Other·October 22, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the findings of the California Department of Public Health during a Federal Abbreviated Standard Survey of Complaint #CA00630522. The inspection was limited to the specific Complaint and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor #34331, Health Facilities Evaluator Nurse. The Department substantiated a violation of the regulation(s) for Complaint #CA00630522. Refer to F-689.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow their policy and procedure and professional nursing standards of medication administration when one of two sampled residents (Resident 1) was left unattended while he received a nebulizer treatment (a drug delivery device that turns the liquid medicine into a mist which is then inhaled LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C75411 Facility ID: CA010000034 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 07/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE into the lungs through a mouthpiece or a mask). Resident 1 was set up for the treatment but the licensed nurse (LN-A) left the room. The nebulizer treatment was completed in a matter of minutes, however, LN-A did not return to Resident 1's room to shut off the nebulizer. Resident 1's family member (FM) looked for LN-A but could not find her. FM ended up turning off the completed nebulizer treatment. The failure of leaving Resident 1 unattended during a nebulizer treatment had the potential for the treatment delivery to become misaligned or interrupted and therefore not having the medication delivered properly, or for LN-A to miss observing any untoward side effects of the nebulized medication. Leaving a resident unattended during a medication administration had the potential to result in a medication error. Findings: The facility's Admission Record indicated Resident 1 was a 90 year old male admitted to the facility in June 2017. Resident 1 had multiple diagnoses which included dementia (a decline in mental ability severe enough to interfere with daily life; memory loss is an example) with behavioral disturbances, repeated falls, pneumonitis (inflammation of the lungs) due to inhalation (breathing in) of food and/or vomit, and chronic (persisting for a long time) atrial fibrillation (an abnormal heart rhythm). Review of Resident 1's Medication Administration Record (MAR) for the month of March 2019 indicated he had an order, as of 3/17/19, for Ipratropion-Albuterol (a combination of two medicines that block the production of mucus in the airways) 0.5mg (milligrams) / 2.5mg per 3mL (milliliters) inhaled orally (by mouth) via (by way of) nebulizer every eight hours (scheduled at 6 a.m., 2 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C75411 Facility ID: CA010000034 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 07/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10 p.m.). Resident 1 also started, on 3/17/19, an antibiotic for pneumonia (lung infection). During an interview on 3/28/19 at 9:45 a.m., FM stated LN-A set up and started Resident 1's nebulizer treatment on the evening of 3/23/19, (exact time unknown, but it was after dinner), then left the room and did not return. FM stated she was ready to leave the facility after visiting with Resident 1 and looked for LN-A, to turn off the finished nebulizer treatment, but could not find her. FM stated she then turned off the nebulizer machine. FM stated she left the facility (on 3/23/19) at 7:10 p.m., and because she did not find LN-A, FM told CNA-C, who was at the nurse's station, to "please tell the nurse I turned off the nebulizer ... and please put [Resident 1] to bed by 7:30 p.m. or 8 p.m. at the latest." During an interview on 4/4/19 at 10:30 a.m., LN-D was asked to describe how she administered nebulizer treatments to resident's. LN-D stated, "I have to stay with [the resident]." LN-D explained the preparation steps and stated, while the treatment was delivered, "I'm right there at the door and give [the other roommates] any meds (medications) due, so I'm in the room too. [It] takes five to seven minutes to complete [the nebulizer treatment]." During an observation on 4/4/19 at 12:15 p.m., LN-D administered a nebulizer treatment to Random Resident 2. LN-D stayed with the resident until the treatment was completed. During an onsite interview on 4/4/19 at 1:15 p.m., FM stated LN-A asked her to bring Resident 1 back to his room sometime after dinner so she could administer his nebulizer treatment. FM stated she looked for LN-A at 6:10 p.m. but could not locate her. Then at 6:15 p.m., FM "shut off" the nebulizer machine FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C75411 Facility ID: CA010000034 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 07/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE because it had stopped administering the nebulized medication. FM stated, "that was my issue ... they (staff) disappear ... they say 'short staffed' a lot. During an telephone interview on 4/5/19 at 12:17 p.m., LN-A was asked why Resident 