Health inspection·March 20, 2025

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet the requirements for a safe discharge for one of three sampled residents (Resident 1) when Resident 1 was discharged due to being unable to get a ride back to the facility at the agreed upon return time during an approved leave. This failure resulted in emotional distress for Resident 1 as she did not have access to equipment for safe ambulation (walking) or her essential medications (medications ordered by a physician for treating/and or preventing symptoms of a significant health condition). Findings: A review of Resident 1's admission record indicated she was admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition characterized by difficulty in blood sugar control and poor wound healing), acute and chronic respiratory failure (a serious condition that makes it difficult to breathe on your own. It develops when the lungs can't get enough oxygen into the blood), acute kidney failure (a sudden and significant decline in kidney function that leads to an accumulation of waste products in the blood), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), anxiety disorder (a mental health disorder where a person experiences frequent, intense, excessive, and persistent worry and fear about everyday situations), muscle weakness, need for assistance with personal care, hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), and hypertension (HTN-high blood pressure). A review of a document titled Order Summary Report for Resident 1 indicated the following medication orders: Albuterol Sulfate Aerosol Solution (a medication breathed through the mouth to open the air passages in the lungs), 1 puff every 4 hours as needed for shortness of breath /wheezing (a high-pitched whistling sound that occurs when air flows through narrowed airways in the lungs); Aspirin Oral Tablet (a medication used to prevent a heart attack or stroke) Chewable 81 mg (milligram, a unit of measure), give 1 tablet by mouth one time a day; Atorvastatin Calcium (a medication used to lower cholesterol [a fat like substance found in all the cells of the body] and prevent heart attacks and strokes) Oral Tablet 40 mg, give 1 tablet by mouth at bedtime; Page 1 of 4 055268 055268 03/20/2025 Sonoma Post Acute 678 2nd Street West Sonoma, CA 95476

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Bupropion HCL Tablet Extended Release (a medication used to treat depression) 12-hour 100 mg, give 1 tablet by mouth two times a day; Fluoxetine Capsule (a medication used to treat depression) 10 mg by mouth one time a day; Insulin Glargine (an injectable medication used to treat high blood sugar in individuals with diabetes)100 unit/ml (milliliter, a unit of measure) solution pen injector, inject 17 units subcutaneously (under the skin) at bedtime; Lorazepam (a medication used to treat anxiety) Oral Tablet 0.5 mg, give 1 tablet by mouth every 8 hours as needed; Lyrica (a medication used to treat neuropathic pain [pain that occurs when there is damage to your nerves due to disease or injury]) Oral Capsule 75 mg, give 1 capsule by mouth 2 times a day; Methocarbamol (a medication used to treat muscle pain and stiffness) Oral Tablet 500 mg, give 3 tablets by mouth two times a day; and, Metoprolol Tartrate (a medication used to treat high blood pressure) Tablet 25 mg, give 1 tablet by mouth two times a day. During an interview on 3/19/25 at 2:15 p.m., Resident 1 stated she had been on an approved leave from the facility when her ride/driver received an emergency call and was unable to drive her back to the facility. Resident 1 stated she called the facility and explained the situation. Resident 1 received a call from the facility the following afternoon and was informed she had been discharged from the facility. Resident 1 stated she begged them to let her come back to the facility. Resident 1 further stated she had a cane but needed a walker. Resident 1 also stated she did not have her medications, and the facility refused to provide them. Resident 1 stated she had suffered two strokes in an acute care facility prior to transferring to the current facility. Resident 1 stated she had no access to care, she was experiencing withdrawal symptoms from her medications, and she was very scared. Resident 1 was crying during the interview. A record review of Resident 1's Care Plan Report, initiated 2/20/25, indicated under focus area of Discharge/Transfer, the following interventions: Assess residents needs for discharge; coordinate durable medical equipment (DME - reusable medical devices and equipment prescribed by a healthcare provider to assist with treatment, monitoring, or management of a medical condition or disability), pharmacy, home health, and/or in home support services; nursing to provide discharge instructions and education for all physician orders including but not limited to level of activity, medications, and follow up appointments; provide community resources for discharge needs; provide post-discharge plan of care in a language that caregivers and resident can understand. During an interview on 3/19/25 at 4:18 p.m., the Social Services Director (SSD) stated Resident 1 had a planned discharge on [DATE]. The SSD stated Resident 1 was on an approved leave on 3/11/25 and wanted to come back to the facility and not be discharged . The SSD further stated Resident 1 told him her ride was unavailable due to an emergency with her ride's family member. During an interview on 3/19/25 at 5:10 p.m., the Director of Rehabilitation (DOR) stated Resident 1 had been discharged from Physical Therapy Services (PT - a healthcare profession focused on promoting, maintaining, or restoring health through movement, exercise, and patient education) but had not 055268 Page 2 of 4 055268 03/20/2025 Sonoma Post Acute 678 2nd Street West Sonoma, CA 95476

