Health inspection·July 28, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review, the facility did not create a care plan for one of two residents (Resident 11) who was on supplemental oxygen (O2) for 7 months. This failure could result to oxygen toxicity or oxygen poisoning (lung damage that happens from breathing in too much extra [supplemental] oxygen), which can cause coughing, trouble breathing, and in severe cases it could potentially cause death. Findings: During the initial tour of the facility on 07/25/23 at 11:36 AM, Resident 11 was observed seated in her wheelchair at the bedside. Resident 11 was on O2 via a nasal cannula (a thin tube which delivers oxygen into the nose) and was receiving the O2 at two Liters (unit of volume) Per Minute (2 LPM). During a follow-up visit on 07/27/23 at 11:19 AM, Resident 11 was on O2 via nasal cannula at 2 LPM. During a review of records on 07/27/23 at 11:54 AM, Resident 11's face sheet (one-page summary of important information about a patient including patient identification, past medical history, medications, allergies, insurance status, or other pertinent information) indicated Resident 11 was admitted at the facility on 11/2/22 with a diagnosis of generalized blood infection (sepsis) urinary tract infection, history of COVID-19 infection and major depression among other conditions. A change in condition report dated 11/24/22 indicated Resident 11 appeared withdrawn, flushed but afebrile (no fever) with oxygen saturation (SpO2 - the amount of oxygen circulating in the blood) of 87% on room air (87% RA). A physician's order dated 12/20/22, indicated, oxygen at 1-2 LPM via nasal cannula as needed (PRN) to keep oxygen saturation above 92% for hypoxia (low levels of oxygen in the blood). During an interview on 07/27/23, at 11:46 AM, Nurse Resource stated Resident 11 was placed on O2 in November 2022 after her O2 saturation was low. When asked where the care plan for the oxygen administration was, Nurse Resource stated they were looking for the care plan. During an interview on 07/27/23 at 12:31 PM, the Director of Staff Development (DSD) provided the order detail for Resident 11's oxygen and stated the order was for an as needed oxygen administration. When asked if there was a care plan with the order, especially since Resident 11 was on oxygen since 12/2022, the DSD did not have a response. A review of the facility policy titled Policy/procedure - Nursing Administration on care planning revised 2/2023 indicated it is the policy of the facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. Revision or updating of the care plan will occur upon significant changes of condition, etc. The policy failed to discuss the purpose of care (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 11 Event ID: 555258 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 555258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley of the Moon Post Acute 347 Andrieux St Sonoma, CA 95476 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)