Inspection·May 16, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews the facility failed to provide services that meet professional standards for one of three sampled residents (Resident 1), when Resident 1 was administered glucose gel (medical product used to treat low blood sugar levels) in his mouth while unresponsive and unable to follow directions. Residents Affected - Few The failure had the potential to cause Resident 1 to choke on or aspirate (accidental entry of food, liquid or other material into the lungs) the glucose gel. Findings: During a review of Resident 1 ' s admission record indicated, Resident 1 was admitted to the facility in February 2025, with a diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1 ' s care plan titled, Diabetes ., initiated on 2/20/25, indicated, .Resident has a diagnosis of diabetes and is at risk for complications . with goals including, .will minimize the risk for complication of diabetes to the extent possible . During an interview on 5/15/25 at 1:22 p.m., Paramedic 1 (PMD 1) stated he responded to a 911 call a for a hypoglycemic emergency on 4/26/25. PMD 1 stated upon arriving at the facility he observed Resident 1 unconscious with clear gel around his mouth and in his mouth, and with a blood glucose level measuring in the low 30s mg/dL (milligrams per deciliter, a unit of measure used for sugar in blood). The paramedic added, the nurse who was in the room with Resident 1, stated she gave Resident 1 glucose gel into his mouth, despite him being unconscious. The paramedic explained, giving glucose gel in the mouth while the resident was unconscious, created a choking or aspiration (accidental entry of food, liquid or other material into the lungs) risk. The paramedic stated, to be aligned with professional standards, he expected a glucagon injection (an emergency medicine used through syringe/need a to treat hypoglycemia for situations where someone cannot take glucose/sugar by mouth) should have been administered to Resident 1 while unconscious. An interview on 5/15/25 at 2:31 p.m., Resident 1 stated on 4/26/25 he had very low blood sugar, measured in the low 30s mg/dL, doesn ' t remember much about the emergency, but remembered waking up in the ambulance on the way to the hospital. An interview on 5/15/25 at 3:01 p.m., the Director of Nursing (DON) confirmed on 4/26/25 Resident 1 experienced a hypoglycemic emergency which rendered Resident 1 unconscious. The DON stated the Lead Nurse (LN 1) called 911 and Resident 1 was ultimately taken to the hospital for care related to his low blood sugar. (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 05/16/2025 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)