Health inspection·April 10, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of Resident 1's Providence After Visit Summary, dated 4/2/25, indicated Resident 1 received blood and urine testing, and a computed tomography scan (CT scan - a medical imaging technique that uses X-rays to create detailed cross-sectional images of the body) of the abdomen. Resident 1 was diagnosed with an acute (a condition or illness that has a sudden onset and relatively short duration) UTI with abdominal pain and was treated with intravenous (existing or taking place within, or administered into, a vein or veins) fluids, pain medications and an antibiotic (medications that specifically target and eliminate bacteria causing infections in humans and animals) injection. Resident 1 was then discharged back to the facility via ambulance at 12:45 a.m. on 4/3/25. A review of Resident 1's Order Summary Report, dated 4/10/25, indicated Resident 1 was prescribed the following: Cefpodoxime Proxetil (used to treat bacterial infections in many different parts of the body) Oral Tablet 200 mg (milligram-a unit of measure), give 1 tablet by mouth two times a day for UTI for 10 days. Order date 4/3/25, end date 4/13/25. During a concurrent interview and record review with the Director of Nursing (DON) on 4/10/25 at 2:51 p.m., the DON acknowledged nursing staff did not initiate a nursing care plan for Resident 1's UTI or for antibiotic treatment. The DON stated this slipped by because the condition was found by an outside hospital, and Resident 1 arrived back at the facility late at night. The DON also stated a UTI care plan was important because it directed nursing staff in appropriate interventions. During an interview on 4/10/25 at 3:35 p.m. with Licensed Vocation Nurse 1 (LVN 1), LVN 1 stated Resident 1 was still on antibiotic treatment for UTI and was doing well. LVN 1 acknowledged there was no nursing care plan for Resident 1's UTI, and this was not facility policy. LVN 1 stated many nursing interventions, such as increased water intake and observing for signs of systemic (affecting the entire body) infection, were typical interventions in a UTI care plan, and nursing staff should have notified the DON that the care plan was missing. During a review of facility policy and procedure (P & P) titled, Urinary Tract Infections/Bacteriuria-Clinical Protocol, dated 1/2018, it indicated, empirical treatment should be based on documented description of an individual's symptoms and on consideration of relevant test results, co-existing conditions, and pertinent risk factors, and, .nursing staff will review the status of individuals who are being treated and adjust treatment accordingly. During a review of facility P & P titled, Care Plans – Comprehensive Person Centered, dated 1/2018, it indicated, the nurse and/or the interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident's condition . 2. During a concurrent interview and record review on 4/10/25 at 3:15 p.m. with the DON, Resident 1's Progress Notes, dated 1/15/25, and the Medication Administration Report (MAR- keeps track of every dose that the individual takes or misses for whatever reason) for January 2025, were reviewed. The DON agreed Resident 1 did not have a bowel movement (BM) for three days on 1/15/25, but no bowel care medications were administered. The DON stated facility bowel protocol was to implement specific interventions if a resident did not have a BM in three days. During a record review of Resident 1's Care Plan Report, printed 4/10/25, it indicated interventions for constipation instructed, administer Dulcolax (rectally inserted medicine used to relieve constipation), Fleet's enema (liquid is inserted into the rectum and colon through the anus), and MOM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 2 of 3 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Milk of Magnesia- Magnesium hydroxide, used to orally treat occasional constipation in children and adults on a short-term basis) as ordered .Follow facility bowel protocol for bowel management. During a record review of Resident 1's Order Details, dated 7/10/24, it indicated the following, Milk of Magnesia (MOM) Suspension 1200 mg/ml (milliliter-a unit of measure) by mouth; give 30 ml by mouth as needed for bowel care management/bowel care; give 30 ml PO (by mouth) if no bowel movement in 3 days in the evening, and Dulcolax Suppository 10 mg rectally; insert 1 suppository rectally as needed for bowel care management/bowel care; give 1 suppository if no (sic) MOM is ineffective on NOC (night) shift. During an interview on 4/10/25 at 3:35 p.m. with LVN 1, LVN 1 stated bowel care, including suppository administration, was done and documented by Licensed Nursing staff, not Certified Nursing Assistants (CNAs), and bowel care intervention is triggered in the electronic medical record (EHR) if a resident has not had a BM in three days. During an interview on 4/10/25 at 3:15 p.m. with the DON, the DON stated she did not know if Resident 1 failed to receive bowel care management per the nursing care plan on 1/15/25, or if the nurse just failed to document it. A record review of facility P & P titled, Bowel (Lower Gastrointestinal Tract) Disorders – Clinical Protocol, dated 1/2018, indicated, treatment/management: the physician will identify and order cause-specific and symptomatic interventions; for example institute a regimen to prevent constipation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 3 of 3