Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on observation, interview, and record review, the facility failed to develop, and implement a
person-centered activity care plan for one of 18 sampled residents (Resident 59).
Residents Affected - Few
This failure had the potential for isolation, psychosocial and physical decline for Resident 59.
Findings:
During a review of the facility policy and procedure (P&P) titled, Care and Treatment, Care Planning,
revised 11/2021, the P&P indicated, POLICY: It is the policy of this facility that the interdisciplinary team
(IDT) shall develop a comprehensive Person-Centered Care Plan for each resident based on resident's
needs to attain or maintain his or her highest practicable physical, mental, and psychological well-being.
PROCEDURES: 4. To the extent possible, the resident, the resident's family and/or responsible party
should participate in the development of the care plan.
During a review of the facility's P&P titled, Activity Assessment, revised 01/2021, the P&P indicated,
POLICY: It is the policy of this facility to provide ongoing program to support residents in their choice of
activities, both facility-sponsored group and individual activities and independent activities based on the
comprehensive assessment and care plan and the preferences of each resident. PROCEDURES: 4. A
quarterly and annual assessment shall be conducted using the Activity - Quarterly or Annual Evaluation
UDA (User Defined Assessment consists of questions compiled together under various headings to create
questionnaires that may be completed within the software) to include: a. Activity Pursuit Patterns and b.
Activity Attendance/Participation Summary.
During a review of Resident 59's admission Record, dated 6/22/23, the admission record indicated,
Resident 59 was 92-years-old with diagnoses including, unspecified dementia (a group of symptoms
affecting memory, thinking and social abilities), muscle weakness, difficulty in walking, major depressive
disorder (a mental condition characterized by a persistently depressed mood and long-term loss of
pleasure or interest in life) and need for assistance with personal care.
During a review of Resident 59's Minimum Data Set (MDS-a standardized assessment tool that measures
health status in nursing home residents), dated 10/8/22, the cognitive section indicated, Resident 59's Brief
Interview for Mental Status (BIMS -a cognitive assessment tool -a resident can score 0 to 15 points on the
test. A score of 13 to 15 suggests the resident cognitively intact, 8 to 12 suggests moderately impaired and
0 to 7 suggests severe impairment) was a score of 6. Resident 59 required supervision to moderate assist
with most activities of daily living (ADL-The tasks of everyday life. Basic ADLs include eating, dressing,
getting into or out of a bed or chair, taking a bath or shower, and using the toilet). In addition, the
Preferences for Customary Routine and Activities section
(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 12
Event ID:
055830
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
055830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Post Acute
425 East Barcellus Avenue
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
indicated, it is very important to resident to have books/newspapers to read, do favorite activities, and go
outside to get fresh air.
During a review of Resident 59's Activities Care Plan, undated, the care plan indicated, Focus - (Resident
59's name) potential alteration in diversional activities r/t (related to) Prefers to initiate activities of choice
independently. (Resident 59's name) likes to independently read the daily chronicle, watch TV, do word
search puzzles, and receive visits from her son and other family members when able. (Resident 59's name)
favorite activities include getting her nails done, reminiscing, and being outdoors at times. Goal - Will
choose and participate in his/her preferred leisure activities daily over the next 90 days as evidenced by
activity attendance logs/progress notes/assessments. Interventions/Tasks - Communicate his/her interests
to health care team.
During a review of Resident 59's Care Plan, undated, the care plan indicated,(Resident 59 name) is at risk
for impaired cognitive function/dementia or impaired thought processes . undated, indicated, /needs
supervision/assistance with all decision-making undated Son is POA (Power of Attorney).
During an observation and interview on 06/19/23 at 3:46 p.m. in Resident 59's room, Resident 59 was
observed in bed, awake. The TV was not on and resident was not observed in any activity. Resident 59
stated used to be very active in her church and greeted people all the time at the church. Resident began to
cry and stated, Not one person has come to visit, not the pastor, no one, and that hurts. It was the Seventh
Day Adventist Church.
During an observation and interview on 06/21/23 at 2:49 p.m. in hallway outside of Resident 59's room with
a certified nurse assistant (CNA 1), CNA 1 confirmed Resident 59 is lying in bed awake with no activity.
