Health inspection·October 22, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1), when documentation of interventions for a change in condition were not accounted for. This failure had the potential to result in Resident 1 not receiving proper treatment during a change of condition. Findings: During a review of Resident 1's Medical Records (MR), MR indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses: palliative care (medical care to improve the quality of life for people with a serious illness), amyotrophic lateral sclerosis (progressive, fatal disease that affects nerve cells in the brain and spinal cord), dysphagia (difficulty swallowing), dysarthria (speech disorder that makes it hard to form and pronounce words due to muscle problems) and anarthria (complete loss of speech), cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs), gastrostomy tube ([g-tube] a tube used to provide an alternative route for delivering nutrition, fluids, and medications directly to the stomach), muscle weakness, and need for assistance with personal care. Review of Resident 1's Minimum Data Set (MDS) (a standardized assessment tool to evaluate the health and functional abilities of residents in nursing homes), dated 10/4/2024, indicated, short term and long term memory problem, and cognitive skills for daily decision making severely impaired. Review of Resident 1's History and Physical (H&P), dated 3/1/2024, indicated, Resident 1 is able to make own decisions. During a concurrent interview and record review on 10/22/2024 at 1 p.m. with the Director of Nursing (DON), Resident 1's medical chart was reviewed. Nursing progress notes (NPN), dated 8/11/24, indicated Sent to ED for further evaluation due to g-tube (gastrostomy tube) being clogged since yesterday. The DON verbalized received a phone call from Licensed Nurse (LN 2) regarding Resident 1's g-tube being clogged and stated, We tried ourselves with milking it, warm water, soda as an acid to try to break it down and were unsuccessful and sent (Resident 1) out the next morning. Further review of the NPN indicated, no documentation of interventions to unclog Resident 1's g-tube. The DON stated, There is no documentation prior to 8/11/24 . I don't know why. During an interview on 10/22/2024 at 2:53 p.m. with the Administrator (ADMIN) and the DON, ADMIN stated, We received a phone call that night and steps were taken to unclog it, and after many attempts we proceeded to send (resdient) out. The ADMIN was unable to recall the time of the phone call. The DON verbalized there is no documentation of Resident 1's g-tube being clogged and there is no (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: 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 10/22/2024 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)