Inspection Reports for
Santa Maria Terrace

The visit was triggered by a complaint regarding a medication error involving Resident 1, where medication was administered outside the prescribed time frame. The complaint was substantiated based on interviews and record reviews.

The facility did not follow the physician's order when medication was given outside the prescribed time frame, specifically administering a PRN Tramadol at 9:55 am instead of at bedtime as ordered, posing a potential health and safety risk to the resident.

The complaint investigation was triggered by allegations that facility staff did not provide medication to a resident for pain management and failed to provide adequate assistance and repositioning during mealtime. The pain medication allegation was unsubstantiated, while the assistance and repositioning allegations were substantiated. Staff member S2 was terminated due to failure to perform duties.

The investigation found the allegation that facility staff did not provide medication for pain management to be unsubstantiated due to lack of preponderance of evidence. However, the allegations that staff failed to provide adequate assistance during mealtime and did not reposition residents were substantiated, resulting in staff termination and citation of regulatory violations.

The complaint investigation was triggered by allegations that facility staff did not provide medication for pain management to a resident, did not provide adequate assistance during mealtime, and failed to reposition residents. The pain medication allegation was unsubstantiated, while the assistance and repositioning allegations were substantiated. Staff member S2 was terminated due to failure to perform duties.

The investigation found the allegation of failure to provide pain medication unsubstantiated due to lack of preponderance of evidence. However, allegations regarding inadequate assistance during mealtime and failure to reposition residents were substantiated, resulting in staff termination and citation of regulatory violations.

The complaint investigation was substantiated. Allegations included medication mismanagement where a resident received an overdose of Warfarin, inadequate staffing leading to neglect, failure to follow admissions agreement regarding housekeeping and personal care, and facility cleanliness issues. Interviews with staff, residents, and document reviews supported these findings.

The investigation substantiated all allegations: a medication error where a resident received three times the prescribed dose of Warfarin; inadequate staffing levels causing neglect and insufficient care; failure to fully comply with admissions agreement regarding housekeeping and personal care; and cleanliness issues including stained dining room tablecloths. A technical violation and a $250 civil penalty for repeat violation were issued.

The complaint investigation was substantiated for allegations that staff did not meet resident’s hygiene needs and that the resident was charged for services not rendered. The allegation regarding staff not adhering to the admission agreement related to cable service issues was unsubstantiated.

The investigation substantiated that staff did not properly assist a resident with showers and the resident was charged for missed showers without timely refund, posing a potential health and safety risk. The facility implemented a new shower log and issued refunds. Another allegation regarding cable service issues was unsubstantiated.

The visit was triggered by an incident report received on 01/27/24 regarding a medication error on 01/21/24 where Staff 1 prepared two different medications simultaneously and administered the wrong one to Resident 1, who was monitored for respiratory depression following the error. Staff 1 was written up and retrained.

The facility failed to properly assist residents with medications, resulting in a medication error that posed an immediate health and safety risk. A civil penalty for a repeat violation of $250 was assessed, and the facility conducted retraining and in-service training for medication technicians.

The complaint investigation was substantiated. Allegations included medication mismanagement where a resident received an overdose of Warfarin; inadequate staffing leading to neglect of residents; failure to follow admissions agreement regarding housekeeping and personal care; and facility cleanliness issues. Interviews with staff, residents, and document reviews supported these findings.

The investigation substantiated all allegations: a medication error where a resident received three times the prescribed dose of Warfarin; insufficient staffing levels causing neglect and inadequate care; failure to fully comply with admissions agreement regarding housekeeping, grooming, and shower assistance; and facility cleanliness issues with stained dining room tablecloths. A technical violation and a $250 civil penalty for a repeat violation were issued.

The complaint investigation was substantiated regarding staff not meeting resident’s hygiene needs and charging for services not rendered. The allegation about staff not adhering to the admission agreement related to cable services was unsubstantiated.

The investigation substantiated that staff did not properly assist a resident with showers and lacked a system to make up missed showers, posing a potential health and safety risk. The facility issued refunds for missed showers. Another allegation regarding adherence to the admission agreement about cable services was found unsubstantiated.