CNA 1 confirmed she does not document residents' activities.
During an observation and interview on 06/21/23 at 2:49 p.m. in hallway outside of Resident 59's room with
a licensed nurse (LN 2), LN 2 confirmed resident is lying in bed awake with no activities. LN 2 does not
know what kind of activities Resident 59 likes and confirmed she does not document activities of residents.
During a review of the Activity-Quarterly Evaluation dated 10/8/22, 4/10/2023, and 10/8/2023 for Resident
59 the Attendance Participation Summary indicated, to refer to attendance records and describe residents
participation/responses in activities. There were no attendance records in Resident 59's medical record.
During an interview and concurrent record review on 06/22/23 at 11:40 a.m. with the Activity Director (AD),
Resident 59's activities care plan and Activity- Quarterly Evaluations were reviewed. Also reviewed the
facility's P&Ps titled, Activity Assessment and Care and Treatment, Care Planning. The AD confirmed does
not have any documentation regarding Resident 59's initial activity assessment or interview with POA. The
AD confirmed facility staff are not informed of Resident 59's Activities, and no staff are documenting
Resident 59's attendance in activities, and stated, To be honest, I used to document but do not anymore.
The AD confirmed the facility is not following and implementing the policies and procedures and should be.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055830
If continuation sheet
Page 2 of 12
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
055830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Post Acute
425 East Barcellus Avenue
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)
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, and interview the facility failed to ensure physician orders were followed for one
resident (Resident 38) when the resident did not rinse their mouth after receiving a medication via an
inhaler.
Residents Affected - Few
This failure had the potential to cause a fungal infection in Resident 38's mouth and throat.
Findings:
Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section
titled, Legal Implications in Nursing Practice indicated, Nurses are obligated to follow physician orders
unless they believe the orders are in error or would harm clients.
Review of the facility policy and procedure (P&P) titled, Medication Administration, revised 11/2021, the
P&P indicated in part, Accurate and timely administration according to MD order is essential .
According to Breo Ellipta product information accessed at https://www.mybreo.com/ on 6/27/23, BREO can
cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth
with water without swallowing after using BREO to help reduce your chance of getting thrush [fungal
infection].
During a medication pass observation on 6/20/23 at 8:10 a.m. licensed nurse 5 (LN 5) was observed
administering Resident 38 Ellipta - Fluticasone Furoate (an inhaled medication to treat asthma and chronic
obstructive disease) from a handheld powdered medication inhaler. LN 5 did not provide education to
Resident 38 of the importance to rinse mouth with water without swallowing after using the inhaler and did
not provide water and basin/cup to spit out rinse water before exiting the room.
During a concurrent interview and record review on 6/20/23 8:26 a.m. with LN 5, Resident 38's physician's
order dated 12/28/22 was reviewed. The order indicated in part, Breo Ellipta Inhalation Aerosol Powder
Breath Activated . (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day for RAD (reactive
airway disease) rinse mouth with water after use. LN 5 confirmed, No, I did not educate Resident 38 to
rinse out mouth after inhaling powdered Fluticasone Furoate medication; provide water and container to
spit out rinse water; and did not witness Resident 38 rinse mouth out and spit out the rinse water. Resident
38 was supposed to do that. It can cause oral fungus if not done.
During an interview on 6/20/23 at 8:27 a.m. with Resident 38, Resident 38 stated, Usually I do rinse and
spit, but I didn't today.
During an interview on 6/22/23 at 9:49 a.m. with the director of Nursing (DON), DON indicated, Licensed
nurses are supposed to educate the need for rinsing out the mouth after inhaling the fluticasone inhaler and
offer residents rinse water and receptacle for spitting out rinse water and remain with resident to ensure
procedure accomplished . The policy and procedures were not followed and should have been.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055830
If continuation sheet
Page 3 of 12
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
055830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Post Acute
425 East Barcellus Avenue
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)
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to implement its policy for activities
when:
Residents Affected - Some
1. One of eighteen sampled residents (Resident 59) was not observed in any activities during onsite
four-day survey.
2. The activity director was not documenting activity pursuit patterns or activity attendance for any of the 75
residents in the facility.
This failure has the potential for psychosocial and physical harm to all 75 residents.
