Santa Paula Post Acute Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 13, 2022

  Based on observation, interview, and record review, the facility failed to ensure Resident 1 received adequate supervision when Resident 1 was left unsupervised in the designated smoking area and proceeded to wheel herself across a parking lot from the designated smoking area. This failure resulted in Resident 1's wheelchair being hit by a car, and Resident 1 being run over by the same car causing critical injuries that led to her death. Findings: During a review of Resident 1's face sheet dated 10/4/21, the face sheet indicated diagnoses including, unspecified mood disorder (a mental health problem that primarily affects a person's emotional state), other secondary Parkinsonism (symptoms similar to [CONDITION(S)] that are caused by certain medicines), unspecified Alzheimer's Disease (a… […]

• No harm, potential for more than minimal, widespreadF812Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary cleaning of dishes and storage practices in the kitchen when:Clean plastic mugs were stored upside down on a tray, with the rims in contact with standing water.An expired bottle of Cayenne Pepper Hot spice was found on the shelf with an expiration date of 3/10/26.These failures had the potential to allow viruses and bacteria to grow and put the residents at risk of developing food borne illnesses (any illness resulting from eating contaminated/spoiled foods).Findings:1. […]

• No harm, potential for more than minimal, widespreadF851Mar 21, 2024

  Based on interviews, review of staffing data reports, and facility policy review, the facility failed to ensure staffing data based on payroll data was submitted to the Centers for Medicare and Medicaid Services (CMS) for 1 (fourth quarter) of 4 quarters reviewed for fiscal year (FY) 2023. Additionally, the facility failed to ensure accurate and valid staffing data was submitted to CMS for 1 (first quarter) of 1 quarter reviewed for FY 2024. Findings included: Review of a facility policy titled, Reporting Direct Care Staffing Information (Payroll-Based Journal), revised in August 2022, revealed, Direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system. The policy indicated, 1. […]

• No harm, potential for more than minimal, patternF578Jul 9, 2026

  Based on interview and record review, the facility failed to ensure the Advance Directive (a written document specifying an individual's medical care wishes) process was completed according to the facility's policies and procedures (P&P) when: 1. There was no documented evidence indicating that 11 of 20 sampled residents (Residents 2, 4, 6, 7, 10, 19, 26, 37, 47, 58, and 91) who had not executed an Advance Directive were offered assistance to formulate one and whether such assistance was accepted or declined. 2. […]

• No harm, potential for more than minimal, patternF761Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure medications and medical supplies were properly labeled and stored when:1. Expired medications and medical supplies remained in the active medication storage areas in one of one Medication Room; and2. A resident-owned (Resident 31) medication with an unreadable expiration date was stored in one of four medication carts without physician review and authorization, and an insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pen was stored beyond the manufacturer's recommended in-use (opened) period.These failures had the potential for residents to receive expired, ineffective, or unauthorized medications, which could compromise resident… […]