Inspection·June 13, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review [AES1] the facility failed to provide pain medicine in the form of a cream (lidocaine) for one out of two sampled residents (Resident 1). This failure potentially caused Resident 1 pain and further suffering by missed medication administrations. Residents Affected - Few Findings: During a review of Resident 1 ' s admission Record, dated 1/23/2007, indicated Resident 1 had initially been admitted to the facility on [DATE] with a medical history of stroke (blockage of blood supply in parts of the brain), quadriplegia (as defined as the dysfunction or loss of motor and sensory function of the cervical area [AES3] of the spinal cord, leading to partial or total loss of function in the arms legs, trunk and pelvis) and high blood pressure. During an interview with Resident 1 on 6/13/24 at 10:38 a.m., Resident 1 stated the medication, Lidocaine (ointment type cream which when applied relieves pain) Ointment was to be administered two times a day and it had not been administered for days and the facility was giving excuses like it been refused (by resident) or it was back ordered. Resident 1 stated when the medication had not been applied, to the buttocks area and could be painful. During a concurrent review of Resident 1 ' s, Medication Administration Record and Physician orders, for the month of Jun, 2024 indicated Resident 1 was administered Lidocaine External Ointment 5%, two times a day (06:30 am, 9pm) on 6/1/24. The Medication Administration Record indicated on 6/2/24 both am and pm doses had a code of nine (indicating the medication was not administered), 6/3/24 the am dose documentation space was left blank, indicating the medication had not been given and at 9 pm, the same code of 9 was documented. On 6/4/24 at 06:30 am the same code of nine was documented but the 9 pm dose was documented to be given as ordered. During a concurrent observation and interview on 6/13/24 at 3:30 pm, at the medication cart , with Licensed Staff A, Licensed Staff A indicated by pulling out a drawer that Resident 1 had a tube of Lidocaine cream with Residents 1 ' s name and prescription information on the tube. The tube filled with medication appeared to be almost full and when Licensed Staff A was asked when would the medication be re-ordered, Licensed Staff A indicated by gesturing, using the thumb and index finger when the top was approximately 1/3 left of the medication and would be re-ordered so it would not run out. Licensed Staff A reviewed the Medication Administration Record, dated 6/1/24 to 6/4/24 and stated the code documented on 6/2/24, 6/3/24 and 6/4/24 meant the medication had not been administered. Licensed Staff A indicated on the Medication Administration Record, dated 6/1/24 to 6/4/24 was reviewed and stated the code documented on 6/2/24, 6/3/24 and 6/4/24, indicated the code meant the (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055268 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sonoma Post Acute 678 2nd Street West Sonoma, CA 95476 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)