Findings:
During a review of the facility's policy and procedure (P&P) titled, Activity Assessment, dated 01/2021, the
P&P indicated, POLICY: It is the policy of this facility to provide ongoing program to support residents in
their choice of activities, both facility-sponsored group and individual activities and independent activities
based on the comprehensive assessment and care plan and the preferences of each resident.
PROCEDURES: 4. A quarterly and annual assessment shall be conducted using the Activity - Quarterly or
Annual Evaluation UDA (User Defined Assessment consists of questions compiled together under various
headings to create questionnaires that may be completed within the software) to include: a. Activity Pursuit
Patterns and b. Activity Attendance/Participation Summary.
During a review of the facility's P&P titled, Activities Program, dated 11/2021, the P&P indicated, POLICY: It
is the policy of this facility to implement an ongoing resident centered activities program that incorporates
the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a
resident's physical, mental, and psychosocial well-being, and independence. It is also the policy of this
facility to create opportunities for each resident to have a meaningful life by supporting his/her domains of
wellness (security, autonomy, growth, connectedness, identity, joy, and meaning). PROCEDURES: 8.
Residents who wish to meet with or participate in social or religious activities, or other community activities,
at or away from the facility, is encouraged to do so.
During a review of Resident 59's admission Record, dated 6/22/23, the admission record indicated,
Resident 59 was 92-years-old with diagnoses including, unspecified dementia (a group of symptoms
affecting memory, thinking and social abilities), muscle weakness, difficulty in walking, major depressive
disorder (a mental condition characterized by a persistently depressed mood and long-term loss of
pleasure or interest in life) and need for assistance with personal care.
During a review of Resident 59's Minimum Data Set (MDS-a standardized assessment tool that measures
health status in nursing home residents), dated 10/8/22, the cognitive section indicated, Resident 59's Brief
Interview for Mental Status (BIMS -a cognitive assessment tool -a resident can score 0 to 15 points on the
test. A score of 13 to 15 suggests the resident cognitively intact, 8 to 12 suggests moderately impaired and
0 to 7 suggests severe impairment) was a score of 6. Resident 59 required supervision to moderate assist
with most activities of daily living (ADL-The tasks of everyday life. Basic ADLs include eating, dressing,
getting into or out of a bed or chair, taking a bath or shower, and using the toilet). In addition, the
Preferences for Customary Routine and Activities section indicated, it is very important to resident to have
books/newspapers to read, do favorite
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055830
If continuation sheet
Page 4 of 12
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
055830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Post Acute
425 East Barcellus Avenue
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)
F 0679
activities, and go outside to get fresh air.
Level of Harm - Minimal harm
or potential for actual harm
During an observation and interview on 06/19/23 at 3:46 p.m. in Resident 59's room, 59 was observed in
bed, awake. The TV was not on and resident was not observed in any activity. Resident 59 stated used to
be very active in her church and greeted people all the time at the church. Resident began to cry and
stated, Not one person has come to visit, not the pastor, no one, and that hurts. May be a long time ago
because I was driving then. It was the Seventh Day Adventist Church.
Residents Affected - Some
During an observation and interview on 06/20/23 at 3:42 p.m. with Resident 59's Representative, Resident
59 was observed lying in bed. Representative stated church is very important to Resident 59, she used to
be a door greeter and is very upset no one from the church comes to visit. Representative stated has not
seen Resident 59 in any activities and would like to.
During observations from 6/19/23 to 6/22/23 from 10 a.m. until 4 p.m., Resident 59 was observed in bed,
awake, without any activity being provided. These observations were conducted on 6/19/23 two occasions,
6/20/23 three occasions, and on 6/21/23 eight occasions.
During an observation and interview on 06/21/23 at 2:49 p.m. in hallway outside of Resident 59's room with
a certified nurse assistant (CNA 1) and Licensed Nurse (LN 2) CNA 1 confirmed Resident 59 is lying in bed
awake with no activity. CNA 1 confirmed she does not document residents' activities. LN 2 does not know
what kind of activities Resident 59 likes and confirmed she does not document activities of residents.
