Inspection Reports for
Ventura Post Acute
4020 Loma Vista Rd, Ventura, CA 93003, CA, 93003
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
133% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 5
Date: Jun 12, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, and facility maintenance at Ventura Post Acute.
Findings
The facility was found deficient in multiple areas including failure to implement care plan interventions for a resident with aphasia, inadequate fingernail care for several residents, inconsistent dialysis care and documentation, unsecured emergency drug supply kit, and improper sanitization of the ice machine.
Deficiencies (5)
F 0656: The facility failed to implement care plan interventions for one resident with aphasia, resulting in unmet communication needs.
F 0677: The facility failed to provide fingernail care for 3 residents, potentially affecting their self-esteem, comfort, and hygiene.
F 0698: The facility failed to ensure consistent dialysis care and accurate documentation for one resident, risking unassessed complications and inaccurate medical records.
F 0761: The facility failed to secure one emergency drug supply kit, allowing potential unauthorized access to medications.
F 0812: The facility failed to properly sanitize the ice machine monthly as required, risking growth of harmful microorganisms and foodborne illness.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: Many
Missed dialysis assessments: 18
Missed dialysis assessments: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Mentioned in relation to communication tools and fingernail care | |
| Licensed Nurse (LN 2) | Acknowledged communication tools not used and fingernail care responsibilities | |
| Director of Staff Development (DSD) | Stated CNAs are responsible for nail trimming | |
| Director of Nurses (DON) | Reviewed dialysis documentation and acknowledged deficiencies | |
| Licensed Nurse (LN 1) | Confirmed emergency drug supply kit should be secured | |
| Nursing Supervisor | Inspected emergency drug supply kit | |
| Maintenance Supervisor (MS) | Responsible for ice machine cleaning and maintenance | |
| Assistant Dietary Supervisor (ADS) | Interviewed about ice machine maintenance | |
| Facility Administrator (ADM) | Acknowledged ice machine sanitization deficiencies |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 12, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, hygiene, dialysis services, medication security, and food safety at Ventura Post Acute facility.
Findings
The facility was found deficient in multiple areas including failure to implement care plan interventions for a non-verbal resident, inadequate fingernail care for several residents, inconsistent dialysis site assessments and inaccurate documentation, unsecured emergency drug supply kit, and failure to properly sanitize the ice machine. All deficiencies were assessed as having minimal harm or potential for actual harm.
Deficiencies (5)
Failed to ensure care plan interventions were implemented for one of five sampled residents (Resident 6) with aphasia, including lack of communication board use.
Failed to provide fingernail care for 3 of 16 sampled residents (Residents 9, 43, and 45), resulting in visibly long and untrimmed nails.
Failed to ensure consistent professional dialysis care for one of four sampled residents (Resident 14) by not assessing dialysis access site pre and post dialysis and documenting inaccurately.
Failed to ensure one emergency drug supply kit (e-kit) was secured when not in use, allowing potential unauthorized access.
Failed to ensure the ice machine was properly and routinely sanitized according to facility policy and manufacturer's service manual.
Report Facts
Residents sampled: 16
Residents affected: 3
Dialysis access site assessments missed: 18
Dialysis access site assessments missed: 19
Date of pharmacy delivery for e-kit: Jun 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Mentioned in relation to communication tools and fingernail care | |
| Licensed Nurse (LN 2) | Acknowledged communication board availability and fingernail care responsibilities | |
| Director of Staff Development (DSD) | Stated CNAs trim residents' fingernails as part of grooming | |
| Director of Nurses (DON) | Reviewed dialysis binder and eMAR, acknowledged documentation errors, and commented on medication security and ice machine sanitization | |
| Licensed Nurse (LN 1) | Confirmed emergency drug supply kit should be secured | |
| Maintenance Supervisor (MS) | Responsible for ice machine maintenance and cleaning | |
| Assistant Dietary Supervisor (ADS) | Provided information on ice machine maintenance | |
| Facility Administrator (ADM) | Acknowledged ice machine sanitization requirements |
Inspection Report
Deficiencies: 1
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration and physician order implementation for a nursing facility resident.
Findings
The facility failed to ensure physician orders were followed and appropriately implemented for one resident. Specifically, blood pressure parameters were not followed before administering Carvedilol, and the physician was not notified of elevated blood sugar levels on two occasions.
Deficiencies (1)
F 0658: The facility failed to follow blood pressure parameters before administering Carvedilol to Resident 1, resulting in medication given despite low blood pressure readings. The physician was not notified as ordered of Resident 1's elevated blood sugar levels on two occasions.
