North Bay Post Acute

During a review of Resident 46's Face Sheet (demographics) dated 1/16/25, the Face Sheet indicated Resident 46 was admitted to the facility on [DATE] with diagnoses of hemiplegia (complete paralysis to one side of the body) following cerebral infarction (stroke- serious condition that occurs when blood flow to the brain is blocked) affecting right dominant side, aphasia (unable to communicate verbally) and weakness.

During an observation on 1/14/25 at 4:02 p.m. in Resident 46's room, Resident 46 was reclined in a geriatric chair (padded chair that is designed to help seniors with limited mobility) in the middle of the room without a call light. Resident 46 threw one pillowcase, in the direction of the door, and waved multiple times. Resident 46 grunted and pointed at the call light, on the floor.

During an interview on 1/14/25 at 4:05 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 46 was non-verbal and required maximum assistance for all Activities of Daily Living (ADL).

CNA 2 stated Resident 46 call light was not within resident's reach.

During an interview on 1/16/25 at 11:25 a.m. with the Director of Nursing (DON), the DON stated that the call light should have been within Resident 46's reach at all times. It is important for all the residents to be able to use the call light for assistance.

During a review of Resident 46's Minimum Data Set (MDS-an assessment tool), dated 4/29/24, MDS indicated Resident 46 had absence of spoken words and rarely/never understood for ability to verbally express ideas or wants.

During a review of Resident 46's Care Plans, dated 10/31/24, the Care Plans indicated, [Resident 46] has a communication problem r/t [related to] Expressive Aphasia (unable to communicate verbally) .

Ensure/provide a safe environment: Call light in reach .

During a review of the facility's policy and procedure (P&P) titled, Call Light, Answering, dated 4/1/19, the P&P indicated, .Make sure call cords are placed within the resident's reach at all times .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review of Resident 83's admission Record (AR), the AR indicated the facility admitted Resident 83 on 11/12/2024 with multiple diagnoses including hypertension (high blood pressure) and muscle weakness.

The AR indicated Resident 83 had a Responsible Party 1 (RP) 1 as the emergency contact.

During a review of Resident 83's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 11/19/24, indicated Resident 83's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 12 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired).

The BIMS assessment indicated Resident 83 had moderate cognitive impairment.

During a concurrent interview and record review on 1/14/25 at 3:57 p.m. with Minimum Data Set Coordinator (MDSC), Resident 83's Physician Orders for Life-Sustaining Treatment (POLST), dated 11/12/24 was reviewed.

The POLST indicated Section D, Information and Signatures was incomplete.

MDSC stated RP 1 did not sign the Advance Directive Acknowledgment form. MDSC stated there was no documented evidence RP 1 was provided information regarding AD and written information on AD formulation.

During a concurrent interview and record review on 1/16/25 at 10:32 a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Residents' Rights Regarding Treatment and Advance Directives dated February 2023 was reviewed.

The P&P indicated, .Advance Directive is a written instruction, such as a living will or durable power of attorney .On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advance directive .

Any decision making regarding the residence choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care .

The DON stated it was the physician's and the nurses' responsibility to ensure that information regarding the advanced directive was discussed and documented.

The DON stated the purpose of the advanced directive was to meet the wishes and desires of the individuals living will.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a concurrent observation and interview on 1/16/25 at 12:32 p.m. with MAIN in room [ROOM NUMBER]'s bathroom, MAIN checked the shower's hot water temperature with a digital thermometer and it read 95.3 degrees Fahrenheit after waiting six minutes. MAIN stated the digital thermometer was calibrated on 1/16/25. MAIN checked the sink's hot water temperature, it read 91.7 degrees Fahrenheit after waiting six minutes. MAIN stated, Yeah, that's not right. A temperature log was requested, and MAIN stated, There were no temperature logs.

During a review of the facility's policy and procedure (P&P) titled, Safe Water Temperatures, undated, the P&P indicated, .maintain appropriate water temperatures in resident care areas .

Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits monthly and as needed.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review of RN 3's employee files titled, CALIFORNIA BOARD OF REGISTERED NURSING- BRN (Board of Registered Nursing) LICENSING DETAILS, dated 1/16/25 and 12/19/23, the documents indicated RN 3 had an administrative disciplinary action against RN 3's license posted on 12/12/23.

