Inspection·December 14, 2018

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 observation, interview, and record review, the facility failed to follow medication administration policy for 1 of 8 residents (Resident 9), when the nurse did not hold the feeding tube before administering Phenytoin (medication used to treat and control seizure/epilepsy.). This failure had the potential to result in Phenytoin subtherapeutic blood levels (a dosage less than the amount required for a therapeutic effect), which could put Resident 9 at risk for seizures. Residents Affected - Few Findings: During a medication administration observation and concurrent interview on 12/12/18, at 10:30 a.m. for Resident 9, Licensed Staff C was preparing to administer medications that would go into the J-tube (Jejunostomy tube - a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine). Resident 9's nutritional supplement, via the feeding tube (medical device used to provide nutrition to people who cannot obtain nutrition by mouth, unable to swallow safely, or need nutritional supplementation), was running at 45 milliliter per hour (ml/hr). At 10:45 a.m., Licensed Staff C verified the feeding tube was running. Licensed Staff C stated staff held the feeding tube at 8 a.m., and restarted it at 10:30 a.m. At 10:48 a.m., Licensed Staff C turned off the feeding tube machine. At 10:55 a.m., Licensed Staff C administered the medications, including Phenytoin 350 mg via the J-tube. At 11:21 a.m., Licensed Staff C turned on the feeding tube machine. Licensed Staff C stated the feeding tube would be held for 50 minutes before it restarted running at 45 ml/hr, automatically. During an interview on 12/12/18, at 2:57 p.m., Administrator A stated the feeding tubes were held before administering Phenytoin. The facility policy and procedure titled, Medication Administration through a Feeding Tube, dated 11/16, indicated, Phenytoin. Administration with continuous tube feeding may result in subtherapeutic blood levels. Discontinue tube feeding 2 hours before and after phenytoin administration. 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 3 Event ID: 555590 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 555590 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healdsburg Hospital D/P Snf 1375 University Avenue Healdsburg, CA 95448 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)