During an interview and concurrent record review on 06/21/23 at 3:28 p.m. with the Activity Director (AD),
the AD confirmed facility P&P, Activity Assessment, indicated, staff should be documenting residents'
activities and are not. The AD confirmed there is no documentation to confirm Resident 59 participating in
any activities. The AD stated, To be honest, I used to document but do not anymore.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055830
If continuation sheet
Page 5 of 12
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
055830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Post Acute
425 East Barcellus Avenue
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)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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 one of 18 sampled residents (Resident 278)
receiving the medication Apixaban (an anticoagulant or medication that prevents the blood from clotting)
was monitored for complications and the monitoring documented in the resident's clinical record.
Residents Affected - Few
This oversight failure had the potential to result in serious harm to Resident 278.
Findings:
During a review of Resident 278's, admission Record, dated 6/20/23, the record indicated in part, Resident
278 was an [AGE] year-old male admitted to the facility on [DATE], with admission diagnoses including,
abscess (a collection of pus within the tissue) of the liver, unspecified atrial fibrillation (fluttering of the
heart), and unspecified psychosis (a condition of the mind that results in difficulties determining what is real
and what is not real) not due to a substance or known physiological condition.
During a review of Resident 278's, Order Recap Report (ORR), dated 6/1/23 - 6/30/23, the ORR indicated
the physician order, dated 6/10/23, Apixaban oral tablet 5 mg (milligram), give one tablet by mouth two
times daily for A-Fib (atrial fibrillation).
During a concurrent interview and record review, on 6/21/23 at 2:40 p.m. with a licensed nurse (LN 1),
Resident 278's Medication Administration Record (MAR), dated June 2023, was reviewed. LN 1 confirmed
that Resident 278 was taking Apixaban 5 mg twice daily as reflected on the MAR. When asked if monitoring
for anticoagulant complications such as bleeding/bruising was done and documented, LN 1 verbalized
monitoring orders were usually transcribed in the MAR as a reminder for staff so they could sign off on
them. LN 1 could not find monitoring documentation for anticoagulant complications transcribed in Resident
278's MAR and acknowledged there should have been one.
During a concurrent interview and record review, on 6/21/23 at 2:48 p.m. with LN 1, Resident 278's, Care
Plan (CP), dated 6/10/23, was reviewed. The CP indicated in part, Anticoagulant therapy (Apixaban) r/t
(related to) Atrial Fibrillation . at risk for bleeding, bruising, shock. The CP indicated further, Interventions .
Monitor/document/report to MD . s/sx (signs/symptoms) of anticoagulant complications: blood tinged or
frank blood in urine, black tarry stools, dark or bright red blood in stools LN 1 acknowledged there should
have been monitoring for anticoagulant complications documented and signed off by staff in Resident 278's
clinical record.
During a review of the facility's, policy and procedures (P&P), titled, Physician Orders, dated 11/21, the
P&P indicated in part, Procedures: .7) Medications that require parameters or monitoring for either signs
and symptoms, behavior, or side effects (i.e.: antihypertensives, psychotropic medications, anticoagulants,
etc.) will have such monitoring reflected in the medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055830
If continuation sheet
Page 6 of 12
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
055830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Post Acute
425 East Barcellus Avenue
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 278) was
properly assessed for the continued use of the medication Quetiapine (brand name: Seroquel - a
medication used to treat certain mental or mood conditions such as schizophrenia, bipolar disorder, and
depression) as required by its policy and procedures on psychotropic (drugs that affect the brain and
behavior) drug use.
This failure resulted in Resident 278 receiving an unnecessary psychotropic medication which had the
potential to result in serious complications from prolonged use without proper monitoring.
Findings:
During a review of the facility's policy and procedures (P&P) titled, Psychotropic Drug Use, dated 5/19, the
P&P indicated in part, Procedures: 1) Psychotropic medications shall not be administered for the purpose
of discipline or convenience. They are to be administered only when required to treat the resident's medical
symptoms . 2) On admission, the admitting nurses will review the transfer orders for psychotropic
medications. All efforts will be made by the licensed nurses to obtain as much history regarding these
medications . Any information obtained will be documented in the resident's clinical record . 3) The licensed
nurses shall review the classification of the drug, the appropriateness of the diagnosis, its
indication/behavior monitors and related adverse side effects prior to verification of admission orders with
the attending physician.