The visit was triggered by an incident report received on 01/27/2024 regarding a medication error on 01/21/2024 where Staff 1 prepared two different medications simultaneously and administered the wrong one to Resident 1. The resident was monitored closely for respiratory depression and declined ER transfer. Staff 1 was written up and retrained.

The facility failed to properly assist residents with medications, resulting in an incorrect dose being given that posed an immediate health and safety risk. Staff involved were retrained and disciplinary action was taken. A civil penalty for a repeat violation was assessed.

The inspection included review of resident and staff records, medication storage and documentation, and staff interviews. Two staff members were found not associated with the facility, posing an immediate health and safety risk, but the issue was corrected during the visit.

The inspection found that resident and staff records were complete, medications were properly stored and labeled, but two staff members were found not associated with the facility, posing an immediate health and safety risk. The administrator corrected this issue during the visit.

The complaint investigation was substantiated for the allegation that staff did not provide complete records to the authorized representative. The allegation that wrong medications were dispensed was unsubstantiated.

The allegation regarding incomplete records was substantiated as the responsible party had not received requested records by mid-April. The allegation regarding wrong medication dispensation was unsubstantiated due to insufficient evidence, though medication training was recommended for staff.

The complaint investigation was triggered by an incident report received on 3/9/23 regarding a resident noticing a medication refill issue. The complaint was substantiated with citations issued for medication administration and record-keeping deficiencies.

The facility failed to properly assist residents with self-administered medications and did not maintain accurate centrally stored medication records, posing immediate and potential health and safety risks to residents.

The complaint alleged that staff did not provide complete records to the authorized representative and that facility staff dispensed wrong medications to a resident. The records allegation was substantiated, while the medication error allegation was unsubstantiated.

The investigation substantiated that staff did not provide complete records to the authorized representative despite multiple requests, posing a potential health, safety, or personal rights risk. The allegation that staff dispensed wrong medications was unsubstantiated due to insufficient evidence, but medication training was recommended.

The complaint investigation was triggered by an incident report received on 3/9/23 regarding Resident 2 noticing that residents' Alendronate medication needed a refill, which was not properly administered for the month of March.

Deficiencies were found related to medication management, including missing quantity information for certain medications in the Centrally Stored Medication and Destruction Record and failure to properly assist residents with medication administration, posing health and safety risks.

The complaint investigation was substantiated for the allegation that the facility did not issue a correct refund for duplicate tray charges. The allegation that the facility charged a resident for services not needed was unsubstantiated.

The investigation substantiated the allegation that the facility did not issue a correct refund for duplicate tray charges, issuing a refund after the complaint. The allegation that the facility charged a resident for services not needed was unsubstantiated based on assessments and refunds issued.

The complaint investigation was substantiated for the allegation that the facility did not issue a correct refund due to duplicate tray charges. The allegation that the facility charged a resident for services not needed was unsubstantiated after review of care assessments and billing adjustments.

The allegation that the facility did not issue a correct refund was substantiated, with evidence of duplicate tray charges and a refund issued after the complaint. The allegation that the facility charged a resident for services not needed was unsubstantiated, as the facility provided care based on assessments and refunded charges for discontinued services.

The facility failed to submit required COVID-19 incident reports timely, with multiple reports submitted late, resulting in deficiencies cited under Title 22 of the CA Code of Regulations and a $250 civil penalty for a repeat violation.

The facility failed to submit required COVID-19 incident reports within the mandated timeframes multiple times, resulting in a $250 civil penalty for a repeat violation. Deficiencies were cited related to late reporting of incidents and epidemic outbreaks.

The complaint investigation was substantiated regarding the allegation that facility staff made medical decisions for residents, specifically forcing Resident 1 to go to the hospital against their wishes. The allegation that staff made false statements was unsubstantiated. The allegation that the facility did not provide emergency information timely was also unsubstantiated.

The investigation substantiated that the facility violated residents' personal rights by forcing a resident to go to the hospital against their wishes. It was found that the facility had a policy requiring residents who hit their head to be transported to the hospital regardless of consent. Two other allegations regarding false statements by staff and delayed emergency information were unsubstantiated, though recommendations were made to improve staff awareness and emergency information processes.

