Health inspection·July 16, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview, the facility failed to create a comprehensive dental care plan for one of two sampled Residents (Resident 1).During a concurrent record review and interview, on 7/16/25, at 11:40 a.m., with the Director of Nursing (DON 1), Resident 1's initial dental exam dated 11/6/24, was reviewed. The initial exam form indicated Resident 1 had five missing teeth, and four broken teeth. The DON 1 confirmed Resident 1's dental exam form indicated Resident 1 had five missing teeth and four broken teeth. When asked if the facility had created a care plan to address Resident 1's dental status and concerns, the DON 1 verbalzied no and acknowledged there should have been one. During a review of the facility policy and procedure titled Care Plans, Comprehensive Person-Centered dated 3/22, indicated in part A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Page 1 of 2 055957 055957 07/16/2025 Santa Paula Post Acute Center 250 March Street Santa Paula, CA 93060

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain physician orders in a timely manner to ensure proper indwelling catheter care was provided to one of two sampled Residents (Resident 1). This facility failure had the potential to place Resident 1 at a higher risk for infection, and lead to negative outcomes. During a review of Resident 1's admission Record undated, indicated in part, Resident 1 was admitted to the facility on [DATE], with diagnoses including a urinary tract infection (an infection in any part of the urinary system), obstructive and reflex uropathy (conditions in which the flow of urine is blocked), and chronic kidney disease (a condition where the kidneys are damaged and can't filter blood as well as they should, leading to a buildup of waste and fluid in the body).During an interview on 7/16/25, at 2:00 p.m., with Resident 1's doctor (MD 1), the MD 1 was asked about indwelling catheter (a flexible tube inserted into the bladder to drain urine, and it's held in place by a balloon) and catheter drainage bag changes, and the frequency in which they should occur. The MD 1 verbalized facility policy was to change the catheter bags and catheter drainage bags once a month.During a record review of Resident 1's Order Summary Report, undated, indicated Resident 1 had the following physician orders dated 5/13/25:1. Catheter-monitor indwelling catheter for S/S (signs and symptoms) of UTI: amber colored urine, foul urine odor, poor urine output, sediments.every shift.2. Catheter- change Q (every) month and PRN (as needed) for blockage or dislodge.3. Catheter - Change urinary drainage bag Q month and PRN.During an interview on 7/15/25, beginning at 3:55 p.m., with the Director of Nursing (DON 1), the DON 1 verbalized Resident 1 was admitted to the facility with an indwelling catheter on 4/7/25. When asked why the above physician orders for catheter care were not obtained upon or shortly after admission, and instead obtained on 5/13/25, the DON 1 could not provide an explanation. When asked if the facility could produce any documentation indicating Resident 1 was being monitored for signs and symptoms of a UTI, prior to 5/13/25, the DON 1 verbalized no.During an interview on 7/16/25, at 2:16 p.m., with the DON 1, the DON 1 verbalized and confirmed the facility could not produce documentation indicating Resident 1's indwelling catheter or drainage bag was changed from Resident 1's admission on [DATE] to discharge 6/1/25. Residents Affected - Few 055957 Page 2 of 2