Health inspection·March 3, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 2/19/25 at 12:42 p.m., the Director of Rehabilitation Services reviewed Resident #1 ' s medical record and stated she was supposed to wear a cervical collar and a right-hand splint. She stated Resident #1 got the right-hand splint for a fractured wrist after she fell in the facility. She stated Resident #1 was sent to hospital on 1/28/25, two days after she fell on 1/26/25. She stated Resident #1 ' s Skilled Nursing Facility ' s (SNF) Physician wrote orders for her to go to the hospital for assessment and placement of a splint on her right wrist. She stated the SNF Physician ' s Order, dated 1/28/25, was to wear the splint 24/7. She stated the doctor wrote orders to monitor the right hand for placement of the splint, circulation of the fingers on the right hand. She stated the daily Nursing Notes indicated staff should complete observation of the right hand and wrist and document it. She stated the risk to the patient for not following the Physician Orders to wear the right wrist brace could result in further injury to Resident #1 ' s wrist. During an interview on 2/19/25 at 1:35 p.m., the Assistant Director of Nursing stated Resident #1 ' s doctor had ordered a right wrist splint 24/7, on 1/28/25, and to monitor every shift for placement and circulation. She stated staff should communicate with each other about the brace, and private sitters could look at the white board in the room that would have important information about the brace. She stated the facility should communicate with private sitters. During a phone interview on 2/20/25 at 3:16 p.m., the Private Sitter ' s Manager stated no one had communicated with his agency or caregivers to ensure the placement of a right wrist brace on Resident #1. He stated it was the responsibility of the nurses to communicate any special concerns or needs to the private sitter. During a phone interview on 2/21/25 at 10 a.m., Private Sitter S stated her responsibility for Resident #1 was to be her companion and be sure she did not fall. She stated she was aware Resident #1 had a broken right wrist with a brace. She stated it was covered with an ace wrap (brace), and Resident #1 kept trying to take it off. She stated the facility nurses and staff had come in and saw that it was off when they gave Resident #1 medications and when they came in to take her to the bathroom, but no one put the brace back on. She stated she left on 2/10/25 at 8 p.m., and the brace was off and when she returned to work on 2/11/25 at 8 a.m., the Resident #1 did not have a brace on her right wrist. During an interview on 2/24/25 at 11:12 a.m., Licensed Staff I stated caregivers did not provide direct patient care and would inform staff of anything special like the need for a resident to go to the bathroom. She stated the caregivers would usually check in with the nurse when they would come to work, and they should have notified the nurse if the right wrist brace was off. During an interview on 2/24/25 at 12:25 p.m., the Director of Nursing stated staff assessed placement of Resident #1 ' s wrist brace, every shift. She stated the wrist brace was not on 2/10/25 or 2/11/25. The Director of Nurses stated the family should have told the sitter to be sure Resident #1 did not take off the wrist brace. During a phone interview on 2/24/25 at 5 p.m., Family Member A stated, during a Care Conference to discuss how Resident #1 ' s wrist brace was not on 2/10/25 or 2/11/25, with the Administrator, Director of Nursing, Social Services and Ombudsman in attendance, she stated the facility admitted they were responsible and, This one was on us. Review of a medical record document title, Progress Notes +New, dated 1/28/25 at 8:46 p.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 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 056364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated, PT WAS NOTED TO BE TRYING TO UNRWAP SPLINT AND FREQUENT REORIENTATION AND EDUCATION PROVIDED TO PREVENT PT FROM REMOVING SPLINT. Review of the medical record document titled, Progress Notes Falls Committee IDT, dated 1/25/25 at 9:01 a.m., indicated, IDT MET AND DISCUSSED PT RECENT FALL. PT WAS admitted TO FACILITY, 1/25/25 @1500 (3 p.m.) . ON 1/26/25 PT HAD A WITNESSED FALL WHILE AT THE NURSES STATION. PT CHAIR ALARM WENT OFF WHEN SHE TOOK A STEP AND TRIPPED ON HER W/C (Wheelchair), AT THIS TIME SHE WAS WITNESSED HITTING HER HEAD AND FALL RESULTED IN MULTIPLE SKIN TEARS (Injury or traumatic wound caused by direct contact of skin to an object resulting in the top layer of skin peeling away) .WHEN ASKED PT REPORTED PAIN TO RT WRIST WITH SUPINATION (Movement). THROUGHOUT SIFT [sic] STAFF NOTED SWELLING AT RT WRIST, MD NOTIFIED AND ORDERED XRAY To R/O (Rule Out) POSSIBLE FX. WHILE WAITING FOR X- RAY TO BE COMPLETED MD VISITED AND ASSESSED PT. MD REQUESTED TO PLACE SPLINT ON R (Right) WRIST. ONCE X-RAY COMPLETED RADIOLOGIST NOTED ACUTE/SUBACUTE FX (Broken bone) AT RT WRIST. DUE TO INCREASED SWELLING AND PAIN PT WAS SENT TO ER (Emergency Room) FOR FURTHER EVALUATION. UPON RETURN TO FACILITY PT WAS PROVIDED WITH 1:1 SITTER. SOFT SPLINT APPLIED AT HOSPITAL. ORDER IN PLACE TO MONITOR CSM (Circulation, Sensation and motion) AND SKIN UNDER SPLINT REGULARLY. Review of a medical record document titled, Care Plan Report, dated 1/28/25, indicated, Alteration in musculoskeletal status r/t Fracture of the RIGHT WRIST. Encourage the use of supportive devices (SPECIFY: splints, braces, canes, crutches etc.) as recommended. Potential for a behavior problem r/t (related to) unsafe behaviors, fall risk, impulsive unsafe behaviors, fall risk, behaviors, and cognitive impairment. Review of a medical record document titled, Order Summary Report, dated 1/28/25, indicated RIGHT WRIST SOFT SPLINT: MONITOR FOR CAPILLARY REFILL (Squeeze the fingertip and see how fast the color goes from a whitish back to pink. A method to assess blood flow) AND ANY S/SX (Signs and/or symptoms) OF SWELLING every shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056364 If continuation sheet Page 3 of 3