During a review of a public court document (legal document available to the public and is part of the court record) titled, BEFORE THE BOARD OF REGISTERED NURSING DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA, dated 11/30/23, the document indicated, .[RN 3] was convicted by a plea of guilty to: (1) child endangerment . felony .

During an interview on 1/17/25 at 8:31 a.m. with the Administrator (ADMIN), the ADMIN identified himself as the facility's abuse coordinator (designated staff member within a nursing home responsible for overseeing and coordinating the facility's efforts to prevent resident abuse).

The ADMIN stated it was the responsibility of the facility to check a registered nurse's license when up for renewal for the expiration date and if anything was added to the license, like a DUI.

The ADMIN stated an employee with a disciplinary action against their nursing license meant the facility had to investigate the issue and go from there.

The facility was unable to provide documentation that the administrative disciplinary action against RN 3's license was investigated and addressed by the facility.

During a review of Registered Nurse (RN) 3's Job Description, dated 1/25/24, the document indicated, .Specific Requirements- Must possess a current, unencumbered (a license that's free of disciplinary limitation), active license to practice as an RN .

During a review of the California Penal Code (a legal document that compiles a jurisdiction's criminal laws, defining various crimes), dated 1/1/23, the PENAL CODE Section 11165.2 indicated, .'Severe neglect' also means those situations of neglect where any person having the care or custody of a child willfully causes or permits the person or health of the child to be placed in a situation such that their person or health is endangered .

During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, the P&P indicated, .Conduct employee background checks and not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . a disciplinary action in effect against his or her professional license by a state licensure body as a result of finding of abuse, neglect, exploitation .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, was reviewed.

The P&P indicated, Protect residents from any further harm .

• During a review of the facility's QAPI Minutes (a written record of a QAPI meeting that documents

topics discussed, decisions made, and actions taken), dated January to December 2024, the minutes indicated there was no analysis of data regarding abuse allegations and no discussion of possible trends regarding abuse occurrence in the facility.

During an interview on 1/17/25 at 9:17 a.m. with the Administrator (ADMIN), the ADMIN identified himself as the facility's abuse coordinator (designated staff member within a nursing home responsible for overseeing and coordinating the facility's efforts to prevent resident abuse).

The ADMIN stated he reported abuse allegations to QAPI but did not keep a log to track trends regarding abuse.

The ADMIN stated, It's not QAPI's job to track abuse.

During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, the P&P indicated, Establish and implement a QAPI review and analysis of reports, allegations or findings of abuse, neglect, mistreatment, misappropriation of property.

During an interview on 1/14/25 at 10:14 a.m. with Resident 84, Resident 84 stated she sometimes felt like she should not report incidents or concerns to staff because she was afraid of staff retaliation.

During an interview on 1/16/25 at 5:56 p.m. with the Administrator (ADMIN), the ADMIN identified himself as the facility's abuse coordinator (designated staff member within a nursing home responsible for overseeing and coordinating the facility's efforts to prevent resident abuse).

The ADMIN stated retaliation only occurred against staff who reported abuse.

The ADMIN stated retaliation against residents who reported abuse was not possible; it's not a thing.

During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, the P&P did not include prohibiting and preventing retaliation against residents, families, or visitors that reported abuse.

The facility was unable to provide a policy or procedure regarding how the facility would ensure residents would not be subjected to acts of retaliation during and after an abuse investigation.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, dated October 2022, the P&P indicated .The resident and representative are notified in writing of the following information: a.

The specific reason for the transfer or discharge, including the basis . A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer is provided to the resident and representative .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During an interview on 1/14/25 at 2:14 p.m. with Registered Dietitian (RD), RD confirmed Resident 25 had a 22.22% weight loss since admission.

During a concurrent interview and record review on 1/15/25 at 11:14 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 25's MDS, dated [DATE], was reviewed.

Under Section K 300, Weight Loss of 5% or more in the last month or loss of 10% or more in the last 6 months, MDSC coded a response of no. MDSC confirmed she did not code the MDS accurately. MDSC stated it was important to code the MDS correctly because the MDS triggered the resident's plan of care.

During a review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, dated October 2024, the RAI Manual indicated, The assessment accurately reflects the resident's status .

