Health inspection·September 2, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided by the facility met professional standards of practice for administering medications as ordered by the physician (MD) for three residents (Resident 1, Resident 2, and Resident 3) of three sampled residents when: 1. Resident 1 did not receive her heart failure medication, antidepressant medication, and ointment for skin redness;2. Resident 2 did not receive a dose of his anti-fungal powder; and,3. Resident 3 did not receive her medication to alleviate pain and itching and medication for her thyroid. These failures decreased the facility's potential to ensure residents received medications that prevented a decline in their health status or prolonged discomfort due to their health diagnoses. Findings:1. A review of Resident 1's admission record indicated she was admitted on [DATE] with a diagnosis of congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and adjustment disorder with depressed mood (a mental health condition characterized by significant and persistent feelings of sadness and hopelessness).A review of Resident 1's Medication Administration Record (MAR), dated August 2025, indicated the following MD orders:a. Sacubitril/Valsartan (medication used to treat heart failure), 24-26 milligrams (mg- a unit of measurement) tablet, one tablet by mouth two times a day for heart failure with a start date of 8/12/25 at 5 p.m. The MAR indicated Resident 1 had not been given the evening dose of the medication on 8/12/25 nor the morning and evening doses on 8/13/25 at 9 a.m. and 5 p.m.b. Sacubitril/Valsartan, 24-26 mg. tablet, one-half tablet by mouth two times a day for heart failure with a start date of 8/26/25 at 6 p.m. The MAR indicated Resident 1 had not been given the evening dose of the medication on 8/30/25 at 6 p.m. and 8/31/25 at 6 p.m.c. Trazadone (used to treat depression), 50 mg. tablet, two tablets by mouth, at bedtime for depression with a start date of 8/12/25 at 8 p.m. The MAR indicated Resident 1 had not been given the dose on 8/12/25 at 8 p.m.d. Menthol Zinc Oxide ointment 0.44 -20.6% (%- a unit of measurement), apply to effected area topically every 8 hours for redness of skin with a start date of 8/12/25 at 5 p.m. The MAR indicated Resident 1 had not been given the evening dose on 8/12/25 at 5 p.m. and the morning dose on 8/13/25 at 1 a.m.2. A review of Resident 2's admission record indicated he was admitted on [DATE] with the diagnosis of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities).A review of Resident 2's MAR, dated August 2025, indicated the following MD orders:a. Nystatin (anti-fungal) Powder, 100000 UNIT/Gram (UNIT/GM.- a unit of measurement), apply to groin topically every shift for moisture-associated skin damage (MASD) with a start date of 8/20/25 at 2:30 p.m. The MAR indicated Resident 2 had not been given the night shift dose (NOC) of the medication on 8/20/25. 3. A review of Resident 3's admission record indicated she was admitted on [DATE] with the diagnosis of a recurring dislocation of the left shoulder and psoriasis (a chronic skin condition characterized by itchy and sometimes painful red, scaly plaques that can appear anywhere on the body). A review of Resident 3's MAR, dated August 2025, indicated the following MD Residents Affected - Some Page 1 of 2 055854 055854 09/02/2025 Santa Rosa Post Acute 4650 Hoen Avenue Santa Rosa, CA 95405

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some orders:a. Lidocaine (medication used to alleviate pain) external patch, 4%, apply to effected area topically one time a day for pain with a start date of 8/27/25 at 9 a.m. The MAR indicated Resident 3 had not been given the medication on 8/27/25 nor 8/28/25 at 9 a.m. b. Betamethasone Dipropionate external cream 0/05%, apply to affected area topically every 8 hours for psoriasis with a start date of 8/26/25 at 5 p.m. The MAR indicated Resident 3 had not been given the evening dose on 8/26/25 at 5 p.m., the morning and mid-day dose on both 8/27/25 and 8/28/25 at 1 a.m. and 9 a.m.c. Levothyroxine Sodium oral tablet, 50 micrograms (mcg. - a unit of measurement), give 50 mcg by mouth in the morning for hypothyroidism (when the thyroid gland is unable to meet the body's needs) with a start date of 8/31/25 at 6 a.m. The MAR indicated Resident 3 had not been given the medication on 8/31/25 at 6 a.m. During a concurrent interview and record review on 9/2/25 at 11:24 a.m., the Infection Preventionist (IP) reviewed Resident 1's, Resident 2's, and Resident 3's August 2025 MARs and confirmed all three residents had missed doses of their medications.During a second interview and concurrent record review on 9/2/25 at 12:10 p.m., the IP stated licensed nurses are expected to check the facility's emergency medication stock for the ordered medication. The licensed nurses are also expected to call the pharmacy to confirm a delivery date and time, then call the physician to notify him of the issue. The physician can then decide whether to order a substitute or confirm that the delay of medication administration is okay. Lastly, the licensed nurses are then expected to document what they did and any instructions they were given in the resident's chart. The IP also stated the pharmacy was located close by so most medications could be delivered the same day; however, if the order is placed at night, the medication would be delivered the following morning. The IP reviewed Resident 1, Resident 2, and Resident 3's progress notes and confirmed there was no documented evidence the pharmacy nor the physician was called. The IP also reviewed the list of medications available in the facility's emergency medication stock and found only the lidocaine patch was available. The IP stated the nurse could have administered the lidocaine from the facility's emergency medication stock.During an interview with the acting Director of Nursing (DON) and the Administrator (ADM) on 9/2/25 at 2:36 p.m., the DON confirmed if a medication was missed then it is considered a medication error and could have negatively affected the health of the residents. A review of the facility's policy titled, Administering Medications, revised April 2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame. 055854 Page 2 of 2