Inspection·July 22, 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 observation, interview, and record review, the facility failed to ensure resident care met professional standards for one resident (Resident 1) of eight sampled residents when following Resident 1's unwitnessed fall nursing and neurological (neuro, relating to the nervous system, includes: brain, spinal cord, and nerves) assessments were not conducted, monitored, or documented in Resident 1's medical record. These failures had the potential to misrepresent Resident 1's actual condition status post (after) fall, which could lead to a delay in treatment and other negative outcomes. Findings:A review of Resident 1's admission record indicated admission to the facility in September 2024 with diagnosis of malignant neoplasm (a cancerous tumor) of unspecified part of the left lung. A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/20/24, indicated Resident 1: Had moderate cognitive (relating to or involving the processes of thinking and reasoning) impairment; Required substantial/maximal assistance (helper does more than half the effort) sit to lying, sit to stand, chair/bed-to-chair transfer, toilet transfer, walk 10-50 feet; and, Was wheelchair dependent.A review of Resident 1's care plan initiated on 9/17/24 indicated, Falls: Resident is at risk for falls with or without injury related to weakness. A review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, a communication technique used in healthcare to facilitate clear and concise information) progress note dated 9/19/24 at 11:33 p.m., indicated Resident 1 had an unwitnessed fall on 9/19/24 at 10:45 p.m. A review of Resident 1's SBAR Communication form dated 9/19/24 indicated, Resident/Patient Evaluation.Functional Status Evaluation [check marked] Falls.Skin Evaluation [check marked] Not clinically applicable to the change in condition being reported.Pain Evaluation [check marked] Not clinically applicable to the change in condition being reported.Neurological Evaluation [check marked] Not clinically applicable to the change in condition being reported. The form further indicated, APPERANCE- Summarize your observations and evaluation: Per report given this morning, [Resident 1] had an unwitnessed fall on 9/19/24 at 10:45 p.m. [Resident 1] was found on the floor in her room, next to her bed and the wall. A review of Resident 1's care plan report initiated on 9/19/24 indicated, Resident had unwitnessed fall found lying on her back.Interventions/Tasks [for nursing staff to implement included] Neuro assessment, nursing assessment. During an interview on 7/21/25 at 3 p.m., the Director of Nursing (DON) stated if a resident had an unwitnessed fall, post fall protocol indicated neuro checks would be initiated automatically. The DON stated the expectation was for neuro checks to be completed every 15 minutes (min) for the first hour (hr), every 30 min. for one hr., every hr. for four hrs., and then every four hrs. for 24 hrs. and documented on a neurological flow sheet. The DON stated, The reason neuro checks are conducted after an unwitnessed fall is because we [facility staff] are not sure if the resident hit their head or not. We [facility staff] want to make sure they [the resident] are monitored and to make sure there is no initial or lasting effects indicating any kind of brain injury. The DON stated it was her expectation for 72 hr monitoring to be conducted at least once a day and documented in the resident's Residents Affected - Few (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 07/22/2025 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)