Sonoma Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of five sampled residents (Resident 1) from abuse when Resident 2 punched Resident 1 in the face and chest while he was in his bed. This failure caused Resident 1's lip to bleed and redness to his chest when Resident 1, who was bed-bound, was unable to get away from Resident 2 when he approached him and began to punch him with his fist. Review of a document from the county sheriff's department titled, Incident/Investigation Report, dated 6/16/26 at 8:13 p.m., indicated an officer responded to a report of an assault that had occurred between two residents who were roommates. The report indicated, The victim was punched twice, once in the chest and once in the lip causing a minor laceration to his lower lip. [...]

Inspectors wroteBased on interview and record review, the facility failed to report to the Department an allegation of abuse. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. Review of a document from the county sheriff's department titled, Incident/Investigation Report, dated 6/16/26 at 8:13 p.m., indicated an officer responded to a report of an assault that had occurred between two residents who were roommates. The report indicated, The victim was punched twice, once in the chest and once in the lip causing a minor laceration to his lower lip. During a record review and concurrent interview on 6/24/26 at 3:20 p.m., the Administrator stated he was aware of the resident-to-resident incident that occurred on 6/16/26 but stated it was not reported to the Department because the resident who was the aggressor had dementia. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide supervision and assistance during meals to prevent accidents for two of six sampled residents (Resident 1 and Resident 2), when staff allowed Resident 1 and Resident 2 to have access to their meal trays without the physician ordered 1:1 assistance. This failure resulted in unwitnessed choking and death for Resident 1 and placed Resident 2 at risk for aspiration (the accidental breathing in of food, liquid, saliva, or vomit into the airways and lungs instead of swallowing it down the food pipe (esophagus) to the stomach) while eating. On 4/16/26, the Department received a complaint from a Family Member (FM) alleging Resident 1 passed away on 3/11/26 after choking on food and being left unattended in the room with access to the breakfast tray. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety for a census of 79, when:Fish fillets, beef patties, and cookie dough stored in the freezer were not sealed and open to air. Sanitizer buckets for surface cleaning were found empty and during preparation of new sanitizing solution the ppm's ( parts per million- a measurement of concentration of sanitizer to water) were insufficient, and staff could not verbalize the correct ppm's needed for proper sanitization. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a safe operating kitchen environment for a census of 79 when the kitchen space was not maintained, and equipment was not effectively repaired or replaced. This failure made it difficult for kitchen staff to maintain a sanitary environment and execute the duties of the food and nutrition services department, and affected the maintenance department's ability to maintain equipment that was in need of replacing. During an observation on 4/13/26 at 9:45 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have survey results available for all residents to review when the binder containing survey results was out of reach for wheelchair-bound residents. This failure had the potential to discourage residents in wheelchairs from reviewing survey results when they could not reach the binder without having to ask for assistance. During an observation and concurrent interview on 4/16/26 at 1:45 p.m., Administrator verified the binder that contained survey results in the wall-mounted file holder approximately 5.5 feet from the floor next to the nurses station was the only binder available for residents to review survey results. Administrator stated the binder containing the survey results could not be reached by someone in a wheelchair. