Santa Clarita Post-Acute Care Center

In the surveyor’s words

From the most serious findings on record at Santa Clarita Post-Acute Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF710Feb 9, 2024

  Based on interview and record review, the facility failed to ensure medical supervision of the care for one of three sampled residents (Resident 399), who was newly admitted to the facility and had diagnosis of diabetes mellitus (DM - is a disorder in which the body does not produce enough or respond normally to insulin [a hormone that controls the amount of sugar in the blood], causing blood sugar (glucose) levels to be abnormally high). Attending Physician 1 (MD 1), who was a new doctor for Resident 399 at the facility, did not perform a thorough review of Resident 399's discharge documents from General Acute Care Hospital 1 (GACH 1) including diagnoses and medications to meet the resident's diabetic care upon Resident 399's admission to the facility on [DATE]. […]

• Immediate jeopardy, isolatedF760Feb 9, 2024

  Based on interview and record review, the facility failed to: A. Ensure one of three sampled residents (Resident 399), who was newly admitted to the facility and had diagnosis of diabetes mellitus (DM - is a disorder in which the body does not produce enough or respond normally to insulin [a hormone that controls the amount of sugar in the blood], causing blood sugar (glucose) levels to be abnormally high), was free from medication error (any error [of commission or omission] that occurs at any point in the medication use process). […]

• Immediate jeopardy, isolatedF678Feb 3, 2023

  Based on interview and record review, the facility failed to provide immediate emergency care including cardiopulmonary resuscitation (CPR- emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) for one of two sampled residents (Resident 73) who was found unresponsive (when a person is at least unconscious[abnormal state in which a person exhibits a complete, or near-complete, inability to maintain an awareness of self and environment], and possibly dead or dying) on [DATE] at 10:40 p.m. This deficient practice resulted in Resident 73's death on [DATE] at 10:45 p.m. […]

• Actual harm, isolatedF686Jul 2, 2024

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received care consistent with professional standards of practice to prevent from development of a Stage 3 pressure ulcers ([PU] a localized injury to the skin and/or underlying tissue usually over a bony prominence because of pressure) by failing to: 1. Ensure Resident 1 ' s right heel was elevated ([offloaded] minimizing or removing weight placed on the foot and heel to help prevent development and assisted in pressure ulcers healing) off the mattress and was not continuously laying directly on the mattress thus contributing to the development of Resident 1 ' s right heel pressure ulcer. 2. […]

• Actual harm, isolatedF689Feb 3, 2023

  Based on observation, interview, and record review, the facility failed to provide to three of six sampled residents (Resident 18, Resident 48, and Resident 66) an environment free of accident hazards and adequate supervision and assistance to prevent falls and injury for Resident 18 and elopement for Resident 66. 1. For Resident 18, the facility failed to ensure: a. The Interdisciplinary Team (IDT, group of healthcare staff from different disciplines involved in the care of the resident), met, reviewed, and/or revised Resident 18's care plans after each fall to develop and implement resident-centered interventions with measurable goals to prevent falls. b. […]