The complaint investigation was substantiated for allegations that the facility did not meet Resident 1's care needs and did not follow refund policy. The allegation that the facility did not follow the admissions agreement regarding transportation was unsubstantiated.

The investigation substantiated that the facility did not meet Resident 1's care needs, specifically failing to provide two showers per week and proper toileting assistance. It was also substantiated that the facility did not provide a 40% refund as required by the admission agreement. Another allegation regarding failure to follow the admissions agreement related to transportation was unsubstantiated.

The complaint investigation was substantiated regarding the facility forcing a resident to hospital against their wishes. The allegation of false statements by staff was unsubstantiated. The allegation of untimely provision of emergency information was unsubstantiated but recommendations were made.

The allegation that facility staff made medical decisions for residents was substantiated, specifically regarding forcing a resident to go to the hospital against their wishes. The allegation that staff made false statements was unsubstantiated due to insufficient evidence. The allegation that emergency information was not provided timely was also unsubstantiated, though recommendations were made to improve processes and organization.

The complaint investigation was substantiated for allegations that the facility did not meet Resident 1's care needs and did not follow refund policy. The allegation that the facility did not follow the admissions agreement regarding transportation was unsubstantiated.

The investigation substantiated that the facility failed to meet Resident 1's care needs, including inadequate showering and toileting assistance, and did not provide a 40% refund as required by the refund policy. Another allegation regarding failure to follow the admissions agreement related to transportation was unsubstantiated due to insufficient evidence.

The facility demonstrated compliance with infection control measures including screening, PPE use, social distancing, and training. However, two staff members were found not to be associated with the facility prior to employment, posing an immediate health and safety risk.

The facility demonstrated compliance with infection control policies including screening, PPE use, social distancing, and training. However, two staff members were found working without being properly associated with the facility, posing an immediate health and safety risk.

The facility was cited for failing to submit incident reports within the required 7-day period on multiple occasions, posing a potential health, safety, and personal rights risk to residents in care.

The complaint investigation was substantiated for allegations that staff did not maintain residents' hygiene and did not provide timely assistance to residents, including delayed response to call pendants. The allegation that lack of assistance resulted in a resident fall was unsubstantiated. A civil penalty of $250 was assessed for repeating the same violation within 12 months.

The investigation substantiated that staff did not maintain resident hygiene adequately and failed to provide timely assistance to residents, as evidenced by delayed or unanswered call pendant responses. However, the allegation that lack of assistance resulted in a resident fall was unsubstantiated. Deficiencies were cited related to insufficient staffing and failure to meet residents' needs for bathing.

The complaint investigation was substantiated based on interviews, record reviews, and photographs showing residents with wet and soiled clothing and sheets, and inadequate hygiene supplies causing delays in care. The facility held staff meetings and training to address these issues.

The investigation substantiated that residents' incontinence care needs were not properly met, with evidence of residents being soaked for over 3-4 hours and missing documentation of incontinent care. Additionally, the facility did not have adequate hygiene supplies readily available, causing delays in restocking briefs and wipes, especially for hospice residents.

The facility was cited for repeatedly submitting incident reports late, with multiple incidents reported beyond the 7-day requirement, posing potential health, safety, and personal rights risks to residents.

The complaint investigation was substantiated for allegations that staff did not maintain residents' hygiene and did not provide timely assistance to residents, with evidence including shower refusals, delayed or unanswered call pendant responses, and insufficient staffing. The allegation that lack of assistance resulted in a fall was unsubstantiated.

The investigation substantiated that staff did not maintain resident hygiene as Resident 1 was not showered twice weekly as required, and staff did not provide timely assistance to residents, with many call pendant alerts unanswered or delayed. However, the allegation that lack of assistance resulted in a fall was unsubstantiated.

The complaint was substantiated based on interviews, record review, photographs, and staff statements. Issues included residents being soaked with urine and fecal matter due to infrequent diaper changes during the night shift and inadequate hygiene supplies for hospice residents, causing delays in restocking briefs and wipes.

The investigation substantiated that residents were not changed frequently enough during the night shift, resulting in soaked clothing and bedding, and that hygiene supplies such as briefs and wipes were not adequately stocked, causing delays in resident care.

