Inspection·August 1, 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 professional standards of practice were met for one of five sampled residents (Resident 1) when supervisory staff did not provide oversight and follow-up after Resident 1 did not receive any showers or baths for seventeen days.This failure had the potential to increase Resident 1's susceptibility to infections, skin problems, and negatively impact his mental health and activities of daily living (ADL, activities such as bathing, dressing and toileting a person performs daily).A review of Resident 1's admission record indicated he was admitted to the facility in May 2025 with medical diagnosis which included vertebrogenic low back pain (chronic low back pain originating from the vertebral endplates, the surfaces of the vertebrae that meet the intervertebral discs in the spine), absence of left leg above the knee, schizophrenia (a mental illness that is characterized by disturbances in thought), depression (depression (a mental health condition characterized by symptoms like sadness, loss of interest and low energy) and PTSD (Post traumatic stress disorder- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 5/23/25 indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 12, which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). In addition, this document indicated Resident 1 had impairment on one side of his lower extremity (hip, knee, ankle & foot) and required substantial/maximal assistance (helper does more than half the effort) with showers and baths. Resident 1's MDS also indicated Resident 1 was wheelchair dependent for ambulation.A review of Resident 1's care plan report, initiated date 5/16/25, indicated, Skin: [Resident 1] is at risk for skin breakdown related to impaired mobility.[staff were expected to] Keep skin clean and dry to the extent possible.A review of Resident 1's care plan report, initiated date 5/17/25, indicated, Mood: [Resident 1] At risk for decreased psychosocial well-being and adjustment issues, emotional distress.[staff were expected to] Encourage participation in ADL's.A review of Resident 1's progress notes, type SBAR [Situation, Background, Assessment, and Recommendation] Summary for Providers, dated 7/03/25 at 10:12 p.m., indicated, Patient [Resident 1] c/o [complain of] pain to R [right] forearm, area assessed and observed to have redden protruding pimple with white head. Slight swelling with firm induration (hardening of tissue) peri pimple and tender to touch observed.A review of Resident 1's progress notes, type Skin/Wound Note, dated 7/7/25 at 2:13 p.m., indicated, This pimple area ruptured now presenting as a abscess. The area is open very bright red with yellow thin pus draining on dressing.with increased swelling forearm to down to hand.now order to start po (by mouth) ATB (antibiotics- a medication used to treat infections).A review of the facility's document titled Shower Schedule, dated 7/16/25, indicated Resident 1 was scheduled to shower on Wednesdays and Saturdays.A review of a facility document titled, Documentation Survey Report v2, for Resident 1 dated 6/1/25-6/30/25, indicated a shower or bath was given on 6/1/25, 6/3/25, 6/12/25, 6/23/25, and 6/26/25. This document indicated Resident 1 refused a shower/bath on 6/30/25. The remaining dates were documented as no (not scheduled for this shift).A review of a facility document titled, Documentation Survey Report v2, for Resident 1 dated 7/1/25-7/31/25, indicated a shower/bath was given on 7/13/25. This document indicated Resident 1 refused a shower/bath on 7/10/25 and was unavailable on 7/3/25, and 7/11/25. The remaining dates were documented as no (not scheduled for this shift).During an interview on 7/31/25 at 1:30 p.m., Certified Nurse Assistant 2 (CNA 2) stated when she offered showers to Resident 1 he would tell her Later. CNA 2 further stated, I will follow up with the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055268 If continuation sheet Page 2 of 4 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 08/01/2025 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident, but he will continue to say Later and then it's another shift and I did not get to it. During an interview on 7/31/25 at 2:30 p.m., Resident 1 stated, It's been a few weeks since I've taken one [a shower], yesterday was the first time in two weeks. Resident 1 further stated, Since the incident [a reported allegation of abuse that occurred in the shower room between himself and a direct care staff member], I'm just not comfortable with it.During an interview and concurrent record review on 8/1/25 at 10:55 p.m., the Director of Nursing (DON) stated the Director of Staff Development (DSD) was responsible for overseeing and auditing (examine) shower check offs. The DON further stated, If showers have not been given, the DSD should interview the nurse and the resident about it. The DON reviewed Resident 1's Documentation Survey Report v2, dated 6/1/25-6/30/25, and verified, based on the documentation, Resident 1 did not receive a shower or bath between the dates of 6/4-6/11 [indicating eight days without bathing], and 6/13-6/22 [indicating ten days without bathing]. The DON reviewed Resident 1's Documentation Survey Report v2, dated 7/1/25-7/31/25, and verified, based on the documentation, Resident 1 only received one shower or bath for the entire month of July. The DON confirmed all other dates were documented as no (not scheduled for this shift). The DON stated, According to the documentation it appears the resident has not been receiving his showers and it's not documented as refused. The DON further stated, If they [the resident] refuse, the CNA is expected to tell the nurse and they [CNA] need to document it as refused.During an interview and concurrent record review on 8/1/25 at 11:31 a.m., the DSD stated she was responsible for auditing the shower check offs, and further stated, Auditing has been a hit and miss. The DSD stated residents were supposed to receive showers twice a week. The DSD stated, We don't want them to go more than a week without a shower, because of skin issues, amongst other things that can happen. The DSD reviewed Resident 1's Documentation Survey Report v2, dated 6/1/25-6/30/25, and stated, Oh my goodness.yeah, 11 days or more.he's gone too long without a shower. That doesn't look good. The DSD reviewed Resident 1's Documentation Survey Report v2, dated 7/1/25-7/31/25, and confirmed a shower was documented as given on 7/13/25 and documented as no (not scheduled for this shift) for the remaining month through 7/30/25. The DSD verified Resident 1 did not receive a shower or bath for seventeen consecutive days. The DSD confirmed Resident 1's lack of bathing could be an underlying psychosocial (a combined influence of psychological [the mental and emotional state of a person] factors and the surrounding social environment on physical, emotional, and/or mental wellness) concern. A review of the facility's policies and procedure (P&P) titled Activities of Daily Living (ADL), Supporting dated 2001 indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Residents will be provided with care, treatment and services to ensure their ADLs do not diminish.Appropriate care and services.including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).Interventions to improve or minimize a resident's functional abilities will be in accordance with.recognized standards of practice.The resident's response to interventions will be monitored, evaluated, and revised as appropriate.A review of the facility's P&P titled Bath, Shower/Tub dated 2001 indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.Reporting.Notify the supervisor if the resident refuses to shower/tub bath.Report other information in accordance with facility policy and professional standards of practice.A review of the facility's document titled Job Description: Certified Nursing Assistant dated 2024 indicated, The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055268 If continuation sheet Page 3 of 4 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 08/01/2025 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)

F 0658 accordance with the resident's assessments and care plan. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055268 If continuation sheet Page 4 of 4