Sonoma Grove

Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in two out of ten residents (R1 & R2) care plans were updated, but not signed by their responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, S4, and S5 did not have the required hours of annual training completed, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above in that room #2 has a broken bathroom window, LPA found a wooden spoon lodged between window and window sill to keep the window open. Room #8 has a broken window, the inner frame of the window is broken and separated from the glass. Room #10 has a hole in the wall opposite of the beds, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above in that water temperature in sink accessible to resident in room #7 measured at 99 degrees F, in room #8 measured at 84 degrees F, in room #11 at 96 degrees F, in room #12 measured at 97 degrees F, and in room #16 measured at 87 degrees F which are all outside of the allowable range of 105 to 120 degrees F, which poses a potential health, safety or personal rights risk to persons in care

Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R5's most current appraisal is dated 2/1/2023, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed urine on toilet chair in room #2 along with spots of a dried brownish reddish substance. Curtains in room #14 had brown substance in various spots, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA and Admin observation, the licensee did not comply with the section cited above in that food items were not found to be stored in a safe manner with open items not covered and sealed; open loaf of bread with bread pieces spilled on the floor, open and uncovered box of croissants, flour in a metal container covered in plastic wrap labeled 12/12/23, sour cream tub and cream cheese tub opened but not labeled with date, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA's observation, records review and interview with the licensee, the licensee did not comply with the section cited above in 10 out of 10 resident's care plans have not been signed by the resident/responsible party within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs interview with licensee, the licensee did not comply with the section cited above in 5 count out of 5 residents did not have a physician's crush order on file, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA's observation, records review and interview with Licensee, the licensee did not comply with the section cited above in 2 out of 10 residents (R7 and R9) who have a dementia diagnosis, but their medical assessments have not been updated since 2021, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs observation, records review and interview with licensee, the licensee did not comply with the section cited above in 5 out of 5 staff members did not have their training records maintained or updated, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's observation, records review and interview with licensee, the licensee did not comply with the section cited above, facility has not contacted a pharmacy to review their medication management at least twice per year as required by regulation, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA/Licensee observation, the licensee did not comply with the section cited above in [4] out of [5] fireextinguishers which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPAs and licensee's observation, the licensee did not comply with the section cited above in resident's bedrooms did not have emergency lighting while electric contractor was working on replacing fuse boxes of electrical system, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's observation and interviews with licensee, the licensee did not comply with the section cited above in facility's resident alert signal did not produce auditory signal to alert staff when residents need assistance, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's observation, records review and interview with the licensee, the licensee did not comply with the section cited above by not maintaining Centrally Stored Medication Records current for residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's observation, records review and interview with Licensee, the licensee did not comply with the section cited above in 1 out of 10 resident (R10) who has a diagnosis of dementia signed their own admissions agreement, without a responsible party acknowledging of the contents of the document, which poses/posed a potential health, safety or personal rights risk to persons in care.

87208 Plan of Operation(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement was not met at evidenced by:Based on observation of the Medication Assessment Record (MAR) during the opening of the complaint on April 27, 2023, LPA observed that the Program Plan of Operation was not being followed as it relates to Medication Policies and Procedures. Furthermore, during a review of the MAR on April 27, 2023, LPA and Administrator observed two residents that did not have the MAR properly documented and had the month of April 2023 missing from the MAR.

87303 Maintenance and Operation(b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. Based on observations this requirement was not met as evidenced by: LPA observed an interior temperature reading of 87 degrees F while exterior temperature was 105 degrees F during inspection on 09/08/2022 which poses an immediate health and safety risk to residents in care.

Based on observation, interview with Licensee & record review, the licensee did not comply with the section cited above in 3 out of 8 staff working were did not have the proper fingerprint clearance and were not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview with Licensee and record review, the licensee did not comply with the section cited above in 1 out of 5 staff weren’t associated to facility which poses a potential health, safety or personal rights risk to persons in care. During visit on 8/9/2022 LPA observed staff S1 was working w/residents and not associated to facility this day.

87412 Personnel Records. (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Licensee did not ensure required verification of training was in each staff file. This poses a potential Safety risk to residents in care.