During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, dated March 2022, the P&P indicated, A comprehensive assessment of every resident's needs . which includes admission assessments, quarterly assessment, annual assessment, Significant change in status assessments, and completion of the MDS .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review of Resident 71's PASRR, dated 7/14/23, the PASRR indicated Level 1 screening was negative. PASRR indicated Resident 71 was not diagnosed with a mental disorder such as anxiety disorder (mental health condition that involves excessive and persistent feelings of fear, worry, dread and uneasiness that can cause physical symptoms) and panic disorder (mental health condition that experiences unexpected and repeated episodes of intense fear accompanied by physical symptoms like chest pain), and not prescribed psychotropic (a drug that affects how the brain works and causes changes in mood, thoughts, feelings and behaviors) medications for mental illness.

During a review of Resident 71's Minimum Data Set (MDS-an assessment tool), dated 7/20/23, the MDS indicated Resident 71's active diagnoses were anxiety disorder and post-traumatic stress disorder (a condition of persistent mental and emotion stress occurring because of injury or severe psychological shock).

The MDS indicated Resident 71's Level II PASRR Conditions were not checked.

During a review of Resident 71's CAA [Care Area Assessment] Worksheet (a tool used to further investigate specific areas of concern identified during MDS assessment), dated 7/20/23, the CAA Worksheet indicated Resident has had thoughts that she would be better off dead, or thoughts of hurting herself, and she was on medication for PTSD and psychosis (symptoms that can cause a person to lose touch with reality such as hallucinations).

The CAA Worksheet further indicated Resident 71 had severe depression and was recommended for a Referral .

PsyD (doctor of psychology) .

During a concurrent interview and record review on 1/16/25 at 9:52 a.m. with Social Services Director (SSD), Resident 71's Medication Administration Record (MAR), dated 1/16/25 was reviewed. Resident 71's MAR indicated Resident received three different medications for post-traumatic stress disorder, panic disorder and depression. SSD stated it was her responsibility to arrange the referral for a PASRR evaluation. SSD stated if a resident had psychosis, depression, anxiety or other mental health related diagnoses, the resident would be referred for clarification for PASRR evaluation. SSD stated Resident 71 was never evaluated or referred for PASRR clarification, but she should have been.

During a review of the facility's policy and procedure (P&P) titled, Preadmission Screen and Resident Review (PASRR), dated July 2016, the P&P indicated, It is the policy of this facility to complete and submit a PASRR screening . If facility is dissatisfied with the recommendations in the PASRR determination letter, they can request a reconsideration . the facility will update the existing PASRR on file for either of the following reasons . there is a significant change in a resident's physical or mental condition .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

Review of Resident 25's admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of the temporal lobe (brain tumor).

During an interview on 1/13/25 at 10:50 a.m. with Resident 25's Responsible Party (RP) 1, RP 1 stated facility staff called her on 1/12/25 and informed her that Resident 25 had rolled out of his bed.

During an observation on 1/13/25 at 9:00 a.m. in Resident 25's room, Resident 25 was in bed asleep.

No fall mat was observed on the floor at his bedside.

During an observation 1/13/25 11:58 a.m. in Resident 25's room, Resident 25 was in bed asleep. No fall mat observed at bedside.

During an interview on 1/15/25 at 8:45 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 25 required assistance to get out of bed. CNA 1 stated he was aware that the resident was found on the floor. CNA 1 confirmed there was not a fall mat at Resident 25's bedside.

During an interview on 1/14/25 at 9:11 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 25 fell on 1/12/25 and was found crawling on the floor. RN 1 stated that a fall mat should have been placed next to Resident 25's bed.

During an interview on 1/15/25 at 9:15 a.m. with Charge Registered Nurse (CRN) 1, CRN 1 stated that Resident 25 recently had a fall on 1/12/25. CRN 1 stated that Resident 25 becomes agitated and scoots around in bed. CRN 1 stated that Resident 25 required a fall mat and that it may have been removed for cleaning.

During an interview on 1/15/25 at 12:30 p.m. with the Director of Nursing (DON) 1, DON 1 stated that the fall mat should be used as an intervention for Resident 25 because he was prone to crawling or rolling out of bed.

During a review of Resident 25's Care Plan, dated 10/15/24, the Care Plan indicated, Resident 25 had been found crawling out of bed and interventions included keep floor mat at bedside.

During a review of the facility's policy titled, Falls and Fall Risk, managing, dated March 2018, the policy indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review of Resident 28's Face Sheet (demographics), the Face Sheet indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including repeated falls, muscle weakness and dementia (impaired ability to remember, think, or make decisions).

