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) Page 1 of 4 056411 056411 01/14/2025 Park View Post Acute 3751 Montgomery Dr Santa Rosa, CA 95405

F 0658 written order .accurate and timely administration according to MD order is essential . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056411 Page 2 of 4 056411 01/14/2025 Park View Post Acute 3751 Montgomery Dr Santa Rosa, CA 95405

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure the contact enteric precaution (used when caring for residents with a suspected or confirmed infection caused by bacteria that spreads through fecal-oral transmission) on room [ROOM NUMBER] was followed when a speech therapist: Residents Affected - Few 1.Did not perform hand hygiene (HH, washing hands with soap and water or using an alcohol-based hand sanitizer to prevent the spread of germs) prior to entering room [ROOM NUMBER], 2.Did not put on gloves prior to entering room [ROOM NUMBER], 3.Did not put on gown prior to entering room [ROOM NUMBER], 4.Did not wash hand with soap and water upon leaving room [ROOM NUMBER]. These failures could result to spread of infection between residents. Findings: A review of Resident 3's face sheet (demographics) indicated an admission date of 1/7/25. A review of Resident 3's Physician's Order's Summary (POS) indicated a diagnoses of Anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and Clostridium Difficile (Cdiff, a germ that causes diarrhea and colitis (an inflammation of the colon), highly contagious, and could be life-threatening). room [ROOM NUMBER] was observed to be on contact enteric precaution due to Resident 8's active Cdiff infection. During an observation on 1/14/25 at 12:55 p.m., the speech therapist (ST) was seen going into room [ROOM NUMBER]. The ST did not perform HH, did not wear gown and gloves prior to entering the room. During a concurrent observation, interview and contact enteric precaution signage record review on 1/14/25 at 12:57 p.m., the ST was seen leaving room [ROOM NUMBER] without first washing her hands with soap and water. The ST verified she did not gown up, performed HH nor wore gloves prior to entering room [ROOM NUMBER]. ST also verified she did not wash her hand with soap and water when she left room [ROOM NUMBER]. ST verified the contact enteric precaution posted on the wall prior to entering room [ROOM NUMBER] which indicated staff should wash or gel hands prior to entry, to use soap and water upon leaving the room and to wear a gown and gloves prior to entering the room. During an interview on 1/14/25 at 1:12 p.m., the Infection Preventionist (IP) stated Resident 3 on room [ROOM NUMBER] had an active CDiff infection. The IP stated all staff should follow the contact enteric precaution when entering and leaving room [ROOM NUMBER]. The IP stated staff should perform HH, wear gowns and gloves prior to entering room [ROOM NUMBER] and should was their hand with soap and water upon leaving the room. The IP stated if staff did not follow these steps, it meant a break in infection control and was a safety issue. The IP stated Resident 3 have an active CDiff and was highly contagious. The IP stated it was important staff follow the contact enteric precaution to prevent spread of CDiff infection. During an interview on 1/14/24 at 2:16 p.m. the Director of Nursing (DON) verified that if a room was on contact enteric precaution, all staff must perform HH, wear gown and gloves prior to entering 056411 Page 3 of 4 056411 01/14/2025 Park View Post Acute 3751 Montgomery Dr Santa Rosa, CA 95405

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the room and should wash their hands with soap and water upon leaving the room. The DON stated it was important the contact enteric precautions were followed to ensure safety of staff and other residents and to prevent spread/outbreak of CDiff infection. A review of contact enteric precaution signage posted on the wall before entering room [ROOM NUMBER], the precautions included all staff should wash or gel hands prior to entry, to use soap and water upon leaving the room and to wear a gown and gloves prior to entering the room. 056411 Page 4 of 4