Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sonoma Post Acute during CMS and state inspections, most recent first.
Two residents with dementia, Parkinson’s disease, oropharyngeal dysphagia, and documented severe swallowing impairments had active physician and SLP orders, care plans, and dietary instructions requiring 1:1 feeding assistance or supervision, small bites and sips, and specific swallowing strategies during meals. One resident, care planned for continuous 1:1 assistance at meals, was left alone with a breakfast tray; an RN later found the resident unresponsive in bed with scrambled eggs in the mouth, and a coroner report identified asphyxia from airway obstruction by a food bolus as the cause of death. Another resident, recently started on pureed oral intake while still on tube feeding and ordered 1:1 supervision during all eating, was observed eating a pureed lunch alone in bed without staff present until an RN entered and acknowledged the resident should not have been left unattended. These events occurred despite a facility policy stating staff will assist residents who require help with eating and will feed residents who cannot feed themselves with attention to safety.
Unsanitary kitchen storage, sanitizing, and equipment conditions were observed when fish fillets, beef patties, and cookie dough were left open in the freezer, sanitizer buckets were empty and a new solution tested at 100 ppm with staff unable to confirm the correct concentration, and food-contact items such as a colander and pans were dirty or damaged. Additional findings included stained plastic tubs stored under the sink, a dirty steel prep table, and cracked, stained flooring and debris under the sinks; the DDS acknowledged several areas were unsanitary.
Kitchen Equipment and Surfaces Not Maintained in Safe Operating Condition: The kitchen was observed with missing, broken, and chipped floor tiles, stained and deteriorated surfaces, rusty cabinet hinges, improvised plumbing repairs, and a stove leaking a brown substance at its base. A kitchen staff member reported only 4 burners and 3 working ovens were available, with one oven broken for a long time, making meal prep difficult and requiring frequent pre-cooking and reheating. The DDS, Maintenance Director, and ADM all acknowledged the kitchen needed updating, replacement, or renovation.
A facility failed to make survey results easily accessible to all residents when the only binder was placed in a wall-mounted holder about 5.5 feet from the floor near the nurses station. During observation and interview, the Administrator confirmed the binder could not be reached by a resident in a wheelchair and stated residents should be able to access it without asking for help. The Resident Rights policy stated residents have the right to examine survey results.
Failure to Provide Trauma Informed Care for Residents with PTSD: The facility did not complete thorough social assessments or develop individualized trauma informed care plans for residents with PTSD. A resident with PTSD and depression said staff treated her like a pariah and that she received only one psychiatric visit with no follow-up; another resident who was a veteran became tearful when discussing trauma, but his care plan lacked triggers and individualized interventions; a third resident with PTSD and severe cognitive impairment had no documented trauma history, triggers, or psychiatric consultation. The SSD and DON acknowledged the gaps, and the facility policy called for person-centered trauma informed care and staff training on triggers and re-traumatization.
Insufficient CNA staffing resulted in missed or delayed toileting help, showers, and meal assistance. A resident reported very few showers and trips outside, another was left waiting in the bathroom for 30 minutes, and a resident with dementia and dysphagia was observed eating without staff assistance during lunch. Surveyors also observed residents waiting for trays, a heavy urine odor in hallways, and staff confirmed chronic short staffing, frequent sick calls, overtime, double shifts, and registry use.
Pureed foods for several residents were prepared without clear texture testing, and a test tray was described as too thin, gummy, stuck to the spoon, and lacking seasoning. Staff used broth and thickener by estimation and could not explain IDDSI testing. In addition, a dietary aide did not read aloud fortified diet orders during tray line, and the staff member plating food did not add any fortification, including fortified soup.
A resident with paraplegia, anxiety, and depression qualified for hearing aids after an ENT eval, but staff did not document follow-up on the hearing aid process for over a year. The MDS coded no hearing impairment or assistive device need, and the care plan had no hearing-loss interventions. The resident reported needing others to repeat themselves, feeling isolated, and struggling to participate in activities and conversations.
