Inspection·June 1, 2023

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate supervision of food pocketing (holding food in the mouth without swallowing) behavior and assistance in oral care was provided to one of three sampled residents (Resident 1). Residents Affected - Few These failures had the potential to impair Resident 1's health and nutrition which could result in serious complications. Findings: During a review of Resident 1's, admission Record, dated 3/4/23, the record indicated, Resident 1 was admitted to the facility on [DATE], with admission diagnoses including, unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), heart failure, muscle weakness, and unspecified lack of coordination. During a review of Resident 1's, Nutrition Care Plan, dated 3/6/23, a care plan focus indicated in part, The resident (Resident 1) has nutritional problem related to poor appetite . disease process (dementia). Care plan interventions included, Explain and reinforce to the resident the importance of maintaining the diet ordered . Monitor/document/report . pocketing . holding food in mouth During a review of Resident 1's, Health Status Note, dated 4/3/23, the note indicated in part, IDT [Interdisciplinary Team - a group of healthcare professionals (e.g., Physician/Medical Director, Administrator, DON, Nurse, Social Services, Dietitian, Activity Director, Pharmacist) with various areas of expertise who work together towards the goals of their residents] Met: .Patient (Resident 1) noted pocketing food on 3/29, no difficulty swallowing noted, no coughing at this time. MD notified and agreed to downgrade diet to mechanical soft, ground meat. Patient (Resident 1) this month weighed 165.8 lbs. (pounds), noted with weight loss During a review of Resident 1's, Nutrition Dietary Note, dated 4/4/23, the note indicated in part, . Intake continues to be low . Inadequate energy intake related to intake not meeting estimated needs, -5.0% (five percent significant weight loss), -8.8 lbs. (8.8 pounds weight loss) in one month During an interview on 4/13/23 at 10:23 a.m., with the Director of Nursing (DON), DON verbalized during an internal investigation, it was found CNA 1 did not provide adequate oral care to Resident 1 after eating on several occasions. During a review of the facility ' s, policy and procedures (P&P), titled, Mouth Care, dated 2/18, the P&P indicated in part, Purpose . The purposes of this procedure are to keep the resident's lips (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 2 Event ID: 055826 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 055826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Oaks Post Acute 830 East Chapel Street Santa Maria, CA 93454 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)