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a trauma informed care environment was provided for three sampled residents ( Resident 7, Resident 29, and Resident 41) with Post Traumatic Stress Disorder (PTSD- A mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events .PTSD occurs when symptoms-such as flashbacks, avoidance, and severe anxiety-last longer than a month and disrupt daily life.) when, social assessments were not thorough, trauma informed care plans were not present or not individualized with no personal triggers identified, and residents were not provided with behavioral health services. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure sufficient Certified Nursing Assistants (CNA) staff to provide care and respond to five resident's (Resident 48, Resident 45, Resident 19, Resident 35 and Resident 68) basic needs when Residents were not provided 1. assistance to use the bathroom, 2. showers or bed baths twice a week and 3. assistance with meals. This lack of assistance resulted in residents and their responsible party (decision makers) frustration and feeling like they were not cared for. During an observation on 4/13/26 at 10:10 a.m., hallway three was observed to have a heavy smell of urine. During an observation and interview with Resident #48 on 4/13/26 at 10:10 a.m., Resident 48 was in her wheelchair in her room facing the wall, with the curtains pulled closed. She stated there was not enough staff to give her showers. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in a manner that resulted in a palatable texture and flavor for 8 residents receiving a pureed diet and failed to follow therapeutic diet requirements for all 8 residents with fortified (diet enriched with extra calories) diet orders when,Pureed foods were prepared using no specifications for texture requirements and the test tray for the pureed diet was runny, gummy/sticky, and lacked seasoning. 2. Fortified diets indicated on tray tickets were not read aloud by Dietary Aide 3 to [NAME] 1 while plating the food, resulting in no added fortification. This failure resulted in residents not receiving their prescribed diets and had the potential to result in residents not consuming their meals which could cause weight loss in an already vulnerable population. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure one of two sampled residents (Resident 39) received ongoing social services for the assistive devices needed for hearing impairment when there was no follow up after her evaluation for hearing aids over one year ago, her MDS assessment did not accurately reflect her hearing status and there was no care plan for addressing adaptive coping strategies for hearing loss. This failure resulted in ongoing hearing impairment without adaptive measures which caused Resident 39 to feel isolated, avoid participation in many activities, and struggle during communication with others. A review of Resident 39's admission record indicated she was admitted on [DATE] with the diagnoses of Paraplegia (loss of movement and/or sensation, to some degree, of the legs), Anxiety and Depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dental needs and services were provided to one of two residents (Resident 31) sampled for dental concerns when Resident 31's MDS did not reflect his current dental status, and he had resided at the facility for one year without an evaluation for dental needs. This failure allowed poor dentation to go unnoticed in an already vulnerable resident with no proper evaluation of dental needs or treatments. A review of Resident 31's admission record indicated he was admitted on [DATE] with the diagnoses of Schizophrenia (a mental illness that is characterized by disturbances in thought), Dysphagia (difficulty swallowing), and need for assistance for personal care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide support personnel to safely and effectively carry out the functions of the food and nutrition services department for a census of 79 residents when the Director of Dietary Services (DDS) did not participate in the essential duties of day-to-day operations, staffing levels were insufficient, and dietary personnel did not demonstrate competency in specific procedures and protocols necessary to carry out the functions of food and nutrition services. This failure had the potential to affect the safety and quality of the food produced by the food and nutrition services department. During an interview with Resident #19, Resident #44 and Resident #74, on 4/13/26 at 1:02 p.m. they stated their lunches were always served last and the food was cold. [...]