Failure to Provide Dental Evaluation and Services: A resident with severe cognitive impairment, schizophrenia, and dysphagia was coded as having no dental concerns on the MDS despite being observed with extensive missing upper teeth, exposed roots, tartar, dry lips, and oral debris. The MDS Nurse said she relied on staff reports rather than completing a full assessment, and the SSD confirmed no dental evaluation or referral had been made because no problem had been reported, even though the resident may not have been able to communicate dental needs.
Insufficient dietary staffing and limited DDS oversight affected meal service and food quality. Residents reported cold meals, delayed lunch service, and the need to ask for food to be reheated, while one resident said bedbound residents were not assisted with meals. Surveyors observed empty sanitizer buckets, a dietary aide who could not state the target sanitizer concentration, staff who could not explain a fortified diet, and a pureed test tray that was too thin, gummy, and lacked seasoning. The DDS stated she split time between DDS and staffing duties, had not participated in tray line or test tray tasting that week, and staff reported the department was short staffed and needed more training.
Failure to complete antibiotic stewardship reviews for three residents. The IP stated the facility used an EMR infection screening tool and an antibiotic timeout 48 to 72 hours after antibiotics were started to monitor treatment and notify the MD if changes were needed. However, documentation could not be produced showing infection screenings or timeouts were completed for three residents who were started on antibiotics for UTI symptoms, and the IP acknowledged she had fallen behind on the reviews.
A resident was not allowed to return to the facility after hospital treatment for CRE, even though hospital CM/SW notes showed the facility initially agreed to accept her back when medically stable and after IV abx were completed. The facility later said it could not accommodate CRE because it lacked private rooms and believed the resident needed lifelong isolation, while hospital notes documented the resident was upset, remained waiting for discharge, and was hospitalized for 42 days. The record also showed the physician considered the infection treated and no longer contagious, and CDPH guidance stated readmission should not be denied based on CRE.
A certified nurse assistant was allowed to begin direct resident care before a criminal background check was completed, with the check being conducted approximately nine months after hire. This action was in direct violation of facility policy, which requires background checks to be completed before employment.
The facility did not ensure that its services met professional standards of quality, as observed during the survey. The report identifies a lack of adherence to established professional guidelines in the care provided.
A resident with multiple chronic conditions was given a blood pressure medication on three occasions when their systolic blood pressure was below the prescriber's ordered parameters. Both the LPN and DON confirmed that the medication should have been held according to the physician's order and facility policy, but it was administered regardless.
A resident with diabetes was found unresponsive with severe hypoglycemia, and a nurse administered glucose gel orally despite the resident's inability to respond or follow commands. Facility policy and staff interviews confirmed that glucagon injection should have been used in this situation, as oral glucose gel poses a risk of aspiration or choking in unresponsive individuals.
A resident with multiple complex medical conditions was discharged after being unable to return from an approved leave, without being provided essential medications or necessary mobility equipment. Facility staff confirmed that standard discharge procedures, including medication provision and DME coordination, were not followed, resulting in the resident experiencing emotional distress and withdrawal symptoms.
The facility failed to provide residents with access to private phone calls, as only one working wireless phone was available and often missing. Two residents reported being unable to make or receive private calls, with staff confirming the phones were frequently lost and uncharged. Residents had to use non-private landline phones at the nursing station, violating their right to privacy.
A resident with a history of stroke and quadriplegia did not receive prescribed Lidocaine cream for pain relief due to the facility's failure to reorder the medication in a timely manner. Despite the availability of the medication in the cart, it was not administered on several occasions, as confirmed by staff and records. The lack of documentation and timely reordering led to missed doses, causing potential pain and suffering for the resident.
