Inspection·March 12, 2025

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement an effective discharge planning process for one resident (Resident 1) of three sampled residents when Resident 1 and his family member were not trained on how to administer Resident 1's enteral nutrition formula (liquid nutrition) using Resident 1's gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and Resident 1's feeding pump (used to deliver the enteral nutrition) had not been delivered to Resident 1's residence upon his discharge. Residents Affected - Few These failures resulted in Resident 1 not having received any nutrition for over 30 hours after his discharge from the facility, his transfer to the Emergency Department (ED) to be evaluated because of the potentially negative effect to his health and well-being, and his readmission to the facility one day after discharge. Findings: A review of Resident 1's admission record indicated he was admitted to the facility on [DATE] with diagnoses which included pneumonitis (the inflammation of lung tissue) due to the inhalation of food and vomit, severe protein-calorie malnutrition, dysphagia (difficulty swallowing food or liquid by mouth), and dyskinesia of the esophagus (when the muscular tube that carries food from the throat to the stomach moves abnormally). A review of Resident 1's transfer/discharge note dated 2/27/24 at 12:24 p.m., indicated, Patient [Resident 1] discharged to home at [11:45 a.m.] per MD [physician] orders .Demonstration on G-tube care provided . During an interview on 3/12/25 at 12:50 p.m., Licensed Nurse A (LN A) stated she was the nurse assigned to Resident 1 on 2/27/25. LN A stated she provided Resident 1 and his family with the enteral feeding formula, tubing, and syringes. The LN A confirmed Resident 1 was not provided with a feeding pump upon discharge because it was her understanding the social services department had arranged for the feeding pump to be delivered to Resident 1's house. The LN A stated she provided Resident 1's family member with discharge instructions which included the medication list. A review of Resident 1's Discharge Instruction , dated 2/24/25 at 3:55 p.m., indicated the following: -discharge date : [DATE]. (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 3 Event ID: 056072 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B Street Petaluma, CA 94952 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)