Health inspection·April 10, 2025

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 record review and interview the facility failed to ensure nursing staff implemented one of four sampled residents (Resident 1) gastrostomy/Jejunostomy feeding tube (G-tube-surgically placed tube that delivers nutrition, fluids, and medications directly into the stomach, bypassing the mouth and esophagus), care recommendations and Physician's orders regarding flushing of the tube. Residents Affected - Few The facility's failure resulted in Resident's G-tube getting clogged frequently. Finding: Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician order unless they believe the orders are in error or would harm patients (residents) A complaint was submitted to the California Department of Public Health (CDPH) on 3/3/25 alleging a Resident has presented to the hospital multiple times because the staff at the facility are . clogging the resident's feeding tube. During an onsite visit to facility on 3/5/25, a record review for Resident 1 was conducted. Record indicated Resident 1 is a [AGE] year old, diagnosis include left hemiparesis (paralysis), dysphasia (impairment of the power to speak or to understand speech, as a result of brain injury), gastrostomy tube, glioblastoma multiforme (a highly aggressive and malignant brain tumor that originates from glial cells, which support and protect neurons in the brain). During a review of change of condition (COC) dated 9/24/24 at 6:51 p.m., the COC indicated 1/17/25 at 9:30 a.m., 2/1/25 at 1:59 a.m., and 3/1/25 at 7:52 a.m., The gastrostomy/Jejunum tube (G-tube) is clogged. During a review of Nurses Progress Note dated 10/18/24 at 1:47 a.m., indicated resident returned to the facility from [hospital name] hospital at about 7:40 p.m. Instructions for facility to manage feedings included in discharge education to provide to staff. 1. Only jejunostomy feeds and water through the port. 2. Flush jejunostomy port with 60 ml water at least every 6 times daily or every four (q4) hours. 3. Gastrostomy port can be used for water and medications including crushed medications. 4. Flush gastrostomy port with 60 ml water every time after administering medications. During a concurrent record review and interview with the director of nursing (DON) on 3/6/25 at 2:55 p.m., the DON was asked the reason the hospital's recommendations for G-tube management were not implemented at the facility. The DON stated, We did, we got a (physician) order, the instructions (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 4 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 04/10/2025 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)