Failure to Provide Ordered 1:1 Supervision During Meals Resulting in Choking Death and Aspiration Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents who had physician-ordered 1:1 assistance or supervision during meals were continuously attended while they had access to meal trays. One resident with dementia, severe cognitive impairment (BIMS score 00), and oropharyngeal dysphagia was admitted with documented swallowing concerns, poor safety awareness, impulsive intake behaviors, and impaired cognition that limited the ability to follow swallowing strategies. The resident’s care plan and physician orders, in place from admission through the date of death, specified 1:1 feeding assistance with meals and continuous assistance at meals, including whole pills to be given in applesauce one at a time. The Speech Therapy evaluation documented ongoing aspiration risk and the need for supervision during oral intake. On the morning of the incident, the nurse assigned to this resident documented that at 7:47 a.m. a CNA was notified to assist the resident with breakfast. When the nurse entered the resident’s room at approximately 8:10 a.m., no nursing staff were present with the resident despite the active 1:1 feeding assistance order. The nurse found the resident upright in bed, unresponsive, without respirations or carotid pulse, and observed scrambled eggs in the oral cavity, which were removed during airway assessment. CPR was initiated, EMS was called, and resuscitative efforts continued until the resident was pronounced deceased. The Sonoma County Sheriff’s Office Death Investigation Report listed the cause of death as asphyxia due to obstruction of the airway by a food bolus, with scene observations noting scrambled eggs on the sheets, pillow, suction device container, and floor near the resident’s head. The medical director, nursing staff, and the director of staff development all confirmed that the resident had an active 1:1 feeding assistance order at the time and that such an order required staff to remain with the resident during meals. A second resident with Parkinson’s disease, oropharyngeal dysphagia, and a feeding tube was also identified as not receiving the ordered 1:1 supervision during oral intake. This resident had recently begun oral intake to transition off tube feedings and had dietary orders for a pureed diet with mildly thick liquids, small bites and sips, chin-down posture when swallowing, and 1:1 supervision during all eating to prevent choking. The SLP evaluation for this resident documented severe swallowing problems, a history of silent aspiration, and the need for 1:1 supervision any time food or liquid was given. During an observation, the resident was seen sitting upright in bed eating a pureed lunch alone, with no nursing staff present to provide the ordered 1:1 supervision. When a nurse entered the room during the observation, the nurse acknowledged that the resident should not have been left alone with the meal tray and remained to provide continuous supervision while the resident finished eating. The facility’s Assistance with Meals Policy stated that staff will help residents who require assistance with eating and that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, which was not followed for these two residents. The facility is disputing this citation.
Unsanitary Kitchen Storage, Sanitizing, and Equipment Conditions
Penalty
Summary
Food was not stored, prepared, distributed, and served under sanitary conditions and in accordance with professional standards in the kitchen. During the initial tour, fish fillets, beef patties, and cookie dough were observed in the freezer with the inner plastic bags open to air. The Director of Dietary Services stated the bags should have been closed and sealed to prevent freezer burn, and a facility policy required foods to be stored in airtight, moisture-resistant wrapping. Sanitizer buckets for surface cleaning were found empty, and when a Dietary Aide prepared a new solution, the sanitizer tested at 100 ppm. The Dietary Aide could not state whether 100 ppm was the correct concentration, and the DDS later stated the desired level was 200 ppm and that staff should know this. The report also noted that the facility policy required staff to check for appropriate Quat levels using test strips, and the product information described food-contact surface use at 150-400 ppm active quat depending on the dilution. Additional kitchen sanitation issues were observed throughout the food service area. A colander had dried food stuck to it, two pans had peeling or flaky cooking surfaces, and 10 plastic tubs used for storage were stained, moist, and stored under the sink near a drainpipe covered in orange foam sealant. A steel table near the stove had dust, debris, sticky residue, and old flour on it, while the floors under the sinks had missing and cracked tiles, staining, and discoloration. The DDS and Maintenance Director both acknowledged the kitchen was old, not optimal, and had areas that were unsanitary.
Kitchen Equipment and Surfaces Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure a safe operating kitchen environment for a census of 79 when the kitchen space was not maintained and equipment was not effectively repaired or replaced. During an initial kitchen tour, floor tiles were observed missing, broken, and chipped with black and brown staining and buildup. Kitchen cabinets were chipped with rusty hinges, and near the garbage disposal there was a tangled mass of plastic and rubber tubing with metal and plastic pipes with brown discoloration to the tile and wall. Sink drains and pipes were reinforced with bright orange spray foam sealant with visible drip marks underneath. During a later observation in the kitchen, leaking of a brown substance was seen pooling at the base of the stove with a towel covering it, and half of the stove top was covered with foil. The kitchen staff member stated the kitchen had only 4 burners and 3 working ovens for all cooking, which made it very difficult to manage, and that cooks had to pre-cook and reheat frequently during meal preparation. The staff member stated the fourth oven had been broken for a very long time and confirmed the stove leak. The DDS stated the kitchen was very old with lots of wear and tear and needed updating. The Maintenance Director stated the floors needed replacement and the kitchen needed renovation, and the ADM stated he was aware the kitchen needed attention and that it was on the list of needed renovations but was last on the list.
