Health 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 Page 1 of 2 055268 055268 07/22/2025 Sonoma Post Acute 678 2nd Street West Sonoma, CA 95476

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few progress notes after a fall was reported. During an interview and concurrent record review on 7/22/25 at 1:05 p.m., the Licensed Nurse 1 (LN 1) stated it was expected for licensed nurses to initiate monitoring with vital signs, neuro assessments, and a nursing assessment following a resident fall every 15 minutes (Q 15 min). LN 1 stated the nursing assessment included an assessment for injury, pain, and any changes to skin (ex: bruising and swelling) and the assessment should be documented when completing the resident's Change of Condition (COC) or SBAR report. LN 1 further stated neuro assessments were expected to be conducted for 72 hrs. post fall and COC progress notes would be completed up to 3 days and documented under the resident's progress notes. LN 1 reviewed Resident 1's progress notes dated 9/19/24 to 9/21/24 and confirmed there were no COC 72 hr. progress notes for Resident 1 status post fall. During an interview and concurrent record review on 7/22/24 at 2 p.m., the DON reviewed Resident 1's SBAR report dated 9/19/25 and confirmed pain, skin, neuro, and appearance should have been thoroughly assessed. The DON further confirmed the nursing assessment was not adequate. After a review of Resident 1's medical record, the DON stated, There is no proof of neuro checks being complete following the fall based on the lack of documentation. A review of the facility's policies and procedure (P&P) titled Change in a Resident's Condition or Status dated 2001 indicated, .the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication form.A review of the facility's P&P titled Assessing Falls and Their Causes dated 2001 indicated, If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities.Observe for delayed complications of a fall for approximately forty-eight hours.and document findings in the medical record.Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in the level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 055268 Page 2 of 2