1's nebulizer treatment was started then she left the room and FM could not find her. LN-A stated, "I was in the middle of med pass (administering medications to the residents)." When asked if she would typically stay with the resident during the nebulizer treatment, LN-A stated, "I do park [the medication cart] outside the room, I don't remember what got me called away ... [when] I went back [to Resident 1's room] and the nebulizer was finished." LN-A was informed that FM looked for her then told CNA-C to alert LN-A that she (FM) turned off the nebulizer machine ..." LN-A stated, "I don't recall [being told] that." According to the National Center for Biotechnology Information/U.S. National Library of Medicine (https://www.ncbi.nlm.nih.gov) working conditions can facilitate medication errors. Conditions that predicate an error may include: Latent conditions such as staffing shortages, and Error-producing conditions such as distractions and interruptions. During a telephone interview on 4/5/19 at 12:23 p.m., the DON stated, "it's not customary to be pulled away [during a treatment]." The facility's policy and procedure titled, "Administering Medication through a Small Volume (Handheld)* Nebulizer," revised 10/2010, indicated "Remain with the resident for the treatment." *The policy and procedure indicated under Step 14 the nebulizer treatment may also be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C75411 Facility ID: CA010000034 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 07/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administered through a face mask (covers the nose and mouth).

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide one of two sampled residents (Resident 1) with adequate supervision or assistance to prevent Resident 1 from falling from his wheelchair when he was left unattended in his bedroom and not put to bed in a timely manner. Resident 1 fell onto the floor and sustained two lacerations (a wound that is produced by the tearing of skin) and bruising to his face. Resident 1 required transport to the acute care hospital emergency department. One laceration required sutures (stitches) and the other was treated with steristrips (small pieces of medical tape used to close a wound). Failure to provide supervision and bedtime care in a timely manner contributed to Resident 1 falling from his wheelchair and sustaining injuries to his face. Findings: The facility's Admission Record indicated Resident 1 was a 90 year old male admitted to the facility in June 2017. Resident 1 had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C75411 Facility ID: CA010000034 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 07/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE multiple diagnoses which included dementia (a decline in mental ability severe enough to interfere with daily life; memory loss is an example) with behavioral disturbances, repeated falls, pneumonitis (inflammation of the lungs) due to inhalation (breathing in) of food and/or vomit, and chronic (persisting for a long time) atrial fibrillation (an abnormal heart rhythm). The quarterly Minimum Data Set (MDS - a resident assessment tool) dated 1/5/19, indicated Resident 1 required a wheelchair for mobility (he no longer could walk), and had severely impaired cognition (attention, comprehension, thinking ability), and disorganized thinking. Resident 1 was dependent on staff for activities of daily living and required extensive assistance of two persons for dressing, toileting, hygiene, bathing, and transfers to and from his bed to the wheelchair. The MDS indicated Resident had a fall with injury (skin tear, abrasion or bruise) since his prior assessment date of 10/5/18. During a telephone interview on 3/28/19 at 9:45 a.m., FM stated she visited Resident 1 on the evening of Saturday, 3/23/19. At approximately 7:10 p.m., FM stated she could not find LN-A and told a male certified nursing assistant (CNA-C) that she was leaving the facility and to "please put [Resident 1] in bed by 7:30 p.m. or 8 p.m. at the latest." FM stated she received a phone call later that evening at 9:10 p.m. from the facility. The facility informed her Resident 1 fell out of his wheelchair, and they could not stop the bleeding to his forehead and he was being sent to the emergency department. FM stated when she met up with Resident 1 at the hospital's emergency department, "he still had his clothes on," and was not in his pajamas for bed. The next day, FM stated she asked a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C75411 Facility ID: CA010000034 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 07/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE nurse at the facility why Resident 1 was not put to bed, as she had requested the evening before, and was told, "the CNA was busy and we're short staffed." FM stated, "they're always saying 'we're short staffed or two people called off '... especially on weekends." When asked how that impacted Resident 1, FM stated, "well, he didn't get put to bed (on 3/23/19) when