Survey Results Binder Out of Reach for Wheelchair Users
Penalty
Summary
The facility failed to have survey results available for all residents to review when the only binder containing survey results was placed in a wall-mounted file holder approximately 5.5 feet from the floor next to the nurses station. During an observation and concurrent interview on 4/16/26 at 1:45 p.m., the Administrator verified that the binder was the only one available for residents to review survey results and stated that it could not be reached by someone in a wheelchair. The Administrator also stated that residents should be able to reach the binder without having to ask for help and said he would move the binder somewhere else. Review of the facility's Resident Rights policy, last revised 8/2009, indicated that residents have the right to examine survey results.
Failure to Provide Trauma Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide a trauma informed care environment for three sampled residents with PTSD because social assessments were not thorough, trauma informed care plans were not present or were not individualized with identified triggers, and behavioral health services were not provided. The report states that this failure resulted in residents feeling their mental health needs were dismissed, not receiving services from qualified clinicians, and staff being unable to mitigate the risk of re-traumatization and keep residents safe. Resident 7 was admitted with diagnoses including PTSD, anxiety disorder, and major depressive disorder. Her MDS showed a BIMS score of 14, indicating no cognitive impairment. Her care plan, last reviewed 3/23/26, did not include a trauma informed care plan, although it did note a mood disorder and a referral to behavioral health services. Social services notes showed the SSD asked her about PTSD, but she said she did not want to talk about it because she did not want him to know. During interview, Resident 7 stated staff treated her like a pariah after her return from hospitalization, that she had PTSD related to multiple traumatic experiences, and that she had asked for proper mental health help because she did not want to keep talking to unqualified staff. She stated a psychiatrist spoke with her once and then there was no further follow-up. The SSD stated he made no other attempts to discuss her trauma or identify triggers and believed she had been referred to psychiatry, but she did not have active mental health services. Resident 29 was admitted with diagnoses including PTSD, transient ischemic attack, and major depressive disorder. His MDS showed a BIMS score of 12, indicating mild cognitive impairment. Social services documentation noted he was a veteran, but there was no indication of a trauma assessment and no subsequent notes about trauma. His care plan included a psychosocial-emotional trauma focus, but it did not identify the type of trauma, triggers, or individualized goals and interventions. During interview, Resident 29 became tearful and said he had spoken to a woman once about his trauma, but she cried and he did not want to continue upsetting her. The SSD stated Resident 29 had no triggers documented, had not received mental health services, and had not been referred to a VA mental health provider. The DON stated she expected trauma to be assessed during the social assessment and that residents with PTSD should have individualized trauma informed care plans with triggers. Resident 41 was admitted with PTSD and had a BIMS score of 7, indicating severe impairment. The SSD stated he knew the resident had PTSD but did not know much about him, did not interview him to learn about the trauma, did not complete an individualized PTSD care plan, and did not notify the physician. The care plan report stated the resident had a behavior problem related to PTSD, but there was no documentation of the cause of the PTSD, triggers, or individualized treatment plans. A VA psychosocial assessment identified him as 70% service-connected for PTSD. Social services documentation stated emotional support services were concluded after one follow-up visit. The MDS nurse stated there were no observed behaviors upon admission, but the resident had hit his roommate and no link was observed between his PTSD diagnosis and behavior. The DON stated the PTSD care plan was not individualized and she did not see evidence of psychiatric consultations. The facility policy stated trauma informed care should be culturally sensitive and person centered, with staff trained to identify triggers and mitigate re-traumatization, but the monthly inservice calendar did not indicate training for PTSD or trauma informed care.