During an observation on 1/14/25 at 8:56 a.m. in Resident 28's room, Resident 28 was observed seated in his wheelchair self-propelling himself out of his room.

During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 12/19/24, the MDS indicated Resident 28's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 3 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired).

The BIMS assessment indicated Resident 28 had severe cognitive impairment.

During a review of Resident 28's Progress Notes, dated 1/12/25, the notes indicated, .

Resident had unwitnessed fall and sustained on left elbow skin tear on upper extremities .

Resident found on lying position by a [Certified Nurse Assistant] CNA .confusion as baseline .

During a concurrent interview and record review on 1/14/25 at 3:40 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 28's Care Plan (CP), dated 9/7/24 was reviewed.

The CP indicated, .is at risk for falls R/T [related to] deconditioning, gait/balance problems . LVN 4 reviewed Resident 28's CP and stated there were no updated interventions after the fall on 1/12/25. LVN 4 stated care plan interventions should be updated after a fall, but was not. LVN 4 stated the fall care plan should have been updated and that it was the nurses' responsibility to update it. LVN 4 stated the purpose of the CP was to implement interventions and measure what was working or not.

During a concurrent interview and record review on 1/16/25 at 10:26 a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated March 2018 was reviewed.

The P&P indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . In conjunction with the attending physician, staff will identify and implement relevant interventions . to try to minimize serious consequences of falling .

The DON stated the CP should be updated after a fall to prevent a serious injury.

The DON stated the purpose of the care plan was to identify problems and implement interventions to maintain or improve conditions.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During an observation on 1/15/25 at 12:35 p.m. in the hallway of Station 1, LVN 2 was standing in front of the medication cart. LVN 2 had two medicine cups on top of the medication cart with unidentified pills: the first medicine cup, labeled 22A in black marker, had one long yellow pill.

The second medicine cup, labeled 22C in black marker, had one round blue pill and one round white pill.

LVN 2 went into the medication cart and dispensed a third pill into the medicine cup labeled 22C. LVN 2 then walked down the hallway, approximately 65 feet, holding the two medicine cups. LVN 2 entered Resident 39 and 193's room and placed the medicine cup labeled 22A on the bedside table for Resident 39. LVN 2 then walked over and placed the medicine cup labeled 22C on the bedside table for Resident 193. LVN 2 did not observe Resident 39 and Resident 193 ingest the medications that were placed on their bedside tables, and did not inform the residents of what medications were in the cups .

During an interview on 1/15/25 at 12:41 p.m. with LVN 2, LVN 2 stated she was supposed to push the medication cart to the resident's room and prepare medications one resident at a time. LVN 2 confirmed she did not follow expectations. LVN 2 further stated she did not observe Resident 39 and Resident 193 ingest the medications because They always take those meds [medications].

During an interview on 1/15/25 at 12:47 p.m. with the Director of Nursing (DON), the DON stated the expectation was the medication cart goes to each room with the nurse during medication administration. DON stated nurses should not prepare multiple residents' medications at one time to avoid the possibility of medication error. DON further stated residents should be observed while taking medications by the nurse.

During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, .Medications are administered at the time they are prepared.

Medications are not pre-poured .

The resident is always observed after administration to ensure that the dose was completely ingested .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review of Resident 290's Face Sheet (demographics), the Face Sheet indicated Resident 290 was admitted on [DATE] with diagnoses including diabetic retinopathy (eye condition that damages the eye's blood vessels due to high blood sugar).

The Face Sheet included a picture of Resident 290 wearing eyeglasses.

During a concurrent observation and interview on 1/14/25 at 4:25 p.m. with Resident 290 in his room, Resident 290 was holding up the crossword puzzle very close to his face. Resident 290 stated that he has been unable to do his crossword puzzles which he loved to do because he did not have eyeglasses for more than two weeks. Resident 290 stated that he reported his eyeglasses missing and requested getting new eyeglasses from the Social Services Director (SSD).

During an interview on 1/14/25 at 4:32 p.m. with the SSD, the SSD stated that she remembered talking to Resident 290 about needing to send him out for a consultation if he needed help with getting eyeglasses, but she did not document the interaction or follow-up afterwards.

The SSD stated that if residents brought up issues to her when she was not in the office, she would sometimes forget to chart them.

The SSD stated that she was responsible for helping residents with setting up an appointment to get new eyeglasses.

The SSD stated that Resident 290 not having his glasses would negatively affect his quality of life by a lot.