I asked, then he fell." Review of a Nurse's Note dated 3/23/19 and documented at 10:38 p.m., indicated the following: "At 8:45pm CNA came and told me that resident is on the floor in his room, found on the floor on his right side. Profuse bleeding was noted on his head. First aid rendered by staffs [sic]. Called 911 for transfer at 8:47 pm. Resident sent to the ER (emergency room) at 9pm ... sent to ... Hospital." An Interdisciplinary Team (IDT) note dated 3/25/19 at 9:50 a.m., which reviewed the fall, indicated on the evening of 3/23/19, after dinner, FM had wheeled Resident 1 (in his wheelchair) back into his room. Resident 1's roommate witnessed the fall and told the Director of Nursing (DON), "he leaned forward and fell out of the wheelchair." During an observation on 4/4/19 at 10:37 p.m., Resident 1 was seated in his wheelchair across from the nurses's station. There were four staff members working at the nurse's station with Resident 1 within line of sight. Resident 1's eyes were closed and he did not respond to a greeting. There was a scar at the center of his forehead about one inch long, and sutures remained over his left eyebrow which was about one and one half inches long. There was faint, remnant bruising to his face. During an interview on 4/4/19 at 10:40 a.m., CNA-B confirmed Resident 1 required two FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C75411 Facility ID: CA010000034 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 07/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE people to transfer him from his wheelchair to his bed and sometimes he could be "very resistant." CNA-B stated she was called into another resident's room on the evening of 3/23/19 to help with a transfer. CNA-B stated while she was in the midst of helping with the other resident's transfer, someone informed her Resident 1 had fallen. CNA-B stated, "I shouldn't have left him in his room, normally he's within sight." CNA-B was tearful as she described being told Resident 1 fell to the floor, and stated, "I was so upset." During an interview on 4/4/19 at 11:40 a.m., the Director of Staff Development (DSD) was asked what fall prevention interventions were being implemented for Resident 1. The DSD stated the facility utilized a wheelchair alarm (an alarm that sounds if a resident attempts to get out of a wheelchair unassisted), bilateral floor pads (padded mats) on each side of the bed one of which had an alarm within it, and a low bed. Resident 1's Plan of Care, initiated on 4/2/18 and revised on 10/19/18, addressed his "high risk for falls" related to his limited physical mobility, loss of strength, and dementia. The Care Plan indicated Resident 1 had poor safety awareness and repeated falls. Although the alarm systems, floor pads, and low bed position were documented as interventions there was no mention of having Resident 1 within line of sight. During an interview on 4/4/19 at 12:45 p.m., Resident 1's Roommate stated he saw him fall (on the evening of 3/23/19). The Roommate stated, "it looked like he was trying to get up from the wheelchair but fell and hit his head." The Roommate stated he had called out to facility staff for help after Resident fell. The Roommate stated Resident 1 "falls easily." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C75411 Facility ID: CA010000034 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 07/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a telephone interview on 4/5/19 at 12:17 p.m., LN-A stated she took care of Resident 1 on the evening of 3/23/19. LN-A stated a CNA notified her that Resident 1 fell and she found him on the floor (in his room) bleeding. When asked how Resident 1 fell, LN-A did not know and stated, "he was found on his side [lying] next to his bed." During a telephone interview and concurrent record review on 7/24/19 at 10:50 a.m., Resident 1's Fall Risk Assessments dated 12/29/18 and 3/24/19 were reviewed with the DON. The DON verified Resident 1's Fall Risk Score for each assessment was 26/high risk for falls. High risk scores were between 16-42; moderate risk scores were between 9-15; and low risk scores were between 0-8. The most recent Fall Risk Assessment dated 6/24/19, indicated Resident 1 remained at a high risk for falls with a score of 26. The facility's policy and procedure titled, "Falls and Fall Risk, Managing," revised 3/2018, indicated under the section "Resident-Centered Approaches to Managing Falls and Fall Risk: #5, If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. #6, If underlying causes cannot be readily ... corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. #7, In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding ...) to try to minimize serious consequences of falling. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C75411 Facility ID: CA010000034 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 07/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: C75411 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA010000034 (X5) COMPLETE DATE If continuation sheet 10 of 10