Insufficient CNA Staffing Led to Missed Basic Care
Penalty
Summary
The facility did not provide sufficient CNA staffing to meet residents’ needs for toileting assistance, showers or bed baths twice weekly, and meal assistance. Surveyors observed a heavy smell of urine in hallway three on multiple occasions, and residents and responsible parties reported that staff were not available when needed, that care was delayed, and that basic needs were not consistently met. Resident 48 stated there was not enough staff to give her showers, reporting only two showers in the last five weeks and only two trips outside during that same period. Facility shower records for Resident 48 showed showers on 3/21/26, 4/1/26, 4/4/26, and 4/15/26. Resident 68, who had dementia and dysphagia and a BIMS score of 03, had a care plan requiring setup assistance and cueing during meals, but during lunch she was observed eating minced and moist food with her fingers while staff did not attempt to assist her. Resident 68’s shower record also showed a six-day gap without a shower and no refusal documented. Resident 45 was observed entering the bathroom in her wheelchair without assistance and then yelling for help for 30 minutes after finishing, with no staff observed to assist her out of the bathroom. Resident 19 stated showers were given very late or not at all, meals were served late and cold, and there was not enough staff to pass trays or provide showers. During lunch, 20 residents were observed waiting 45 minutes for trays, and one resident stated he had not been given anything to drink during the meal. Staff interviews confirmed chronic short staffing, with assignments of 10 to 11 residents per CNA, frequent sick calls, overtime, double shifts, and registry use. The Dietary Supervisor stated the facility did not have enough CNAs and was short staffed at least 75% of the time, and the Administrator stated hiring enough CNAs was a big challenge.
Pureed Diet Texture and Fortified Diet Orders Not Followed
Penalty
Summary
Food and drink were not prepared in a palatable, attractive, and safe temperature for 8 residents receiving a pureed diet, and therapeutic diet requirements were not followed for 8 residents with fortified diet orders. During lunch meal preparation, peas and carrots for the pureed diets were already being boiled on the stove, and staff described using broth and adding thickener little by little to pureed meats, vegetables, rice, and egg rolls. One dietary aide stated she preferred using a commercial thickener pump, while another stated he used broth or other nutrient-containing liquid and thickener powder until the consistency was satisfactory. Neither staff member could verbalize how to test for correct consistency, and one could not recall whether he had IDDSI training. When a pureed test tray was sampled, the texture of all pureed items was found to be too thin, very gummy, stuck to the spoon, and lacking seasoning, and staff stated the food looked and tasted like baby food. For fortified diets, a dietary aide read aloud the diet type on tray tickets to the staff member plating food, but did not read aloud which residents had fortified diets ordered. The staff member plating the trays did not have her own tray tickets or another reference and depended on the dietary aide for the correct diet information. After tray line, the dietary aide could not explain what a fortified diet was, and the staff member confirmed she had not plated any fortification, including fortified chicken soup. The Director of Dietary Services and the Registered Dietician stated the missing fortification did not meet their expectations.
Failure to Follow Up on Hearing Aid Services and Care Planning
Penalty
Summary
The facility failed to ensure one of two sampled residents, Resident 39, received ongoing social services support for hearing impairment after an ENT evaluation on 1/7/25 indicated she qualified for hearing aids for both ears and a referral was sent to start the process. More than one year later, there was no documented follow-up in Social Services notes regarding the hearing aid process, and Resident 39 reported she never received an update from staff. She stated she had to ask people to repeat themselves, felt isolated, and was having increasing difficulty participating in activities and conversations. Resident 39 was admitted with diagnoses including paraplegia, anxiety, and depression. Her MDS dated 2/24/26 indicated a BIMS score of 14 with no cognitive impairment and coded no impaired hearing or need for assistive devices, despite the prior hearing evaluation and documented hearing aid qualification. Her care plan, last reviewed 2/27/26, contained no goals or interventions related to hearing loss. The MDS Nurse stated she relied on verbal interview and did not code issues if the resident did not report them, while the SSD confirmed there was no follow-up documented and no care plan addressing the hearing impairment. The DON stated she expected the MDS Nurse to complete a full assessment and expected timely facilitation of follow-up needs when a resident qualified for hearing aids.