Inspectors wroteBased on interview and record review, the facility infection preventionist failed to review three of three residents sampled for antibiotic stewardship (Residents 8, 16, and 24). This failure had the potential to result in residents receiving unnecessary antibiotics and further contribute to antibiotic resistance. During an interview and concurrent record review on 4/16/26 at 9:06 a.m., Infection Preventionist (IP) pulled up on her laptop her line list of residents who were prescribed antibiotics for the month of April 2026. IP stated her antibiotic stewardship program included using an infection screening tool built into the electronic medical record that reviewed the symptoms of the resident's suspected infection and determined if the symptoms met criteria for treatment with antibiotics. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow one resident (Resident 1) of two sampled residents to return to the facility after completing treatment for Carbapenem-Resistant Enterobacteralus (CRE- a group of bacteria that are difficult to treat because they are resistant to carbapenems, which are a class of powerful antibiotics typically used for severe infections) at the hospital. This failure caused Resident 1 to experience an unnecessary 42-day hospitalization and anxiety over the forced eviction from her home.

Inspectors wroteBased on interview and record review the facility failed to ensure criminal background checks were completed prior to direct resident care employment for one of three direct care staff (Certified Nurse Assistant 1 [CNA 1]) when CNA 1's criminal background check was completed nine months after he was hired. This failure had the potential to result in resident abuse, neglect and/or mistreatment by hiring staff with possible criminal records. A review of the facility's document titled, General Orientation List, dated 1/17/23, indicated CNA 1's date of hire was 1/17/23. A review of an undated facility document titled, Background Report, indicated a background report was conducted on 10/16/23 for CNA 1 by the facility. During an interview on 7/30/25 at 3:32 p.m., the Director of Staff Development (DSD) verified CNA 1's date of hire was 1/17/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were met for one of five sampled residents (Resident 1) when supervisory staff did not provide oversight and follow-up after Resident 1 did not receive any showers or baths for seventeen days. This failure had the potential to increase Resident 1's susceptibility to infections, skin problems, and negatively impact his mental health and activities of daily living (ADL, activities such as bathing, dressing and toileting a person performs daily). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care met professional standards for one resident (Resident 1) of eight sampled residents when following Resident 1's unwitnessed fall nursing and neurological (neuro, relating to the nervous system, includes: brain, spinal cord, and nerves) assessments were not conducted, monitored, or documented in Resident 1's medical record. These failures had the potential to misrepresent Resident 1's actual condition status post (after) fall, which could lead to a delay in treatment and other negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide services that met professional standards of quality for one resident (Resident 1) of three sampled residents when prescriber order to hold a blood pressure (BP - the force of your blood pushing against blood vessels) medication when BP measurement was below a certain parameter was not followed. This failure had the potential for Resident 1 to become hypotensive (low blood pressure) and experience dizziness, lightheadedness, fatigue, visual disturbances, and/or fainting, especially when standing up quickly.

Inspectors wroteBased on interviews and record reviews the facility failed to provide services that meet professional standards for one of three sampled residents (Resident 1), when Resident 1 was administered glucose gel (medical product used to treat low blood sugar levels) in his mouth while unresponsive and unable to follow directions. The failure had the potential to cause Resident 1 to choke on or aspirate (accidental entry of food, liquid or other material into the lungs) the glucose gel.

Inspectors wroteBased on interview and record review, the facility failed to meet the requirements for a safe discharge for one of three sampled residents (Resident 1) when Resident 1 was discharged due to being unable to get a ride back to the facility at the agreed upon return time during an approved leave. This failure resulted in emotional distress for Resident 1 as she did not have access to equipment for safe ambulation (walking) or her essential medications (medications ordered by a physician for treating/and or preventing symptoms of a significant health condition).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure two residents (Resident 1 and Resident 2) of three sampled residents had access to a telephone, to make private calls with friends and family. The facility only had one working wireless telephone for resident use, and this phone could not be located during an onsite visit on 1/30/25. This failure decreased the facility's potential to ensure residents, including those who were bedbound, were to free to speak to family members or acquaintances in private.

Inspectors wroteBased on observation, interview and record review [AES1] the facility failed to provide pain medicine in the form of a cream (lidocaine) for one out of two sampled residents (Resident 1). This failure potentially caused Resident 1 pain and further suffering by missed medication administrations.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure safe oxygen therapy when: 1. Facility staff did not assess and monitor the volume of oxygen remaining in portable oxygen tanks for two of nine sampled residents (Resident 10 and Resident 48) with physician orders for oxygen therapy. Facility staff did not replace Resident 10 and Resident 48's portable oxygen tanks when they were empty. (Portable oxygen tanks are steel cylinders filled with concentrated oxygen; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 76 out of 76 residents were provided activities on weekends, when no Activity Staff were available. This failure had the potential for all residents to experience isolation, decreased enjoyment of life and depression.

Inspectors wroteBased on food production observation, dietary staff interview, and dietary document review, the facility failed to ensure a Registered Dietician (RD) was overseeing the operations of the facility's Food Service Department, resulting in issues with safe and effective food storage, meal production, infection control, and a clean kitchen. Failure to ensure adequate oversight may result in compromising the nutritional status of all residents and cross contamination of resident food and foodborne illness.

