatures as required. The Assistant Director of Nursing (ADON) acknowledged that temperature logs were only checked during the PM shift, contrary to the policy that required checks during both AM and PM shifts. Furthermore, there was no documentation of corrective actions for out-of-range temperatures. Lastly, the facility used inappropriate drainage piping material for the ice machine, which did not maintain the required air gap to prevent contamination, as confirmed by the Director of Maintenance and the Department of Health Care Access and Information.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medications for one of the residents, identified as Resident 37. This deficiency was identified during a review of Resident 37's records, which showed that the resident was admitted with several diagnoses, including a psychotic disorder, vascular dementia with agitation, depressive episodes, and chronic PTSD. The physician had prescribed Seroquel and Olanzapine for the resident's conditions. However, the informed consent forms for these medications were not signed by the resident or their representative before the medications were administered. During an interview and record review with the Assistant Director of Nursing, it was confirmed that the informed consents for Seroquel and Olanzapine were not signed prior to the resident receiving the medications. The facility's policy and procedures on psychotropic drug use, dated November 2023, require that informed consent be obtained before the use of such medications. The failure to adhere to this policy resulted in a violation of the resident's right to make an informed decision regarding their treatment.
Failure to Document POLST and Advance Directives
Penalty
Summary
The facility failed to complete and accurately document a Physician Order for Life Sustaining Treatment (POLST) and Advance Directive for two residents. For Resident 5, the POLST form was not included in the clinical record upon admission, and it was only signed on a later date, indicating a delay in obtaining the necessary documentation. The resident confirmed signing multiple documents that were not previously signed at the time of admission, highlighting a lapse in the facility's process for ensuring timely completion of critical care directives. For Resident 37, there was a discrepancy between the physician orders and the resident's documented wishes. The clinical record showed conflicting orders of Do Not Resuscitate (DNR) and Full Code, while the resident's Advance Directive indicated a preference for DNR. The Assistant Director of Nursing acknowledged the inconsistency and the failure to update the POLST form to reflect the resident's wishes. This oversight could potentially lead to actions contrary to the resident's end-of-life treatment preferences.
Failure to Follow Policy on Resident Property Loss
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the loss or theft of resident property. During an observation, a brown wallet containing a driver's license, social security card, and military identification was found in a locked medication drawer of medication cart number one. The wallet belonged to a resident who had been discharged against medical advice several months prior. A licensed nurse acknowledged that the wallet should not have been kept in the medication cart and should have been taken to social services. The facility's policy requires that any loss or theft of resident property worth $25 or more be documented and reported for investigation, but this procedure was not followed in this instance.
Failure to Conduct Comprehensive Assessment for Significant Change in Condition
Penalty
Summary
The facility failed to conduct a comprehensive assessment for a significant change in condition for one resident, identified as Resident 15. This resident was readmitted to the facility from the hospital and had recently been taken off antipsychotic medications, leading to increased disorganization. A psychologist recommended restarting the previous medication, Seroquel, which had been effective. However, the facility did not initiate a comprehensive assessment following this significant change in the resident's condition. During an interview, the Director of Nursing and two MDS nurses acknowledged that the significant change in status assessment was not completed for Resident 15. The facility's policy on change of condition assessment and reporting, dated November 2021, requires timely notification and modification of the Resident Assessment Instrument and Comprehensive Care Plan as needed.
Failure to Complete PASRR Level II Evaluations
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) Level II evaluations were completed for three residents, leading to potential deficiencies in their care. Resident 15 experienced a significant decline in mental health after being readmitted from the hospital, as noted by a psychologist who recommended restarting antipsychotic medication. Despite this significant change, the facility did not initiate a PASRR screening or comprehensive assessment. The facility's policy required a new PASRR if there was a significant change in a resident's condition upon return from a temporary absence, which was not followed in this case. For Residents 37 and 66, the facility failed to complete the necessary PASRR Level II evaluations after positive Level I screenings indicated the need for further assessment. Resident 37's positive Level I screening required a Level II evaluation, which was acknowledged as overlooked by the Assistant Director of Nursing. Similarly, Resident 66 had a positive Level I screening, but the facility did not have a Level II evaluation on file due to a duplicate PASRR issue. The facility was informed that a new Level I screening was required after the resident's hospital stay exceeded 15 days, but this was not completed, as confirmed by the facility's PASRR Consultant.