During a review of Resident 278's admission Record, dated 6/20/23, the record indicated in part, Resident
278 was an [AGE] year-old male resident admitted to the facility on [DATE], with admission diagnoses
including, abscess (a collection of pus within the tissue) of the liver, unspecified atrial fibrillation (fluttering
of the heart), and unspecified psychosis (a condition of the mind that results in difficulties determining what
is real and what is not real) not due to a substance or known physiological condition.
During a review of Resident 278's Order Recap Report (ORR), dated 6/1/23 - 6/30/23, the ORR indicated
the physician order, dated 6/10/23, Quetiapine Fumarate oral tablet 50 mg (milligram) give one tablet by
mouth two times a day for psychosis amb (as manifested by) agitation. This order was discontinued on
6/14/23. The ORR indicated further the physician order, dated 6/14/23, Quetiapine Fumarate oral tablet 50
mg give one tablet by mouth two time a day for psychosis with manic sx (symptoms) of agitation related to
unspecified psychosis . amb resisting ADL (activities of daily living)/personal care necessary for resident's
health and safety. This order was discontinued on 6/15/23.
During a concurrent interview and record review on 6/21/23 at 10:21 a.m. with a licensed nurse (LN 1),
Resident 278's, Medication Administration Record (MAR), dated June 2023, was reviewed. The MAR
indicated in part, staff administered Quetiapine 50 mg to Resident 278 on the following dates and times: on
6/10/23 at 5 p.m., 6/11/23 through 6/14/23 at 9 a.m. and 5 p.m., and 6/15/23 at 9 a.m. When asked where
staff documented Resident 278's observed behavior (i.e., agitation) as an indication of the medication, LN 1
could not provide any documentation.
During a review of Resident 278's, Initial admission Record (IAR), dated 6/10/23, a section of the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055830
If continuation sheet
Page 7 of 12
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
055830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Post Acute
425 East Barcellus Avenue
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
IAR indicated in part, . 7) Other Assessments . Psychotropic Drugs . E) Resident receives psychotropic
medication(s). [If yes, a Psychoactive (or psychotropic) Medication Evaluation will be triggered]. The option,
NO, was selected for this item which suggested Resident 278 did not receive psychotropic medication(s),
hence a Psychoactive Medication Evaluation was not initiated. The IAR indicated further, . 2) Neuro/Mental
. Level of Consciousness . B) Agitated . The option, NO, was selected for this item which suggested
Resident 278 was not observed with agitation.
During a review of Resident 278's, Verbal Consent for Psychotropic Medications, Physician Order, dated
6/10/23, the Consent indicated, Specific Condition/Behavior Being Treated: psychosis amb agitation.
During a review of Resident 278's admission Drug Regimen Review (ADRR), dated 6/10/23, a section of
the ADRR indicated in part, I. Review of Potential/Actual Clinically Significant Medication Issues . 2) Use of
medication(s) without evidence of adequate indication for use . The option, NO, was selected for this item.
During a review of the facility's, CMS (Center for Medicare/Medicaid Services) 802 Matrix for Providers (a
form used to list all current residents and to note pertinent care categories), dated 6/19/23, a section of the
form under Medications failed to indicate Resident 278 was on antipsychotic medication(s).
During a review of Resident 278's, Facility Verification of Informed Consent . Psychotherapeutic Drugs,
dated 6/10/23, the consent failed to indicate the physician's name and signature who obtained the consent.
During a concurrent interview and record review, on 6/22/23 at 10:15 a.m., with the Director of Nursing
(DON), Resident 278's clinical record was reviewed. DON verbalized Resident 278's Quetiapine order was
included in the resident's discharge medication list from the hospital prior to getting transferred to the facility
and was considered a home medication. DON also verbalized a review from the interdisciplinary team (IDT)
was conducted for new or current resident psychotropic medication orders to ensure appropriateness of the
medication based on the resident's diagnosed behavioral issue or condition. An IDT review of Resident
278's Quetiapine use was conducted on 6/15/23, five days after the medication was initiated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055830
If continuation sheet
Page 8 of 12
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
055830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Post Acute
425 East Barcellus Avenue
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)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to ensure its medication error rate was
less than five percent when:
Residents Affected - Some
1. Licensed Nurse 5 (LN 5) left medications intended for Resident 38 unattended on the medication cart.
2. LN 5 did not educate and provide Resident 38 water to rinse mouth out after inhalation of Ellipta powder
medication.
