Health inspection·January 28, 2026

F 0826 Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. 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 rehabilitative services were provided for one of four sampled residents (Resident 1) when Physical Therapy (PT) was not provided according to the plan of care and physician orders.This failure had the potential to result in the resident failing to attain her highest practicable level of physical and functional well-being.During an interview with the Administrator on 1/27/26 at 10:10 a.m., the Administrator stated that the facility was transitioning to having in-house rehab staff rather than staff from an outside rehab provider. The facility ended the contract with the outside rehab providers at the start of the year. The Administrator stated he hired one Occupational Therapist (OT) from the outside rehab providers to continue to work for this facility. She became the facilities employee on the day the outside rehab providers contract ended. The Administrator stated that the facility had a Physical Therapist Assistant (PTA), to start work next week and to serve as the Director of Rehab. The Facility had several positions advertised as available for PT, OT, and Speech Language Pathology (SLT.) The facility planned to utilize telehealth services to provide PT, OT and SLT services and have PT Aides and OT aides at the facility.During an interview with the OT on 1/27/26 at 10:30 a.m., the OT stated the transition happened on 1/5/26. The last day of the contract with the outside rehab providers was 1/4/26. They had not sent any PT, OT, or SLT to the facility since 1/4/26. The OT stated she has been able to provide the OT services ordered by physicians. The OT stated she did not think any Residents had needed PT or SLT services over the last month. The OT stated the facility could only provide OT services at this time. During an interview on 1/27/26 at 12:20 p.m., in Resident 1's room, Resident 1 stated I need to get walking and to get PT. I would like to be able to walk so I can go to another facility like a shelter. Resident 1 stated she maybe saw a therapist once and was promised therapy would start soon. Resident 1 stated, I have not had any PT appointments.A review of Resident 1's admission record indicated she was admitted [DATE] with the diagnosis Acute and Chronic respiratory failure, recent pulmonary emboli (blood clot to the lung,) muscle weakness and need for assistance with personal care.A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/6/26, indicated she had no memory impairment.A review of Resident 1's Order Summary Report, dated 12/30/25 indicated the following physician's (MD) orders for PT: skilled PT services 5x/wk. x 4wks. for (diagnosis code). PT may include: thera ex, thera acts, neuro re-ed, gait training and pt/caregiver training. (Physical therapy for 5 times a week for 4 weeks. PT may include Therapeutic exercises, Therapeutic activities, help Resident regain normal movement and to gain a safe ability to ambulate.)A review of Resident 1's Care Plan Report initiated 12/30/25 documented the Focus: Patient represents with generalized weakness, impaired functional mobility, balance deficit and increase need of assistance with caregivers. Interventions included skilled PT services 5x/wk. x 4wks. for (diagnosis code). PT may include: thera ex, thera acts, neuro re-ed, gait training and pt/caregiver training. During Residents Affected - Few Page 1 of 2 056259 056259 01/28/2026 Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407

F 0826 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few an interview with the Director of Nursing (DON) and concurrent record review on 1/27/26 at 12:35 p.m., the DON opened the electronic record of Resident 1 and noted a Physician order dated 12/30/25 for Physical Therapy. The order read: skilled PT services 5x/wk. x 4wks. for (diagnosis code). PT may include: thera ex, thera acts, neuro re-ed, gait training and pt/caregiver training. The DON stated that most of Resident 1's PT was due in Jan. 2026. The DON stated that was when they transitioned to an in-house therapy department rather than a contracted company to provide the PT.During an interview on 1/27/26 at 12:45 p.m., with the DON and RNA (Restorative Nursing Assistant) (trained certified nursing assistants who help residents maintain their functional level after therapy ends) Staff, the RNA staff stated that Resident 1 was not on her resident list. RNA stated that PT staff did not discharge Resident 1 to RNA services. During an interview on 1/27/28 at 12:50 p.m., the OT stated that the contracted company to provide therapy services has not sent any Physical Therapists, Occupation Therapists or other staff to the facility since 1/4/26. OT stated she provided the services ordered for OT for Resident 1. OT stated the facility did not have a PT so Resident 1 did not get the ordered service.During a review of the facility's policy titled, Scheduling Therapy Services, dated Jan. 2018, the policy stipulated Therapy services shall be scheduled in accordance with the resident's treatment plan. 056259 Page 2 of 2