Inspectors wroteBased on dietary staff observation, interview, and dietary record review, the facility failed to ensure staff possessed required competency as evidenced by dietary staff members not: 1) thawing meat according to the facility's policy and procedure, 2) using the correct Cool Down Process for cooked meats and ambient (room temperature) foods like tuna for tuna salad, 3) Following recipes, and 4) Taking food temperatures prior to food service. Failure to ensure staff competency could: 1) put residents at risk for foodborne illness, 2) result in decreased food distribution and food production systems to ensure food palpability and nutritional content, which could result in decreased dietary intake that did not meet individual resident nutritional requirement. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of 25 sampled residents (Resident 57), who's Annual MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 2/24/22, indicated Resident 57 was incontinent of bowel and bladder, but no care plan was developed. This failure had the potential for Resident 57 not to be checked frequently for incontinence, which could lead to skin breakdown, a urinary tract infection (an infection in any part of the urinary system), feeling of low self-esteem and further impact Resident 57's physical and psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure nursing staff utilized professional standards when providing resident care when: 1) Licensed Staff G did not verify placement of Resident 38's PEG tube (percutaneous endoscopic gastrostomy tube; a tube inserted through the wall of the abdomen directly into the stomach) per facility policy and procedure. This failure caused potential for injury when LN G did not ensure Resident 38's feeding tube was in his stomach immediately prior to administering medication. Feeding tubes can become displaced (for example: into the abdominal cavity or lungs) and delivery of tube feeding liquid into an area of the body other than the stomach can cause serious injury and death; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to recognize, evaluate and address 1 out of 25 residents (Resident 34) continued multiple meal refusals for the last 2 months. This failure had the potential for Resident 34 to have a decline in function, weakness, and unplanned weight changes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 38 received appropriate nursing care to minimize potential complications associated with enteral feeding/nutrition (tube feeding; delivering nutrition directly into the stomach or small intestine as a liquid) when: 1) Licensed nurses failed to ensure administration of enteral nutrition was consistent and followed physicians orders and; 2) Licensed Staff G did not verify placement of Resident 38's PEG tube (percutaneous endoscopic gastrostomy tube; a tube inserted through the wall of the abdomen directly into the stomach) prior to medication administration per facility policy and procedure. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure sufficient nursing staff when: 1. Consistent and accurate meals preferences were not honored for 5 sampled residents (Resident 59, Resident 48, Resident 31, Resident 58, Resident 55, Resident 219). 2. Call lights were not answered resulting in incontinence for 2 of 8 sampled residents (Resident 220 and Resident 58). 3. All residents did not have access to activities on weekends. 4. All residents did not have access to the RNA (Restorative Nursing Assistant) program (specially trained CNA's (Certified Nursing Assistant) who provide ongoing long-term physical and occupational care to improve patient's quality of life - physically, mentally and emotionally) because the RNA had been pulled to the floor to work as a CNA for the past five months. These failures resulted in: 1. [...]

Inspectors wroteBased on Observation, interview and record review the facility failed to ensure all staff were competent and trained for: 1. Abuse Prevention Training. 2. Infection Prevention. This had to potential for resident harm when: 1. Staff were not trained to recognize and respond to family and resident complaints of abuse to ensure resident safety. 2. Staff were unable to prevent cross contamination during resident care and result in resident infection.

