Health inspection·June 2, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a resident centered care plan for one resident (Resident 1) out of four sampled residents when licensed nurse staff did not develop a care plan for Resident 1's use of a Bilevel Positive Airway Pressure (BIPAP- therapy for assisted breathing by delivering pressurized air through a mask). This failure decreased the facility's potential to provide resident centered care and ensure safety for Resident 1. Findings: A review of a facility document titled admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia (a severe condition in which the body struggles to remove carbon dioxide from the blood, leading to lung diseases), Sleep Apnea (a sleep disorder where the upper airway collapses, causing pauses with breathing) and Morbid Obesity (a severe disorder which involves too much body fat with co-existing health issues such as Sleep Apnea). A review of a facility document titled Care Plan Report , dated 5/5/25, indicated Resident 1's care plan for Altered Respiratory Status/Difficulty Breathing was not updated to include an intervention for BIPAP therapy. A review of a facility document dated 5/6/25, at 4:26 p.m., indicated a telephone order was placed by Medical Doctor 2 (MD 2) for Resident 1 to receive BIPAP with home settings at bedtime for Obstructive Sleep Apnea (OSA- a condition where breathing repeatedly stops or becomes very shallow during sleep, often due to a blockage in the upper airway). A review of Resident 1's Medication Administration Record (MAR), dated May 2025, indicated Resident 1 did not receive his ordered BIPAP therapy on 5/11/25. A review of Resident 1's progress note dated 5/11/25 at 9:43 p.m., indicated, BIPAP held due to broken part and inoperable. During an interview on 6/2/25 at 12:40 p.m., MD 1 stated if a resident did not receive BIPAP therapy as ordered their sleep would be unmanaged and it had the potential to cause the resident increased confusion due to a carbon dioxide buildup in their blood. MD 1 further stated it could make other blood chemistries elevate, causing the resident's condition to worsen. During a concurrent interview and record review on 6/3/25 at 1:22 p.m., Licensed Nurse 2 (LN 2) (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 5 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 06/02/2025 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)