3. LN 5 left Resident 38's medications unattended on bedside table and did not witness medication
consumption.
These failures resulted in a 10% medication error rate and had the potential for Resident 38 to have
medication complications.
Findings:
Review of the facility's policy and procedures (P&P) titled, 6.0 General Dose Preparation and Medication
Administration, revised 1/1/13, the P&P indicated in part, . Facility staff should not leave medications or
chemicals unattended . Provide the resident with any necessary instructions (e.g., using an inhaler) .
Observe the resident's consumption of the medications(s) .
1. During an observation and record review on 6/19/23, at 1:32 p.m., LN 5 entered Resident 38's room with
back turned toward the medication cart and left a tablet of Clonidine (medication to control elevated blood
pressure) 0.2 mg (milligrams) in a medication cup unattended on the surface of a medication cart outside of
Resident 38's room. Record review of Resident 38's Physician's order dated 10/15/22 indicated, cloNIDine
HCI tablet 0.2 mg Give 1 tablet by mouth three times a day .
During an interview on 6/19/23 at 1:34 p.m. with LN 5, LN 5 acknowledged leaving Resident 38's
medication unattended on the medication cart and stated, Clonidine, yes, I left it unattended on my med
(medication) cart. I should not have done that.
2. During a medication pass observation on 6/20/23 at 8:10 a.m. LN 5 was observed administering
Resident 38 Ellipta - Fluticasone Furoate (an inhaled medication to treat asthma and chronic obstructive
disease) from a handheld powdered medication inhaler. LN 5 did not provide education to Resident 38 of
the importance to rinse mouth with water without swallowing after using the inhaler and did not provide
water and basin/cup to spit out rinse water before exiting the room.
During a concurrent interview and record review on 6/20/23 8:26 a.m. with LN 5, Resident 38's physician's
order dated 12/28/22 was reviewed. The order indicated in part, Breo Ellipta Inhalation Aerosol Powder
Breath Activated . (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day for RAD (reactive
airway disease) rinse mouth with water after use. LN 5 confirmed, No, I did not educate Resident 38 to
rinse out mouth after inhaling powdered Fluticasone Furoate medication; provide water and container to
spit out rinse water; and did not witness Resident 38 rinse mouth out and spit out the rinse water. Resident
38 was supposed to do that. It can cause oral fungus if not done.
During an interview on 6/20/23 at 8:27 a.m. with Resident 38, Resident 38 stated, Usually I do
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055830
If continuation sheet
Page 9 of 12
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
055830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Post Acute
425 East Barcellus Avenue
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)
F 0759
rinse and spit, but I didn't today.
Level of Harm - Minimal harm
or potential for actual harm
3. During the same medication pass observation on 6/20/23, at 8:10 a.m., LN 5 was observed placing
Resident 38's Physician ordered medications Carvedilol 3.125 mg tablet (treats high blood pressure),
clonidine 0.2 mg tablet (treats high blood pressure), and docusate sodium 100 mg gel cap (prevents and
treats constipation) into a medication cup, LN 5 then placed the medication cup with medications onto
Resident 38's bedside table, and exited Resident 38's room. LN 5 did not stay to witness Resident 38
consume the medications. When asked if Resident 38's medications were left unattended, LN 5 confirmed
and acknowledged, I also left the medications unattended on the bedside table and did not witness the
Resident 38 consume his medications before I left the room.
Residents Affected - Some
During an interview on 6/22/23 at 9:49 a.m. with the director of Nursing (DON), the DON indicated,
Licensed nurses are supposed to educate the need for rinsing out the mouth after inhaling the fluticasone
inhaler and offer residents rinse water and receptacle for spitting out rinse water and remain with resident
to ensure procedure is accomplished. Licensed nurses are never supposed to leave medication unattended
in the resident's rooms and/or unattended on the medication cart. Licensed nurses are supposed to stay
and witness the resident consume the medications administered. The policy and procedures were not
followed and should have been.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055830
If continuation sheet
Page 10 of 12
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
055830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Post Acute
425 East Barcellus Avenue
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review, the facility failed to ensure pharmacy services policy
and procedure (P&P) for medication disposal was followed when medication pills were observed inside a
trash receptacle.