The complaint investigation was substantiated regarding staff not responding to residents' calls for help timely. Other allegations including failure to assist with hygiene needs, medication mismanagement, facility overcharging, and lack of dignity in treatment were unsubstantiated.

The investigation substantiated that staff did not respond timely to residents' call buttons, posing an immediate health and safety risk due to inadequate staffing. Other allegations including failure to assist with hygiene, medication mismanagement, overcharging, and lack of dignity in treatment were found unsubstantiated.

The complaint investigation was substantiated. Allegations included staff not following COVID-19 protocols, delayed response to resident calls, inadequate staffing, water leaks in resident bathrooms, and facility disrepair. One allegation regarding electrical conduit accessibility was unsubstantiated.

The investigation substantiated several allegations including failure to enforce COVID-19 visitor protocols, delayed staff response to resident calls, inadequate staffing levels, water leaks in resident bathrooms, and unsanitary conditions in resident rooms. One allegation regarding accessible electrical conduit was unsubstantiated.

The complaint investigation was substantiated regarding staff not responding timely to residents' calls for help. Other allegations including failure to assist with hygiene needs, medication mismanagement, overcharging, and lack of dignity were unsubstantiated.

The investigation substantiated that staff did not respond timely to residents' call buttons, posing an immediate health and safety risk due to inadequate staffing. Other allegations regarding hygiene assistance, medication mismanagement, overcharging, and dignity were found unsubstantiated based on interviews and record reviews.

The complaint investigation was substantiated for allegations including staff not following COVID-19 protocols, delayed response to resident calls, inadequate staffing, resident bathroom water leaks, and facility disrepair. The allegation regarding electrical conduit accessibility was unsubstantiated.

The investigation substantiated several allegations including failure to follow COVID-19 visitor protocols, delayed staff response to resident calls, inadequate staffing levels, water leaks in resident bathrooms, and facility disrepair posing health and safety risks. The allegation regarding accessible electrical conduit was unsubstantiated.

The complaint investigation was substantiated for the allegation that staff did not ensure a resident received insulin due to lack of communication among staff. The allegation regarding inadequate food service was unsubstantiated based on resident interviews and observations.

The allegation that staff did not ensure a resident received insulin was substantiated due to a communication failure resulting in a resident missing insulin. The allegation that staff did not provide adequate food service was unsubstantiated, with residents reporting satisfaction with food quality and quantity.

The complaint investigation was substantiated regarding the failure to ensure a resident received insulin due to lack of communication among staff. The allegation regarding inadequate food service was unsubstantiated based on resident interviews and observations.

The allegation that staff did not ensure a resident received insulin was substantiated due to a communication failure resulting in a resident not receiving insulin one morning. The allegation that staff did not provide adequate food service was unsubstantiated, with residents reporting satisfaction with food quality and quantity.

The complaint investigation was substantiated for the allegation that staff administered another resident's medications to a resident. The Administrator and Wellness Director admitted fault regarding the medication error involving resident R1 on 2020-05-16. Other allegations were unsubstantiated.

The investigation substantiated the allegation that staff administered another resident's medications to a resident, confirming a medication error. All other allegations including inadequate supervision, shower assistance, food quality and quantity, pendant functionality, linens provision, housekeeping services, and charging for services not received were deemed unsubstantiated based on interviews, observations, and record reviews.

The complaint investigation was substantiated for the allegation that staff administered another resident's medications to a resident (medication error involving resident R1 on 2020-05-16). Other allegations including lack of supervision, inadequate shower assistance, food quality and quantity, malfunctioning pendants, lack of linens, inadequate housekeeping, and improper charges were unsubstantiated.

The investigation substantiated the allegation that staff administered another resident's medication to a resident, confirming a medication error. All other allegations including inadequate supervision, assistance with showers, food quality and quantity, functioning pendants, provision of linens, housekeeping services, and charging for services not received were deemed unsubstantiated based on interviews, observations, and record reviews.

The facility was found to have posted required CDSS PINs and emergency contact information as advised. However, a deficiency was cited for an individual working without CDSS clearance, posing an immediate health, safety, or personal rights risk.

The facility was found to have submitted a mitigation plan and addressed infection control requirements satisfactorily. However, a deficiency was cited for an individual working without CDSS clearance, posing an immediate health and safety risk.