Health inspection·August 20, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow physician orders for one of three sampled residents (Resident 1), as evidenced by: Residents Affected - Few 1. Oxygen set at a flow rate of 3 liters per minute instead of 2 liters per minute. 2. Missing entries for G-tube (flexible hollow tube that is inserted into the stomach through abdomen used for nutrition and medication administration) 3. Dispensed blood pressure medication outside of the health parameters specifications. This failure had the potential for Resident 1's physical state to decline. Findings: 1. During an observation on 8/20/24 at 10:12 a.m., in Resident 1's room, Resident 1 was observed sleeping with a continuous flow of oxygen via nasal canula (mask) at a flow rate of 3 liters per minute. During a review of Resident 1's Physician's Orders, dated 8/19/24, the orders indicated Oxygen to be set at 2 liters per minute. During a concurrent observation and interview on 8/20/24 at 12:15 p.m., with Director of Nursing (DON) and Administrator in Resident 1's room, DON and Administrator confirmed the Oxygen set at 3 liters per minute and physician's orders were not followed. 2. During a review of Resident 1's Treatment Administration Record (TAR), dated August 2024, the TAR had missing staff initials in the box for G-tube site cleaning ordered for 2 times a day (at 7 a.m. and 7 p.m.) The missing entries were on 8/3/24 and 8/11/24 at 7:00 a.m. During an interview on 8/20/24 at 11:35 a.m. with DON, DON confirmed the missing entries and stated It's said if not documented then it isn't done. 3. During a review of Resident 1's Physician's Orders, dated 8/2/24, the orders indicated, Midodrine 5 milligrams (medication which increases blood pressure) Give 2 tablets via G-tube two times a day for HYPOTENSION *HOLD IF SBP >110 (Hold if Systolic Blood Pressure (SBP) top number of blood pressure is above 110 millimeters of mercury. During a concurrent interview and record review on 8/20/24 at 12:10 p.m., with DON, Resident 1's (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: 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 08/20/2024 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)