Health inspection·August 14, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow physician orders and a care planned intervention for supplemental oxygen, for one of two sampled residents (Resident 1). Residents Affected - Few These failures had the potential for Resident 1 to experience resipiratory complications and lack of oxygen throughout the body. Findings: During a review of Resident 1's admission Record, undated, the admission Record indicated in part, Resident 1 had diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (low levels of oxygen in body tissues). During a concurrent observation and interview, on 8/14/24, starting at 1:15 p.m., with the Director of Staff Development (DSD 1), Resident 1 was observed wearing a nasal cannula (a medical device that provides supplemental oxygen through the nose). The DSD 1 confirmed Resident 1 was wearing a nasal canula and verbalized Resident 1 was receiving supplemental oxygen between two to three liters per minute. During a concurrent record review and interview, on 8/14/24, starting at 2:01 p.m., with the Assistant Director of Nursing (ADON 1), Resident 1's physician orders and care plan were reviewed. Resident 1's care plan indicated in part, Monitor 02 (oxygen) sats (Saturation) Q (every) shift. The ADON 1 verbalized Resident 1 did not have an active physician order for supplemental oxygen and there should have been one. The ADON 1 verbalized the facility could not provide documentation indicating staff were monitoring Resident 1's oxygen status each shift, from 7/15/24 through 8/13/24. During a review of the facility's policy and procedure (P&P) titled Administering Medications, undated, the P&P indicated in part, Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders. During a review of the facility's policy and procedure titled, Oxygen Administration, dated 10/10, the P&P indicated in part, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Review the resident's care plan to assess for any special needs of the resident. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 3/22, the P&P indicated in part The comprehensive, person-centered care plan .Describes (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: 055957 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 055957 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Paula Post Acute Center 250 March Street Santa Paula, CA 93060 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)