Failure to Provide Dental Evaluation and Services
Penalty
Summary
The facility failed to provide dental services for a resident who had been admitted with schizophrenia, dysphagia, and a need for assistance with personal care. The resident’s MDS dated 4/13/26 indicated a BIMS score of 6, showing severe cognitive impairment, and Section L of the MDS coded no dental concerns. However, during observation on 4/14/26, the resident was noted to be missing almost all upper teeth, with nubs of brown, grey, and yellow enamel, exposed root, built up tartar, dry lips, and spit build up in the corners of the mouth. During interview and record review, the MDS Nurse confirmed the resident was coded as having no dental concerns and stated she did not perform a full assessment, relying instead on direct care staff to report concerns. The Social Services Director stated the facility had two dental providers that cycled through the census and that he did not refer residents unless a problem was reported; he also confirmed this resident had not been evaluated for dental needs by the facility’s dental providers and no referral had been completed to the insurance provider’s dental provider. The SSD acknowledged the resident had cognition and communication issues and may not have been able to relay dental concerns. Facility policy stated oral healthcare and dental services would be provided to each resident and Social Services would be responsible for making necessary dental appointments.
Insufficient dietary staffing and supervision affected meal service and food quality
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out food and nutrition services for a census of 79 residents. The Director of Dietary Services (DDS) stated she split her time 50/50 between the DDS role and Staffing Coordinator role, worked remotely, and worked more than 40 hours per week to meet both demands. The Administrator reviewed the job descriptions but could not state how many hours per week would be needed for each position and stated there was no way to illustrate how many hours per week the DDS devoted to the kitchen versus staffing duties. The Administrator also stated the DDS had an assistant in the kitchen, identified as [NAME] 1, but [NAME] 1 stated she was not the DDS's assistant and was working overtime to meet kitchen demands after the loss of a full-time cook. Resident interviews described meal service problems, including lunches being served last and arriving cold. Resident #19 stated he often had to ask dietary staff to reheat his food, disliked the food because vegetables were never fresh and were always overcooked, and stated residents who could not get out of bed were not assisted with meals. Resident #19 later stated his breakfast was served cold and had to be reheated. An unlicensed staff member stated residents complained that food was served cold and that it came out of the kitchen cold, and said he told kitchen staff repeatedly but they did not have a supervisor. Record review showed the kitchen staffing schedule included 2 full-time cooks, 3 full-time dietary aides, and 3 part-time dietary aides, with the PM shift often staffed by only one cook and one aide, Sundays staffed by one cook for both shifts, and most AM and PM shifts staffed with only one cook and 1-3 aides. During observations, sanitization buckets were empty, a dietary aide prepared sanitizer and tested it at 100 ppm but could not state whether that was the goal concentration, and dietary staff could not verbalize what a fortified diet was. A pureed test tray was sampled by surveyors and kitchen staff, and they concluded the texture was too thin, very gummy, stuck to the spoon, and lacked seasoning. The DDS stated she had not participated in tray line or test tray tasting that week and had been out on the floor most of the week, while staff stated the largest obstacle in the department was lack of sufficient staffing.
Failure to Complete Antibiotic Stewardship Reviews
Penalty
Summary
The facility infection preventionist failed to review three of three sampled residents for antibiotic stewardship: Residents 8, 16, and 24. During an interview and concurrent record review on 4/16/26, the infection preventionist stated that the facility’s antibiotic stewardship program used an infection screening tool in the electronic medical record to review symptoms of a suspected infection and determine whether they met criteria for antibiotic treatment. She also stated that when an antibiotic was prescribed, she completed an antibiotic timeout 48 to 72 hours after the start of therapy to monitor for reactions and notify the doctor so the course could be continued, discontinued, or changed based on lab work or cultures. Review of the antibiotic line list showed Resident 16 was started on an antibiotic for urinary tract infection symptoms on 4/9/26 with an end date of 4/16/26, Resident 8 was started on an antibiotic for urinary tract infection symptoms on 4/10/26 with an end date of 7/17/26, and Resident 24 was started on an antibiotic for urinary tract infection symptoms on 4/2/26 with an end date of 4/7/26. The infection preventionist was not able to produce documentation that infection screenings or antibiotic timeouts were completed for any of these three residents. She stated it was her responsibility to complete these reviews, acknowledged she had gotten a little behind, and verified that Resident 16’s antibiotic was completed on 4/16/26. Facility policy stated antibiotics would be prescribed and administered under the guidance of the facility’s Antibiotic Stewardship Program, which was intended to monitor antibiotic use in residents.
