Health inspection·January 14, 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 Based on interviews and record reviews, the facility failed to ensure one of two sampled residents (Resident 1) received care in accordance with professional standards of practice when: Residents Affected - Few 1. Resident 1 did not receive her six of her scheduled medications. 2. The physician was not notified when Resident 1 did not receive their scheduled medications. These failures could lead to worsening of condition, hospitalization, seizure (sudden burst of electrical activity in the brain) or even death. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admission date of 7/26/24 with a diagnosis of Epilepsy (a brain condition that causes recurring seizures) and Restless Leg Syndrome (RLS, a condition that causes a very strong urge to move the legs). A review of Resident 1 ' s electronic medication administration record (EMAR, electronic documentation of medications administered to a resident) with corresponding progress note dated 7/26/24 indicated the following medications where not administered as ordered because it was still awaiting for arrival: Atorvastatin (used to treat high cholesterol) 40 milligram (mg, unit of measure) 1 tablet (tab) by mouth (PO) at bedtime, Latanoprost (used to treat increased eye pressure) eye drops (gtts) to both eyes at bedtime, Dorzolomide (used to treat increased eye pressure) 2 gtts to left eye afternoon dose, Ropinorole (to treat RLS) 1 tab PO at bedtime, Levetiracetam 500 mg ½ tab PO afternoon dose and Lubiprostone 2 capsules by mouth afternoon dose. During a concurrent interview and 7/2024 EMAR record review on 1/14/25 at 2:16 p.m., the Director of Nursing (DON) confirmed Resident 1 did not receive the following ordered scheduled medications on 7/26/24: atorvastatin at 8:00 p.m., latanoprost at 8:00 p.m., ropinorole at 8:00 p.m., levetiracetam at 4:00 p.m., Dorzolomide at 4:00 p.m. and Lubiprostone at 4:00 p.m. When asked if Resident 1 should have received these medications as ordered on 7/26/24, the DON stated yes. The DON stated if residents missed multiple medications, staff would notify the physician especially for Levetiracetam which could result to seizure activity. During a telephone interview on 1/15/25 at 10:05 a.m., the pharmacist stated missing a dose of Levetiracetam could result to rebound seizure and risk of seizure build up. A review of the facility ' s policy and procedure (P&P) titled Medication Administration-Oral, revised 11/2019, the P&P indicated, .no medication is to be administered without a physician ' s (MD) (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 4 Event ID: 056411 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 056411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park View Post Acute 3751 Montgomery Dr 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)