Health inspection·December 3, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 1) was treated with dignity when the resident's behavior was escalating, and de-escalation techniques were not utilized. This failure had the potential to cause psychosocial harm to Resident 1 Findings: During an observation on 12/2/24 at 12 p.m. with the administrator (ADMIN), in the Admin's office, video footage dated 11/17/24 was observed. The video indicated, Resident 1 was at the nurse's station and a licensed nurse (LN 1) was on the phone behind the station. Resident 1 was cursing and reaching over the station to grab the phone while LN 1 continued to sit at the station. During an interview on 12/2/24 at 11:09 a.m. with licensed nurse (LN 1), LN 1 stated Resident 1 kept asking for medication, by shouting and cursing. LN 1 stated Resident 1's medications were late and was upset the medications were not given at a specific time. LN 1 stated Resident 1 kept coming up to the nurse's station upset, swearing, and cursing and requesting LN 2 who was in another room and continued medication pass while Resident 1 was at the nurses station continuing to esculate. LN 1 stated she called Resident 1's representative to see if she could calm her down, Resident 1 stood yelling at the nurse's station and demanded the phone, reached over the station to grab the phone that LN 1 was on and in the process of pulling her arm back, sustained a skin tear to her left arm. LN 1 denied Resident 1 her requests and did not employ any de-escalation techniques to calm Resident 1. LN 2 continued to give the rest of her assigned residents medications and did not offer Resident 1 her medications sooner causing Resident 1 to wait until last to recieve hers while escalating Resident 1 behaviors further. During an interview on 12/2/24 at 11:19 a.m. with LN 2, LN 2 stated she was Resident 1's primary nurse on 11/26/24 p.m. shift, which was the morning of 11/27/24. LN 2 stated she went into Resident 1's room to give Resident 2's medications and was explaining Resident 2's medications during administration. Resident 1 overheard the discussion and became upset and requested her medications. LN 2 stated to Resident 1 she was helping Resident 2 and told Resident 1 to relax, Resident 1 then called LN 2 a bitch. The activities director came in and tried to redirect Resident 1. LN 1 stated Resident 1 came to the nurse's station and called her a fat pig. LN 2 stated she gave Resident 2's medications and left the room. Additionally, LN 2 continued medication administrations which escalated Resident 1's behaviors. LN 2 stated Resident 1 would follow her on medication pass to each room until Resident 1 received her medications. LN 2 stated she (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055563 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Maria Post Acute 820 West Cook Street Santa Maria, CA 93458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)