Failure to Readmit Resident After CRE Treatment
Penalty
Summary
The facility failed to allow a resident to return after hospitalization for treatment of CRE, despite multiple hospital discharge planning notes indicating the resident’s anticipated discharge disposition was back to the SNF and that the facility had initially confirmed it would accept the resident when medically stable. The resident had been admitted to the facility with diagnoses including COPD, neutropenia, difficulty walking, depression, and anxiety disorder, and later went to the hospital after an unplanned event during a physician appointment for shortness of breath and cough. Hospital case management and social work notes documented repeated communication with the facility about readmission. The facility’s admission director initially stated the resident could return, including once outpatient IV antibiotics were in place and later after completion of IV antibiotics. However, the admission director then emailed the hospital that the resident’s bed hold had expired and that the facility could not accommodate CRE because it did not have single bedrooms and believed the resident would require lifetime isolation. Hospital notes also documented that the resident was upset after receiving a phone call from the facility saying she could not return and that her belongings were being packed up. Additional hospital notes reflected that the resident had completed the antibiotic course, was no longer considered contagious by the physician, and was waiting for discharge placement. The facility’s infection preventionist stated residents with CRE would require isolation for the entirety of their stay and dedicated staff, while the administrator stated he would rather incur penalties than place other residents at risk and cited lack of private rooms and shared bathrooms as barriers. The facility policy stated residents have the right to remain in the facility and that residents may return after therapeutic leave, and CDPH guidance included in the record stated admission or readmission should not be denied based on CRE colonization or infection. The resident remained hospitalized for 42 days and stated she did not understand why she was being treated like a pariah.
Failure to Complete Background Check Prior to Direct Care Employment
Penalty
Summary
The facility failed to complete a criminal background check prior to allowing a certified nurse assistant (CNA) to begin direct resident care. According to facility records, the CNA was hired and started working with residents on 1/17/23, but the required background check was not conducted until 10/16/23, approximately nine months after employment began. During an interview, the Director of Staff Development confirmed that the CNA's background check was ordered after the employee had already started working with residents, contrary to facility policy, which requires background checks to be completed before employment. Facility policy also states that background and criminal checks are to be initiated within two days of an offer and completed prior to employment.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Follow Prescriber Parameters for Blood Pressure Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including lung cancer, chronic lung disease, heart failure, and hypertension was administered doxazosin mesylate, a blood pressure medication, despite prescriber orders to hold the medication if the resident's systolic blood pressure (SBP) was less than 100 or pulse was less than 60. Medication Administration Records (MARs) showed that the medication was given on three occasions when the resident's SBP was below the ordered parameter: 99, 93, and 96, respectively. Interviews with a licensed nurse and the Director of Nursing confirmed that the medication should have been held on those dates, as per the physician's order and facility policy. Both staff members acknowledged the importance of following medication parameters to prevent adverse effects. The facility's policy required medications to be administered in accordance with prescriber orders, and the failure to do so resulted in the identified deficiency.
Improper Administration of Glucose Gel to Unresponsive Resident During Hypoglycemic Emergency
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of diabetes mellitus was found unresponsive with a critically low blood glucose level. The lead nurse administered glucose gel into the resident's mouth while the resident was unconscious and unable to follow commands. This action was observed by a paramedic who responded to the emergency and noted the presence of glucose gel in and around the resident's mouth. The nurse confirmed during interview that the resident was unresponsive at the time of administration. Facility policy for management of hypoglycemia, as well as staff interviews, indicated that in cases of unresponsiveness due to hypoglycemia, the appropriate intervention is to administer a glucagon injection, not oral glucose gel, due to the risk of aspiration or choking. The Director of Nursing and another licensed nurse both confirmed that the facility's policy requires glucagon administration in such situations, and that glucose gel should not be given to an unconscious resident.