Failure to Notify State Mental Health Authority of Resident's Condition Change
Penalty
Summary
The facility failed to notify the State mental health authority following a significant decline in the mental health condition of a resident who required mental health services. This deficiency was identified during a review of the resident's psychologist progress notes, which indicated that the resident had been taken off anti-psychotic medication after being discharged from the hospital and had become increasingly disorganized. The facility documented the change in the resident's condition for 72 hours but did not initiate a PASSAR screening to evaluate the resident's mental health status accurately. During an interview with the Director of Nursing (DON) and two MDS nurses, it was confirmed that the PASSAR screening for the resident's significant mental change of condition was not conducted. The facility's policy and procedure on change of condition assessment and reporting, dated November 2021, required a comprehensive care plan to be completed or modified as needed, but this was not adhered to in this case.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to ensure proper pharmaceutical services by not discarding expired Povidone-Iodine prep pads, not dating an opened vial of purified protein derivative (PPD) solution, and not dating an open container of glucose test strips. During an inspection of the medication storage area, a box of expired Povidone-Iodine prep pads was found, and a vial of PPD was opened without a date. The facility's policy and procedures (P&P) require that outdated or deteriorated medications be immediately removed and disposed of, and that PPD bottles be dated when opened and discarded after 30 days. Additionally, a container of diabetic glucose test strips was opened and undated, contrary to the manufacturer's guidelines, which state that test strips should be used within three months of opening the vial. Furthermore, Barium Sulfate, a contrast agent stored in the medication refrigerator, lacked a documented physician order for specific resident use. The facility's P&P mandates that drugs or biologicals be administered only upon written order from a licensed and authorized prescriber, with orders recorded on the physician's order sheet in the resident chart. During a review of all resident physician orders, the Director of Nursing confirmed that no orders for Barium Sulfate were found in the facility's electronic or paper charting system. These failures had the potential for residents to receive expired, ineffective, and unprescribed medications and treatments.
Deficiencies in Drug Storage and Administration Protocols
Penalty
Summary
The facility failed to adhere to its policy and procedure (P&P) regarding the storage and administration of Schedule II drugs, which are known for their high potential for abuse and dependence. During an inspection, it was observed that these drugs were not stored under double lock as required by the facility's P&P. Additionally, a controlled drug count sheet was found unsigned after medication administration, contrary to the P&P that mandates the licensed nurse to immediately document the date, time, amount administered, and their signature after administering a controlled medication. Furthermore, the facility did not maintain proper refrigerator temperatures for medication storage, as evidenced by the refrigerator log showing out-of-range temperatures for April, May, and June of 2024. The facility's P&P specifies that medications requiring refrigeration should be kept at temperatures between 2°C (36°F) and 8°C (46°F) with a thermometer for monitoring. These lapses in protocol could potentially lead to Schedule II drugs being accessible to unauthorized individuals and medications losing their efficacy due to improper storage conditions.
Failure to Implement Transmission-Based Precautions for MDRO
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident diagnosed with a Multidrug Resistant Organism (MDRO), specifically Extended-spectrum beta-lactamases (ESBL). The resident's History and Physical indicated a urinary tract infection with a history of ESBL, and the resident was supposed to be on contact isolation. However, during a review of the clinical record with the Assistant Director of Nursing, it was acknowledged that the resident was colonized with ESBL on admission and should have been placed on Enhanced Barrier Precautions (EBP). Interviews with a Licensed Nurse and the Infection Preventionist revealed that the resident was not on any isolation, including EBP, despite having completed treatment for an ESBL infection. The facility's policy on infection prevention and control, which includes the use of EBP for MDROs, was not followed. This oversight had the potential to result in the spread of harmful microorganisms to staff, residents, and visitors.
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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.
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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) |
|---|---|---|---|---|
| Valley Oaks Post Acute | 0.6 mi | ★★★★★ | 11 | 0 |
| Marian Regional Medical Center D/p Snf | 1.2 mi | ★★★★★ | 5 | 0 |
| Santa Maria Post Acute | 1.2 mi | ★★★★★ | 4 | 0 |
| Arroyo Grande Care Center | 14.3 mi | ★★★★★ | 0 | 0 |
| Lompoc Skilled Nursing & Rehabilitation Center | 21.1 mi | ★★★★★ | 0 | 0 |
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