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) Page 1 of 5 056411 056411 06/02/2025 Park View Post Acute 3751 Montgomery Dr Santa Rosa, CA 95405

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated resident care plans were designed to treat the whole person, and it was necessary to review care plans often to ensure nursing was aware of all changes. LN 2 confirmed Resident 1 did not have any care plans that identified BIPAP therapy. A review of facility policy titled Care and Treatment: Care Planning , revised 6/25, indicated It is the policy of this facility that the Interdisciplinary Team shall develop a comprehensive Person-Centered Care Plan for each resident based on resident's needs to attain or maintain his or her highest practicable physical, mental and psychosocial well-being .the care plan will reflect the interdisciplinary approach to Person-Centered Care and considering the different individual needs .identified during the assessment process of the resident. 056411 Page 2 of 5 056411 06/02/2025 Park View Post Acute 3751 Montgomery Dr Santa Rosa, CA 95405

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 provide care and services in accordance with professional standards of care for one resident (Resident 1) out of four sampled residents when: Residents Affected - Few 1. A Licensed Nurse (LN) failed to notify the physician when Resident 1's Bilevel Positive Airway Pressure (BIPAP- therapy for assisted breathing by delivering pressurized air through a mask) machine became inoperable; and, 2. An LN did not notify the physician when Resident 1 was not administered an ordered medication. These failures had the potential to cause Resident 1's condition to deteriorate and complicate his clinical condition. Findings: 1. 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), Type 2 Diabetes (a chronic condition in which the body does not produce enough insulin), 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 Type 2 Diabetes or Sleep Apnea). A review of Resident 1's physician order, dated 5/6/25, at 4:26 p.m., indicated a telephone order was placed by Medical Doctor 2 (MDS 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 notes, dated 5/11/25, at 9:43 p.m., indicated, BIPAP held due to broken part and inoperable. PT [Resident 1] agreed to [nasal cannula-medical tubing that provides oxygen]. During an interview on 6/2/25 at 12:40 p.m., MD 1 stated he expected to receive a phone call regarding a resident's broken BIPAP machine. MD 1 stated if a resident did not receive their BIPAP therapy as ordered, their sleep would be unmanaged and had the potential to cause the resident increased confusion due to a carbon dioxide buildup in their blood. MD 1 further stated it also could make other blood chemistries elevate, causing the resident's condition to worsen. During an interview on 6/2/25 at 1:21 p.m., the Director of Nursing (DON) stated, It is not ok that we broke his BIPAP . The expectation for an event of this magnitude is to alert myself, and the MD or ask someone from home to bring in supplies. During a concurrent interview and record review on 6/2/25 at 3:15 p.m., the Assistant Director of Nursing (ADON) confirmed Resident 1 did not receive his BIPAP therapy on the night of 5/11/25. The 056411 Page 3 of 5 056411 06/02/2025 Park View Post Acute 3751 Montgomery Dr Santa Rosa, CA 95405

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ADON further confirmed there was no documented evidence the MD was notified of Resident 1's BIPAP being inoperable. During an interview on 6/3/25 at 11:49 a.m., LN 1 stated she understood the importance of maintaining the BIPAP as ordered and if the machine became inoperable, she would immediately notify the physician and escalate the situation to the DON or nursing supervisor. 2. A review of Resident 1's physician order dated 5/3/25 at 10:45 a.m., indicated a telephone order was placed for ,Ozempic® [medication used to control Diabetes Mellitus] 2 mg [milligram- a unit of measure]/dose Subcutaneous [administered under the skin] Solution Pen Injector 8 mg/3 ml [milliliter- a measure of volume]. Inject 2 mg subcutaneously one time a day every Monday for Diabetes Mellitus 2 [Type 2 Diabetes]. A review of a facility document titled Care Plan Report , dated 5/5/25, indicated Resident 1 had Diabetes Mellitus 2 with the goal to experience no complications related to Diabetes. Staff were expected to implement the following interventions to assist Resident 1 meet his goal, Diabetes medication as ordered by doctor . [ensure Resident 1 and family understood]Diabetes is a chronic disease where compliance is essential to prevent complications of the disease. A review of Resident 1's MAR, dated 5/1/25-5/31/25, indicated Resident 1 did not receive his ordered dose of Ozempic® on 5/19/25. A review of Resident 1's progress note, dated 5/19/25, at 10:38 a.m., indicated, Ozempic® .medication not available. During an interview on 6/2/25, at 11:19 a.m., LN 1 stated if medications were missing, she would call the facility pharmacy, look in the E-kit (a collection of medications kept in a secure location to quickly treat residents) and communicate with the physician that the medication was missing. During an interview on 6/2/25, at 12:40 p.m., MD 1 stated he, should always receive a call about missing medications. MD 1 further stated missed doses of diabetic medication could lead to complications in Resident 1's health such as delayed healing and worsening heart disease. During an interview on 6/2/25, at 1:21 p.m., the DON stated staff were expected to notify the physician about missed medications and to escalate the situation to her if needed. The DON also stated, It is not ok .that we lost [Resident 1's] Ozempic® pen. During a concurrent interview and record review on 6/2/25, at 1:53 p.m., the ADON confirmed Resident 1 missed his prescribed dose of Ozempic® on 5/19/25. During an interview on 6/2/25, at 3:30 p.m., the DON stated the facility did not have a policy regarding physician notification for medication errors or medication omissions. During a phone interview on 6/3/25 at 8:10 a.m., the DON acknowledged insulin was a critical, high-risk medication and not receiving prescribed doses of insulin had the potential to result in hyperglycemia (a condition where there is an abnormally high level of glucose (sugar) in the blood) and additional complications such as further kidney damage. The DON clarified she did not direct her nurses not to call the physician until a resident missed two doses of a medication as indicated in the Preparation and General Guidelines policy; however, the DON also stated she left the discretion up to 056411 Page 4 of 5 056411 06/02/2025 Park View Post Acute 3751 Montgomery Dr Santa Rosa, CA 95405

F 0658 the licensed nurse to notify the physician. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy titled Administering Medications , dated April 2019, indicated, Medications are administered in accordance with prescriber orders . Residents Affected - Few A review of the facility's policy titled Preparation and General Guidelines , dated October 2019, indicated, If (two consecutive doses) of a vital medication are .not available, the physician is notified. 056411 Page 5 of 5