Failure to Ensure Safe and Proper Discharge for a Resident
Penalty
Summary
A deficiency occurred when a resident was discharged from the facility without adequate reason and without proper discharge planning, after being unable to return from an approved leave due to her ride's emergency. The resident contacted the facility to explain her situation, but was informed the following day that she had been discharged. Despite her requests to return, the facility did not allow her back and did not provide her with her essential medications or necessary durable medical equipment (DME) for safe ambulation. The resident had multiple significant medical diagnoses, including type 2 diabetes, acute and chronic respiratory failure, acute kidney failure, bipolar disorder, anxiety disorder, muscle weakness, and a history of strokes. She required assistance with personal care and had orders for several essential medications, such as insulin, antidepressants, and medications for blood pressure and cholesterol. At the time of discharge, she did not have access to her medications or a walker, only a single cane, which was not considered safe for her ambulation needs. The facility also failed to provide her with a planned ankle foot orthosis (AFO) for her left foot drop. Interviews with facility staff confirmed that the resident did not leave against medical advice and that the facility's standard discharge process was not followed. Staff acknowledged that essential medications and appropriate DME were not provided at discharge, and that the resident was left without access to care, experiencing withdrawal symptoms and emotional distress. The facility's own policy required assessment and coordination of discharge needs, including medications and equipment, but these steps were not completed for this resident.
Lack of Access to Private Phone Calls for Residents
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically telephones. During an onsite visit, it was observed that the facility only had one working wireless telephone for resident use, which could not be located. This issue affected two residents, who were unable to make or receive private phone calls. Resident 1, who had medical diagnoses including a fracture of the right femur and chronic obstructive pulmonary disease, was unreachable by phone despite multiple attempts by a family member and the surveyor. The Director of Nursing confirmed that two of the three phones intended for resident use were not working, and the remaining phone was missing. Interviews with staff and residents revealed that the wireless phone was frequently lost and not charged, making it unavailable for resident use. Unlicensed staff members reported that residents had complained about the lack of phone access, and they often had to search for the phones throughout the facility. Residents were forced to use landline phones at the nursing station, which did not provide privacy. Resident 1 confirmed that he was not notified of incoming calls and had to borrow another resident's cell phone or use the nursing station's phone, while Resident 2 also reported a lack of privacy when using the nursing station phone. The facility's policy on resident rights, which guarantees the right to use a telephone in privacy, was not upheld in this situation.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required Lidocaine cream for pain relief. The resident, who had a medical history of stroke, quadriplegia, and high blood pressure, reported that the Lidocaine ointment was supposed to be administered twice daily but had not been applied for several days. The resident mentioned that the facility provided excuses such as the medication being refused or back-ordered. A review of the Medication Administration Record and Physician orders for June 2024 showed that the medication was not administered on multiple occasions, with codes indicating non-administration or missing documentation. During an observation and interview, it was found that a tube of Lidocaine cream was available in the medication cart, but the medication had not been reordered in a timely manner, leading to missed doses. Licensed Staff A confirmed that the medication was not administered on specific dates due to it being reordered but not yet delivered. The Director of Nursing indicated that the medication was ordered and reordered, but there was no documentation to explain why it was not reordered before running out. The lack of documentation and timely reordering resulted in the resident not receiving the necessary pain management.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sonoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Of The Moon Post Acute | 0.5 mi | ★★★★★ | 1 | 0 |
| Broadway Villa Post Acute | 0.7 mi | ★★★★★ | 11 | 0 |
| The Meadows Of Napa Valley | 8.7 mi | ★★★★★ | 0 | 0 |
| Piners Nursing Home | 8.8 mi | ★★★★★ | 40 | 0 |
| Veterans Home Of California - Yountville - Snf | 9.1 mi | ★★★★★ | 16 | 0 |
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