During a review of Resident 290's Nursing admission Screening, dated 12/27/24, the document indicated, Resident 290 wears glasses.

The facility was unable to provide a policy and procedure regarding ensuring that residents received the proper assistive devices, such as eyeglasses, to maintain vision abilities.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review of Resident 25's Face Sheet (demographics), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the temporal lobe (brain tumor), iron deficiency anemia (fewer red blood cells in the body due to a lack of iron), type 2 diabetes mellitus (condition that causes the level of sugar in the blood to become too high), and dysphasia (difficulty swallowing).

During an interview on 1/15/25 at 3:20 p.m. with Medical Director (MD), MD stated she visited the facility daily and saw the residents who need medication changes. MD stated she was unaware of the requirements for physician's visits, but she tried to see all residents monthly. MD stated, Sometimes I just pop in and see how they are doing and I don't document that.

When I do an examination, I document it.

During a concurrent interview and record review of Resident 25's Medical Record on 1/15/25 at 4:00 p.m. with the Director of Nursing (DON), DON stated he was unsure how often the MD visited Resident 25. DON confirmed there was no documentation in the record which indicated that Resident 25 was seen by MD between 9/20/24 and 11/28/24 (58 days). DON stated, [MD] must not have visited Resident 25 during that timeframe.

During a review of the facility's policy and procedure (P&P) titled, Physician Visits, dated April 2013, the P&P indicated, The Attending Physician must visit his/her patients at least once every thirty days for the first ninety days . physician must perform relevant tasks at the time of each visit including a review of the resident's total program of care and appropriate documentation.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During multiple observations on 1/15/25 at various times with Registered Nurse (RN) 3, RN 4, RN 5, RN 6, and Licensed Vocational Nurse (LVN) 2, medications were administered to Resident 36, 39, 71, 81, 193, and 291.

The medication error rate was 24%.

During an interview on 1/15/25 at 12:55 p.m. with the Director of Nursing (DON), the DON stated nurses were evaluated for medication administration competency upon hire and if there were any errors with competency during medication administration audits (observations to help identify potential and actual medication errors at different stages).

The DON further stated medication administration audits were completed by the Pharmacist (PHARM).

During an interview on 1/16/25 at 3:26 p.m. with the PHARM, the PHARM stated he has not completed medication administration audits and that was not his responsibility.

During a review of Duties and Responsibilities (job description), for RN 3, 4, 5, 6 and LVN 2, the Duties and Responsibilities indicated, Implement and maintain established nursing objectives and standards .

Ensure that established departmental policies and procedures are followed .

Prepare and administer medications as ordered by the physician .

During a review of [facility name] Facility Assessment, dated 1/6/25, the Facility Assessment indicated, .Staff Training/Education & Competencies .

Upon hire skills checks are completed through competency evaluations and are reviewed annually thereafter or as needed.

Performance evaluations are performed annually to ensure staff are meeting the facility standards of performance and conduct .

During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices .

Medications are administered in accordance with written orders .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

services .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During an interview on 1/15/25 at 5:14 p.m. with the Medical Director (MD), the MD stated Resident 71 definitely had depression and sometimes aggression.

During an interview on 1/16/25 at 9:16 a.m. with Resident 71, Resident 71 stated the facility had not provided behavioral health services and she further stated she had informed the Social Services Director that she wanted counseling. Resident 71 stated she had been dealing with so much mentally for 10 years, I'm sad mostly all day.

During an interview on 1/16/25 at 9:52 a.m. with the Social Services Director (SSD), the SSD stated Resident 71 had not been evaluated or seen by any mental health professional.

During a concurrent interview and record review on 1/16/25 at 4:02 p.m. with the Administrator (ADMIN), Resident 71's CAA [Care Area Assessment] Worksheet (a tool used to further investigate specific areas of concern identified during MDS assessment), dated 7/20/23 was reviewed.

The CAA Worksheet indicated Resident has had thoughts that she would be better off dead, or thoughts of hurting herself, and she was on medication for PTSD and psychosis (symptoms that can cause a person to lose touch with reality such as hallucinations).

The CAA Worksheet further indicated Resident 71 had severe depression and was recommended for a Referral .

PsyD (doctor of psychology) .

The ADMIN confirmed Resident 71 did not have any mental health services and stated, I'm very surprised, she should have had help.