Report Facts
Medication dose: 6.25
Blood sugar level: 513
Blood sugar level: 383
Insulin units administered: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Verified medication administration and documentation discrepancies | |
| Director of Staff Development | Verified medication administration and documentation discrepancies |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration and physician order implementation for residents, specifically focusing on Resident 1's care.
Findings
The facility failed to ensure physician orders were followed and appropriately implemented for Resident 1, including not adhering to blood pressure parameters before administering Carvedilol and failing to notify the physician of elevated blood sugar levels on two occasions. These failures had the potential to result in inappropriate care affecting resident health and safety.
Deficiencies (2)
Blood pressure parameters were not followed prior to Resident 1 receiving Carvedilol medication.
Physician was not notified of Resident 1's elevated blood sugar levels on two occasions as ordered.
Report Facts
Medication dose: 6.25
Blood sugar level: 513
Blood sugar level: 383
Insulin units administered: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Verified administration and documentation discrepancies for Resident 1 | |
| Director of Staff Development | Verified administration and documentation discrepancies for Resident 1 |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 5, 2024
Visit Reason
The inspection was conducted to assess the safety, usability, cleanliness, and comfort of the nursing home environment, specifically focusing on the functionality of an exterior metal framed sliding glass door.
Findings
The facility failed to ensure the exterior metal framed sliding glass door across the hallway leading outside opened and closed properly, leaving a gap that allowed cold air to enter the facility. Maintenance efforts such as replacing rollers did not fully resolve the issue, and the door remained ajar, potentially exposing residents to a cold environment.
Deficiencies (1)
F 0921: The exterior metal framed sliding glass door across the hallway leading outside was partially open and could not be securely closed, allowing cold air to enter the facility and placing residents at risk of a cold environment. Maintenance confirmed the door track was warped and broken, and attempts to repair it did not fully resolve the issue.
Report Facts
Temperature reading: 69
Gap measurement: 0.375
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper | Attempted to close sliding glass door but was unable to close it evenly. | |
| Head of Maintenance | Confirmed door gap and warped door track; replaced rollers; measured hallway temperature. | |
| Certified Nursing Assistant | Reported sliding glass door has always been ajar and does not close well. | |
| Administrator | Acknowledged being informed of sliding glass door problem and confirmed outside air still enters through the gap. |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to evaluate the safety, usability, cleanliness, and comfort of the nursing home environment, specifically focusing on the functionality of the exterior metal framed sliding glass door leading outside the facility.
Findings
The facility failed to ensure the exterior metal framed sliding glass door across the hallway leading outside opened and closed properly, leaving a gap that allowed cold air to enter the facility. This condition posed a risk of a cold environment for residents. Maintenance confirmed the door track was warped and broken, and despite replacing rollers, the door remained ajar.
Deficiencies (1)
Exterior metal framed sliding glass door across the hallway did not close properly, leaving a gap that allowed cold air to enter the facility.
Report Facts
Temperature reading: 69
Gap measurement: 0.375
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Head of Maintenance | Head of Maintenance | Confirmed door gap and broken metal piece; replaced rollers; measured hallway temperature |
| Housekeeper | Housekeeper | Attempted to close sliding glass door and confirmed it was not working properly |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Reported sliding glass door has always been ajar and does not close well |
| Administrator | Administrator | Acknowledged being informed of sliding glass door problem and confirmed outside air still enters |
Inspection Report
Routine
Deficiencies: 7
Date: Dec 8, 2023
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to document and inform residents about personal belongings, unsanitary kitchen conditions, untimely and inaccurate resident assessments, incomplete and outdated care plans, failure to accommodate resident allergies in food service, and unsafe equipment maintenance.
Deficiencies (7)
F 0557: The facility failed to document and inform Resident 17 about personal belongings, risking loss of rights and mental anguish.
F 0584: The facility failed to maintain sanitary conditions in the kitchen, with rust and uncleaned buildup on dishwasher and drain basin.
F 0636: The facility failed to complete the Minimum Data Set quarterly assessment on time for Resident 18.
F 0641: The facility failed to ensure accurate MDS assessments for Residents 560, 50, and 2, including language preference, fall history, and wound care documentation.
F 0657: The facility failed to develop and update comprehensive care plans for Residents 13 and 17, missing a newly discovered medication allergy and long-term care plan update.