F 0622 Level of Harm - Minimal harm or potential for actual harm been discharged from Occupational Services (OT - a healthcare profession focused on developing and improving skills that are needed to live life as independently as possible). The DOR further stated the rehabilitation department had planned to order Resident 1 an ankle foot orthosis (AFO - a medical device, often a brace, designed to support and improve the function of the foot and ankle) for left foot drop (a condition where the muscles that lift the front of the foot are weakened or paralyzed). Residents Affected - Few During an interview on 3/19/25 at 5:10 p.m., the director of Nursing (DON) stated the facility received a phone call from a friend of Resident 1 and the friend explained he had an emergency with a family member and was unable to drive Resident 1 back to the facility. When asked if Resident 1 left the facility against medical advice (AMA) the DON stated AMA was when a resident left the facility even though they were advised not to for medical reasons. The DON stated this did not apply to Resident 1 as she wanted to stay in the facility. During an interview on 3/19/25 at 6 p.m., the DON stated when residents were discharged from the facility the nursing department ensured adequate medications were on hand and provided to the resident on the day of discharge. During an interview on 3/20/25 at 10:10 a.m., Licensed Nurse B (LN B) stated the facility had a consistent process for discharging residents. When the nursing department was notified of an upcoming discharge, they called the pharmacy and ordered enough medications for the resident to transition to home or another facility. The goal was for the discharged resident to have time to get their medications from their primary care provider (PCP) at their usual pharmacy. The discharging nurse provided education to the resident regarding dosage, timing, and any special considerations such as blood pressure parameters (refers to keeping blood pressure within a safe range). Certain medications prescribed to Resident 1 were considered essential and therefore vital to maintaining Resident 1's well-being. LN B stated Resident 1 had been taking a medication for blood clot prevention and medications for depression. LN B further stated it had not been safe for Resident 1 to suddenly stop taking antidepressant medication as this could have caused a deeper depression, suicidal ideation (thoughts or ideas centered around death or suicide), and interference with mental stability and daily life. During an interview on 3/20/25 at 10:55 a.m., Licensed Nurse C (LN C), LN C stated the facility procedure had been to order medications from the pharmacy four to five days before a discharge. LN C stated Resident 1 should have continued her medications after she was discharged from the facility. LN C further stated Resident 1 had an order for insulin, which was considered an essential medication to treat diabetes. LN C stated Resident 1 could have suffered from hyperglycemia (high blood sugar) if she did not have insulin available. LN C also stated it was standard practice for a physician to taper (gradually decrease) the dose of an antidepressant instead of stopping it suddenly. LN C stated stopping an antidepressant suddenly could have affected Resident 1's mental health and Resident 1 could have experienced withdrawal effects such as insomnia (inability to sleep), mood swings, agitation, and sweating. During an interview on 3/20/25 at 11:30 a. m. Licensed Nurse D (LN D) stated Resident 1 had been prescribed essential medications. LN D stated aspirin, atorvastatin, and metoprolol were important to prevent high blood pressure and decrease Resident 1's risk for another stroke. LN D stated insulin was an essential medication for Resident 1 to prevent hyperglycemia. LN D also stated Resident 1's medications for depression should have been tapered to prevent increased feelings of depression. During an interview on 3/20/25 at 12:55 p.m. the DOR stated he had seen Resident 1 in front of the 055268 Page 3 of 4 055268 03/20/2025 Sonoma Post Acute 678 2nd Street West Sonoma, CA 95476

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility with a single cane. The DOR stated the facility only issued quad canes (a mobility aid featuring a four-point base for enhanced stability, offering more support than a standard cane, and designed for individuals with limited mobility or balance issues) when a resident was discharged . He further stated quad canes were a lot safer than single canes for ambulation. The DOR stated the Interdisciplinary Team (IDT - a team of healthcare providers that collaborate on health care planning) decided what was necessary for a home discharge and arranged for equipment to be supplied. The DOR confirmed Resident 1 did not receive any DME when discharged from the facility. A record review of the facility policy titled, Transfer or Discharge, Facility-Initiated, revised October 2022, indicated, Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility c. the safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident d. the health of individuals in the facility would otherwise be endangered e. the resident has failed, after reasonable and appropriate notice, to pay for (or have paid under Medicare or Medicaid) a stay at this facility f. the facility ceases to operate. 055268 Page 4 of 4