Ventura Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF600Feb 13, 2023

  Based on observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 1) from physical abuse by a Certified Nursing Assistant (CNA 1) when CNA 1 threw a cordless telephone at Resident 1 and hit him in the mouth. This failure resulted in physical injury to the resident including a bloody mouth and swollen lips. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated, Resident 1 is a [AGE] year old male admitted to the facility on [DATE] with a history of a stroke with left sided weakness/partial paralysis. During an interview on 11/22/22, at 1:30 p.m., with Resident 1, Resident 1 stated, on 11/21/22, CNA 1 brought a portable phone from the nursing station for the resident to use to call his wife. […]

• No harm, potential for more than minimal, widespreadF812Jun 12, 2025

  Based on interview and record review, the facility failed to ensure the ice machine was properly and routinely sanitized according to facility policy and procedures (P&P) and manufacturer's service manual. This failure had the potential to result in the growth of harmful microorganisms which can cause foodborne illness to its vulnerable residents. Findings: During a concurrent interview and record review on 6/9/25 at 10:40 a.m., with the Assistant Dietary Supervisor (ADS), ADS verbalized that the facility's Maintenance Supervisor (MS) was in charge of the ice machine maintenance. The facility form titled, Bi-Monthly Ice Machine Cleaning Log, dated 11/8/24 through 5/23/25, which was posted on the side of the ice machine, was reviewed. […]

• No harm, potential for more than minimal, patternF677Jun 12, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure fingernail care was provided for 3 of 16 sampled residents (Residents 9, 43, and 45). This failure had the potential to negatively affect their self-esteem, comfort, and personal hygiene. Findings: During a concurrent observation and interview on 6/10/2025 at 9:15 a.m. with Resident 9, the resident was observed with visibly long fingernails. Resident 9 stated she is unable to cut her fingernails, and her nails have not been cut for a few weeks. During a concurrent observation and interview on 6/11/25 at 9:10 a.m. with Certified Nursing Assistant (CNA), CNA observed Resident 9's fingernails and stated they needed to be trimmed. During a concurrent observation and interview on 6/10/25 at 9:37 a.m. […]

• No harm, potential for more than minimal, patternF761Jun 12, 2025

  Based on observation, interview, and record review, the facility failed to ensure one emergency drug supply kit (e-kit) was secured when not in use. This failure had the potential to allow unauthorized personnel access to emergency drug supply. Findings: During an observation on 6/10/25 at 9:48 a.m. in Medication room [ROOM NUMBER], one e-kit was found to be unsealed with a delivered by pharmacy date of 6/8/25. Upon further observation, this e-kit contained but not limited to, antibiotics and blood pressure medications. During an interview on 6/10/25 at 9:49 a.m. […]

• No harm, potential for more than minimal, isolatedF656Jun 12, 2025

  Based on observation, interview, and record review, the facility failed to ensure care plan interventions were implemented for one of five sampled residents (Resident 6). This failure had the potential to result in Resident 6's needs not being met. Findings: During a review of Resident 6's admission Record (AR), dated 6/11/25, the AR indicated, Resident 6 was admitted [DATE] with diagnoses including but not limited to, Cerebral Infarction (a condition in which blood flow to part of the brain is blocked or reduced), and Aphasia (a language disorder affecting communication). During a concurrent observation and interview on 6/11/25 at 9 a.m. with Resident 6, the resident was observed in bed, awake and alert, making eye contact but not responding to questions. […]