F 0806: The facility failed to prevent serving food containing pineapple to Resident 47 who was allergic, causing an allergic reaction.
F 0908: The facility failed to safely secure the gas pipe of the oven, risking gas leaks and fire.
Report Facts
Residents sampled: 19
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Inspection Report
Routine
Deficiencies: 7
Date: Dec 8, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, safety, care planning, assessments, food allergies, sanitation, and equipment safety at Ventura Post Acute nursing home.
Findings
The facility was found deficient in multiple areas including failure to document and inform residents about personal belongings, maintain sanitary kitchen conditions, complete timely and accurate resident assessments, update care plans to reflect new allergies and discharge status, prevent serving food to residents with known allergies, and safely secure essential equipment such as the kitchen oven gas pipe. All deficiencies were assessed as causing minimal harm or potential for actual harm affecting a few residents.
Deficiencies (7)
Failed to document and inform Resident 17 about personal belongings leading to potential loss of rights and mental anguish.
Failed to maintain sanitary conditions in the kitchen with rust and uncleaned substances on dishwasher and drain basin.
Failed to complete Minimum Data Set (MDS) quarterly assessment on time for Resident 18.
Failed to ensure accurate MDS assessments for Residents 560, 50, and 2 including language preference, fall history, and skin assessments.
Failed to develop and update comprehensive care plans for Residents 13 and 17, including new medication allergy and long-term care status.
Failed to prevent serving food containing pineapple to Resident 47 who was allergic, causing allergic reaction symptoms.
Failed to safely secure the gas pipe of the kitchen oven, posing risk of gas leaks and fire.
Report Facts
Residents sampled: 19
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Date of survey completion: Dec 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in deficiency related to failure to document Resident 17's personal belongings |
| MDSC 1 | MDS Coordinator | Acknowledged late and inaccurate MDS assessments for Residents 18, 560, and 50 |
| LN 1 | Licensed Nurse | Involved in allergy incident with Resident 47 and skin assessment for Resident 2 |
| ADS | Assistant Dietary Supervisor | Acknowledged food allergy incident involving Resident 47 |
| DON | Director of Nursing | Confirmed care plan and skin assessment deficiencies |
| SSD | Social Service Director | Provided information on Resident 17's care status change |
| ADON | Assistant Director of Nursing | Reviewed allergy care plan deficiency for Resident 13 |
| IP | Infection Preventionist | Reviewed allergy care plan deficiency for Resident 13 |
| NS | Nursing Supervisor | Reviewed allergy care plan deficiency for Resident 13 |
| MTS | Maintenance Supervisor | Interviewed regarding unsafe gas pipe support in kitchen |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of physical abuse by a Certified Nursing Assistant (CNA 1) against Resident 1.
Complaint Details
The complaint investigation was substantiated. Resident 1 reported being punched in the mouth by CNA 1 after a verbal altercation involving a cordless phone. Multiple staff and police interviews confirmed visible injury and the resident's account of abuse.
Findings
The facility failed to protect Resident 1 from physical abuse when CNA 1 threw a cordless telephone that hit Resident 1 in the mouth, causing physical injury including a bloody mouth and swollen lips. Multiple interviews and statements confirmed the incident and injury.
Deficiencies (1)
F 0600: The facility failed to protect Resident 1 from physical abuse by CNA 1 who threw a cordless telephone that hit the resident in the mouth causing injury. This resulted in actual harm including a bloody mouth and swollen lips.
Report Facts
Date of survey completion: Feb 13, 2023
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in physical abuse finding against Resident 1 |
| LN 1 | Licensed Nurse | Responded to Resident 1's call for help and observed injuries |
| DON | Director of Nursing | Conducted facility investigation and interviewed CNA 1 and Resident 1 |
| ADON | Assistant Director of Nursing | Interviewed Resident 1 and reported observations of injury |
| ADM 1 | Facility Administrator | Part of investigation and reviewed CNA 1's statement |
| VPO | Police Officer | Conducted police investigation and observed resident injury |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation that a Certified Nursing Assistant (CNA 1) physically abused Resident 1 by hitting him in the mouth.
Complaint Details
The complaint investigation was substantiated with multiple interviews from Resident 1, nursing staff, certified nursing assistant students, social services assistant, facility administrator, assistant director of nursing, and a police officer confirming the physical abuse incident. Resident 1 reported being punched in the mouth by CNA 1 after throwing a phone. CNA 1 admitted to throwing the phone which hit Resident 1 in the mouth, claiming it was accidental.