Inspectors wroteBased on observation, interview and record review, the facility: 1) Failed to ensure the consulting Pharmacist's (Consultant L) review of medications identified and addressed irregularities with Resident 38's physician order for rapid-acting insulin (medication to treat high blood sugar in diabetics; onset of action is within 15 minutes). This failure resulted in Consultant L not addressing and potentially correcting the timing and administration of Resident 38's insulin (designed to be given with meals) and potentially impairing the control of his blood sugar; and, 2) Failed to ensure Pharmacy services provided physician ordered medications when Vitamin D was not onsite and available for one resident (Resident 14) . This failure caused Resident 14 to miss two days of Vitamin D ordered by her physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pharmacy Consultant L's recommendation to attempt a dose reduction for the antidepressant Mirtazapine for one of 25 sampled residents (Resident 59) was sent to Resident 59's physician. Pharmacy Consultant L identified Resident 59 had not had any reported instances of restlessness in the past five months, but Resident 59 continued on Mirtazapine 15 mg (milligrams). This failure had the potential for the Resident 59 to have adverse consequences such as increased sleepiness, increase hunger, weight gain, amongst other adverse side effect, which could have negatively impact Resident 59's physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and accurate medication administration when the nursing medication error rate was 19.23%. Licensed nurse F (LN F) did not give Resident 14 her scheduled dose of Vitamin D (as it was not available) and LN D gave Resident 33 his morning medications, scheduled for 9 a.m., approximately 1 hour and 47 minutes late. These failures: 1) Caused Resident 14 to miss two days of Vitamin D ordered by her physician, and 2) Caused Resident 33 to receive his medications for blood pressure, seizures, and diabetes (to control blood sugar) almost 2 hours late, potentially impacting the control of his blood pressure, seizures and blood sugar.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from medication error for one out of 25 residents, when one resident (Resident 17) was administered a medication without a physician's order. Resident 17 had an antifungal powder in use at his bedside which did not have a physician's order. This failure had the potential for ineffective treatment, unwarranted side effects, or an allergic response from using an antifungal medication product without the physician's order.

Inspectors wroteBased on food storage observation, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by: 1. The facility did not ensure food temperature and palatability, 2. Penne pasta was being cooked 2 hours or longer prior to the beginning of meal service, 3. Recipes where not followed, and, 4. Broccoli mushy and grayish green, pureed spinach had a gluey texture causing pureed spinach hard to swallow, and the pureed meatloaf tasted like the added thickener (additive to pureed foods to make a pudding-like consistencies), no flavor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare a meal tray with the individual diet consistency for two of 25 sampled residents (Resident 6 and Resident 29). when 1) Resident 6's physician order for a regular diet (example: sandwich) once a week, on Saturdays, did not reflect Resident 6 was receiving on Saturdays, and 2) Resident 29, who was on a Mechanical Soft Diet (texture-modified diet that restricts foods that are difficult to chew or swallow) was served green beans that were hard. A review of residents' lunch Meal Card, dated 3/23/22, indicated fourteen residents were on a Mechanical Soft diet and two residents were on a Dysphagia Mechanical diet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preferences were honored for four of 25 sampled residents (Resident 31, 55, 57, and 58), when Resident 31's dislike for gravy was not being honored, Resident 57, who requested two packets of hot sauce with each meal, but was not receiving routinely, Resident 55 did not receive two glasses of milk on her meal tray per her diet card, and Resident 58 did not receive salad dressing for her salad. These failures could result in decreased dietary intake, leading to residents not meeting their individual resident nutritional requirement, which may result in weight loss and further compromise residents' medical status.

Inspectors wroteBased on kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) the facility did not follow its storage guidelines to store the bread, 2) the kitchen floor was dirty/sticky, and 3) garbage can lids were not on the garbage cans located underneath the cook's food prep counter. Failure to ensure effective dietetic services operations may result in placing residents at risk for foodborne illness as well as bacterial and foreign object contamination resulting in gastrointestinal (stomach and intestines) distress, weight loss and in severe instances may result in death.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) accurately and completely for two out of 25 residents (Resident 10 and Resident 34). This failure resulted in Resident 10 and Resident 34 not receiving Specialized Services needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a Nosey Cup (drinking cup with cut out for nose) and Plate Guard (curved to prevent food from falling off the plate and can be used as a barrier to push food against when scooping food onto a spoon or fork) when meal tray was served for one of 25 sampled residents (Resident 6), who had a CVA (cerebrovascular accident, stroke), causing flaccid (floppy or without muscle tone) hemiparesis (weakness or the inability to move one side of the body), of his left upper extremity (dominant side). This failure had the potential to impact Resident 6's: dignity, nutritional status, independence in self-feeding skills being maintained or improved when consuming meals and snacks, and swallowing difficulties, which could cause aspiration (when liquids enter the airway), leading to negative clinical outcomes.