During a review of Resident 71's admission Record, dated 1/16/25, the admission Record indicated, Resident 71 was admitted to the facility on [DATE], with diagnoses of depression, panic disorder (mental health condition that experiences unexpected and repeated episodes of intense fear accompanied by physical symptoms like chest pain), generalized anxiety disorder (mental health condition that involves excessive and persistent feelings of fear, worry, dread and uneasiness that can cause physical symptoms), and chronic post-traumatic stress disorder (a condition of persistent mental and emotion stress occurring because of injury or severe psychological shock).

During a review of Resident 71's Minimum Data Set (MDS-an assessment tool), dated 7/20/23, the MDS indicated, Resident 71's active diagnoses are anxiety disorder and post-traumatic stress disorder.

During a review of the facility's policy and procedure (P&P) titled, Behavioral Health Services,' undated, the P&P indicated, The facility will provide, and residents will receive behavioral health services .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review of Resident 61's Face Sheet (demographics), the Face Sheet indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including Lewy body dementia (brain disease that causes a gradual decline in thinking, movement, and behavior) and major depressive disorder (a mental disorder causing low mood, lack of interest and feelings of hopelessness).

During an interview on 1/16/25 at 3:14 p.m. with Pharmacist (PHARM), PHARM stated that he should conduct a MMR every month to look for any medication concerns such as duplicate therapy or medication interactions and email the results to the Director of Nursing (DON) so that any issues with the resident's medications could be addressed.

During a concurrent interview and record review of Resident 61's MMRs on 1/16/25 at 3:50 p.m. with DON, there were no documentation of MMRs found in Resident 61's Medical Record for the months of January and August 2024. DON confirmed MMRs were not conducted.

During a review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Reports, dated December 2016, the P&P indicated, The consultant pharmacist performs a comprehensive medication regimen review at least monthly . to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy . the findings are documented and stored within 72 hours.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During an interview on 1/15/25 at 3:20 p.m. with Medical Director (MD), MD stated Resident 61 had not exhibited any behaviors. MD further stated she was aware of the Mental Health Physician's recommendations to discontinue quetiapine and decrease escitalopram. MD confirmed she did not attempt a GDR over the past year for either medication. MD stated she did not discuss a GDR with Resident 61's Responsible Party over the past year.

During an interview on 1/16/25 at 3:14 p.m. with Pharmacist (PHARM), PHARM stated he made a recommendation regarding Resident 61 for a GDR of quetiapine on 4/11/24, and the recommendation was declined by MD. PHARM stated he made a recommendation for a dose reduction for escitalopram in May of 2024 as 10 mg was the maximum recommended dose for the elderly, and the recommendation was declined by MD.

During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication (medications that affect how the brain works and cause changes in mood, awareness, thoughts, feelings, or behavior) Use, dated October 2017, the P&P indicated, Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated.

After the first year, a GDR must be attempted Annually, unless clinically contraindicated.

During a review of the FDA (Food and Drug Administration) instructions for use and black box warning for escitalopram oxalate, revised January 2017, the instructions indicated, 10 mg per day is the recommended dose for most elderly patients . elderly may be at greater risk for hyponatremia (low salt in the blood).

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a concurrent observation and interview on 1/15/25 at 4:15 p.m. with Registered Nurse (RN) 3

that measures the amount of sugar in the bloodstream) and stated the result was 205 milligram/deciliter (mg/dL, unit of measurement). RN 3 went to the medication cart and documented 305 mg/dL into Resident 291's Medication Administration Record (MAR) for the blood sugar result. RN 3 stated the sliding scale for blood sugar result of 305, was to administer 8 units of insulin (medication that manages blood sugar levels). RN 3 turned the dial to 8 units of insulin and confirmed the prefilled pen injector was turned to 8 units. RN 3 stated, Yes, I'm ready to give, and began to walk towards Resident 291. RN 3 was then stopped and was asked to show the history on the glucometer results. RN 3 recalled the history on the glucometer and stated the value was 205! Oh, my god! That would have been so bad. RN 3 reviewed Resident 291's MAR and confirmed the correct dose of insulin should have been 4 units.

During a review of Resident 291's Physician's Order, dated 1/8/25, the Physician's Orders indicated, insulin injected per sliding scale (increasing administration of the insulin dose based on blood sugar levels) was for blood sugar value of 0-149= 0 units to be given, 150-200= 2 units, 201-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400= 10 units, and 401-500= 12 units and call physician.