Findings
The facility failed to protect Resident 1 from physical abuse by CNA 1, who threw a cordless telephone that hit Resident 1 in the mouth, causing a bloody mouth and swollen lips. Multiple interviews and statements confirmed the incident, with CNA 1 admitting to throwing the phone, though claiming it was accidental.
Deficiencies (1)
Failure to protect Resident 1 from physical abuse by CNA 1 resulting in injury.
Report Facts
Date of incident: Nov 21, 2022
Date of interviews: Nov 22, 2022
Date of police interview: Dec 15, 2022
Date of CNA student interviews: Jan 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in physical abuse finding against Resident 1 |
| LN 1 | Licensed Nurse | Responded to Resident 1's call for help and observed injuries |
| DON | Director of Nursing | Conducted investigation and reviewed CNA 1's statement |
| ADM 1 | Facility Administrator | Part of investigation and reviewed CNA 1's statement |
| ADON | Assistant Director of Nursing | Interviewed Resident 1 and confirmed injuries |
| SSA | Social Services Assistant | Interviewed Resident 1 and reviewed incident |
| VPO | Police Officer | Conducted police investigation and observed injury |
| CNAS 1 | Certified Nursing Assistant Student | Witnessed incident aftermath and reported blood on Resident 1 |
| CNAS 2 | Certified Nursing Assistant Student | Witnessed incident and reported to LN 1 |
| CNAS 3 | Certified Nursing Assistant Student | Observed Resident 1's injuries and reported incident |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 24, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, activities of daily living, rehabilitative nursing care, and overall facility policies.
Findings
The facility failed to properly document advanced directives for one resident, provide adequate nail care for another resident, and ensure restorative nursing assistance was delivered as ordered for a third resident. These failures posed potential risks of harm including lack of informed medical decisions, complications from poor hygiene, and worsening health conditions.
Deficiencies (3)
F 0578: The facility failed to formulate and document an advanced directive for one of sixteen sampled residents, resulting in incomplete POLST and Advanced Directive Acknowledgement forms and lack of resident representative information in medical records.
F 0677: The facility failed to provide nail care for one of sixteen sampled residents, resulting in dirty, jagged, and overgrown toenails and lack of follow-up to ensure podiatrist care per facility policy.
F 0825: The facility failed to provide restorative nursing assistance as ordered for one of sixteen sampled residents, resulting in the resident remaining in bed and risking loneliness, worsening pressure ulcers, and suboptimal care.
Report Facts
Residents sampled: 16
RNA order frequency: 2
Inspection Report
Routine
Deficiencies: 3
Date: Jun 24, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, activities of daily living, and rehabilitative nursing care at Ventura Post Acute facility.
Findings
The facility was found deficient in documenting advanced directives for one resident, providing nail care for another resident, and ensuring rehabilitative nursing care per physician orders for a third resident. These deficiencies posed potential risks of harm including lack of informed medical decisions, complications from poor hygiene, and worsening health conditions due to lack of mobility.
Deficiencies (3)
Failed to formulate and document an advanced directive for Resident 1, with incomplete POLST and Advanced Directive Acknowledgement forms.
Failed to provide nail care for Resident 47, resulting in dirty, jagged, and overgrown toenails.
Failed to provide restorative nursing assistance to Resident 18 per physician order, resulting in resident remaining in bed and risk of worsening pressure ulcer and isolation.
Report Facts
Residents sampled: 16
RNA order frequency: 2
RNA order duration: 1
MDS date: May 28, 2022
Wound assessment date: Jun 14, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/IP | Registered Nurse/Infection Preventionist | Interviewed and verified incomplete advanced directive documentation for Resident 1 |
| Director of Nursing | DON | Acknowledged advanced directive documentation deficiency for Resident 1 |
| CNA 3 | Certified Nurse Assistant | Confirmed Resident 47's toenails were long and dirty |
| LN 6 | Licensed Nurse | Confirmed Resident 47's toenails condition |
| SSA | Social Service Assistant | Responsible for tracking podiatrist appointments for Resident 47 |
| CNA1 | Certified Nurse Assistant | Observed Resident 18 in bed and confirmed lack of RNA per orders |
| RNA 1 | Restorative Nurse Assistant | Confirmed no documentation of Resident 18 being up in wheelchair per orders |
| LN/IP | Licensed Nurse/Infection Preventionist | Confirmed Resident 18 not up in wheelchair per orders |
| Director of Rehabilitation | DOR | Confirmed Resident 18 not up in wheelchair per orders |
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