Santa Maria Post Acute

In the surveyor’s words

From the most serious findings on record at Santa Maria Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF803Aug 6, 2026

  Based on observations, interviews, and record review, the facility failed to ensure the dietitian reviewed the substituted lunch menu to be serve on 8/4/26.This failure had the potential to result in the facility serving substitution meals not approved and reviewed by the dietician per faciity protocol. During an observation on 08/04/2026 at 12:50 p.m. in the Kitchen, the lunch menu for Tuesday 8/4/26, indicated, modifications for polenta (an Italian dish made from boiled cornmeal) and fresh green salad which were substituted with mashed potato and carrots. During an interview on 08/04/2026 at 2:48 p.m. […]

• No harm, potential for more than minimal, widespreadF812Nov 21, 2024

  Based on observation, interview, and record review, the facility failed to ensure food safety standards were followed when: 1. A dietary aide/cook (DAC) was observed not following proper hygiene and sanitary practices during lunch tray preparation. 2. The frequency of the facility's ice machine sanitization schedule was not followed according to manufacturer's recommendations. These failures had the potential to cause food-borne illness to vulnerable residents currently residing in the facility. Findings: 1. During a lunch tray line observation on 11/19/24 at 12:15 p.m. inside the facility kitchen, with the registered dietitian (RD), certified dietary manager (CDM), and DAC, DAC was observed preparing cooked food for resident lunch tray distribution. […]

• No harm, potential for more than minimal, patternF755Aug 6, 2026

  Based on observation, interview, and record review, the facility failed to implement pharmacy policy and procedures when: A refrigerated medication emergency kit (e-kit) was replaced within 72 hours.The narcotic endorsement count sheet between oncoming and outgoing nurses to indicate the narcotic counts were correct was signed each change of shift.These failures had the potential to result in unavailability of emergency medications when needed, secondary to unreplenish medication e-kit, and unaccounted controlled drugs with potential for drug diversion.a. During an observation on 8/4/26, at 10:47 a.m., in the medication room, the refrigerated e-kit was observed missing a Glargin insulin pen, which was used on 7/8/26 and Ativan which was used on 7/19/26. […]

• No harm, potential for more than minimal, patternF809Aug 6, 2026

  Based on observation, interview, and record review, the facility failed to serve residents lunch at the scheduled mealtime.This failure had the potential to result in disruption of residents preference also in alignment with individual rights.Based on observation, interview, and record review, the facility failed to serve lunch at the scheduled mealtime.This failure had the potential to result in inadequate nutritional intake, hunger, and a negative impact on resident health and well-being due to the delay in receiving meals as scheduled. […]

• No harm, potential for more than minimal, patternF725Nov 21, 2024

  Based on interview and record review, the facility failed to provide nursing staff on a 24-hour basis to care for the residents' needs. This failure had the potential to result in residents not receiving necessary care. Findings: During a review of Report: Calculated Time by Entry, transmitted by the facility for the Payroll Based Journal (PBJ - quarterly staffing data report submitted to the Centers for Medicare and Medicaid Services [CMS] by long-term care facilities including the hours nursing staff are paid to work each day) Report for Quarter 1, 2024 (October 1, 2023 - December 31, 2023) with infraction dates of 11/05 (Sunday), 11/09 (Thursday), 11/12 (Sunday), 12/10 (Sunday) and 12/25 (Monday), there were no assigned Registered Nurses on the staffing assignments. […]