This failure had the potential for misuse of medications and jeopardize residents' health and safety.
Findings:
During an observation and subsequent interview on 6/19/23 at 4:51 p.m. with licensed nurse (LN 6) and the
director of nursing (DON), a trash can at nursing station two-three was observed and contained a discarded
medication card bubble pack with two unused tablets. Inside of each individual segmented plastic bubble
was a single tablet of Amlodipine Besylate (medication to treat high blood pressure) Tab USP (United
States Pharmacopeia - quality standards of the United States) 10 mg (milligrams). LN 6 confirmed and
acknowledged being responsible for throwing the bubble pack containing two tablets of Amlodipine
Besylate Tab USP 10 mg Tab into the trash can and not disposing the medications properly. LN 6 stated, I
was disposing of the medications, and I must have missed those. I have my drug buster inside the
medication room and the medications should be disposed of in the drug buster. The DON confirmed the
medication card bubble pack with 2 unused tablets of Amlodipine Besylate Tab USP 10 mg removed from
the nursing station 2-3 trash can and acknowledged, Amlodipine besylate tab USP 10 mg was not disposed
of properly into the drug buster.
During a review of the facility's P&P titled, Pharmacy Services, revised 11/2021, indicated in part,
PROCEDURES: 4. Facility should place all discontinued or out-dated medications in a designated, secure
location which is solely for discontinued medications or marked to identify the medications are discontinued
and subject to destruction, Disposal of non-controlled medications 6. Facility should destroy non-controlled
medications in the presence of two nurses, in accordance with Facility policy or Applicable Law.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055830
If continuation sheet
Page 11 of 12
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
055830
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Post Acute
425 East Barcellus Avenue
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review the facility failed to store two boxes containing eggs
inside of refrigerator and off the kitchen floor in accordance with professional standards of food safety for a
total of 72 residents who received food from the kitchen.
These failures had the potential to result in foodborne illnesses among residents.
Findings:
According to the Food Code 2022, Annex 3. Public Health Reasons/Administrative,
2-103.11, page 308 All food must be appropriately stored in a safe and secure manner within the food
establishment. For example, time/temperature control for safety foods must be stored within refrigeration
units and held at temperatures of 41°F or below. Also, 3-202.11 Temperature, page 376 indicated in
part, USDA published a final rule (63 FR 45663, August 27, 1998 Shell Eggs; Refrigeration and Labeling
Requirements) to require that shell eggs packed for consumer use be stored and transported at an ambient
temperature not to exceed 7.2ºC (45ºF). Additionally, 6-501.12 Cleaning, Frequency and
Restrictions, page 504 indicated, Primary cleaning should be done at times when foods are in protected
storage .
The facility policy and procedure titled, Dietary Services revised 8/2021, indicated in part, All foods stored
in walk-in refrigerators and freezers shall be stored above the floor on shelves, racks, dollies, or other
surfaces that facilitate thorough cleaning.
During a concurrent observation and interview on 6/19/23 at 10:50 a.m. with kitchen aide 1 (KA 1) and the
acting dietary manager (DM-A), two boxes were observed one on top of the other outside of the refrigerator
and directly on the soiled kitchen floor while cleaning refrigerator number three. The boxes contained two
varieties of eggs. The box directly on the soiled kitchen floor contained boiled eggs with another opened
box on top containing a plastic bag of liquid eggs. KA 1 confirmed the above, made no comment, and did
not remove/relocate the unrefrigerated boxes of boiled and liquid eggs stored on the soiled kitchen floor.
The DM-A confirmed and acknowledged, Foods should be stored onto kitchen carts not on floor. The DM-A
did not acknowledge that refrigerated eggs should remain inside of the refrigerator during cleaning.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055830
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F679 - Activities
Provide activities to meet all resident's needs.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the June 22, 2023 survey of Villa Maria Post Acute?
This was a inspection survey of Villa Maria Post Acute on June 22, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Villa Maria Post Acute on June 22, 2023?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.