During an interview on 1/15/25 at 4:54 p.m. with the Medical Director (MD), MD stated, It's always life threatening to give too much insulin.

During an interview on 1/16/25 at 3:30 p.m. with the Pharmacist (PHARM), the PHARM stated if double the dose of insulin was administered, that would be quite a jump, and significant damage could be caused to Resident 291.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, .Medications are administered in accordance with written orders .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review Resident 291's Face Sheet (demographics), the Face Sheet indicated Resident 291 was admitted on [DATE] with diagnoses including diabetes mellitus type 2 (disease that causes high blood sugars).

During a review of Resident 291's Face Sheet (demographics), the Face Sheet indicated Resident 291 was admitted on [DATE] with diagnoses including diabetes mellitus type 2 (disease that causes high blood sugars).

During a concurrent observation and interview on 1/15/25 at 4:15 p.m. with Registered Nurse (RN) 3 in Resident 291 ' s room, RN 3 checked Resident 291's blood sugar with a glucometer (handheld device that measures the amount of sugar in the bloodstream) and stated the result was 205 milligram/deciliter (mg/dL, unit of measurement). RN 3 went to the medication cart and documented 305 mg/dL into Resident 291's Medication Administration Record (MAR) for the blood sugar result. RN 3 stated the sliding scale for blood sugar result of 305, was to administer 8 units of insulin (medication that manages blood sugar levels). RN 3 turned the dial to 8 units of insulin and confirmed the prefilled pen injector was turned to 8 units. RN 3 stated, Yes, I'm ready to give, and began to walk towards Resident 291. RN 3 was then stopped and was asked to show the history on the glucometer results. RN 3 recalled the history on the glucometer and stated the value was 205! Oh, my god! That would have been so bad. RN 3 reviewed Resident 291's MAR and confirmed the correct dose of insulin should have been 4 units.

During a review of Resident 291's Physician's Order, dated 1/8/25, the Physician's Orders indicated, insulin injected per sliding scale (increasing administration of the insulin dose based on blood sugar levels) was for blood sugar value of 0-149= 0 units to be given, 150-200= 2 units, 201-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400= 10 units, and 401-500= 12 units and call physician.

During an interview on 1/15/25 at 4:54 p.m. with the Medical Director (MD), MD stated, It's always life threatening to give too much insulin.

During an interview on 1/16/25 at 3:30 p.m. with the Pharmacist (PHARM), the PHARM stated if double the dose of insulin was administered, that would be quite a jump, and significant damage could be caused to Resident 291.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, .Medications are administered in accordance with written orders .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

punctured) are dated and discarded within 28 days . 'If medication containers have missing,

returning or destroying these items'.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a concurrent observation and interview on 1/16/25 at 9:35 a.m. with Resident 71, Resident 71 had multiple teeth missing. Resident 71 stated she had only seen the dentist one time since admission. Resident 71 further stated she verbally requested a dental visit multiple times.

During an interview on 1/16/25 at 9:46 a.m. with Social Services Director (SSD), SSD stated Resident 71 was admitted on [DATE] and was not seen by dental until 11/14/24. SSD stated the resident should have been seen every 6 months and as needed.

During a review of Resident 71's Minimum Data Set (MDS-an assessment tool), dated 12/26/24, the MDS indicated, Resident 71's Oral/Dental Status is no natural teeth or tooth fragment(s) (edentulous-lacking teeth).

The MDS indicated Care Area Triggered was Dental Care.

The facility was unable to provide a policy and procedure regarding dental services.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a concurrent observation and interview on 1/13/25 at 8:21 a.m., with the Dietary Supervisor (DS) a white powdery (dusty) substance was noted on top of the dishwasher.

The dishwasher was also noted to have a thick greasy buildup up on the bar going across the bottom of the equipment.

The DS agreed that the equipment was dirty and needed to be cleaned.

During a review of the facility's policy and procedure (P&P) titled, Shelves, Counters, and Other surfaces Including Sinks (Handwashing, Food Preparation, ETC.), dated 2023, the P&P indicated, Remove any large debris and wash surface with warm detergent solution .Rinse with clear water using a clean sponge or cloth.

Wipe dry with a clean cloth.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a concurrent observation and interview on 1/13/25 at 10:57 a.m., in Resident 56's room, Resident 56 was observed opening her bedside bottom drawer and pulling out a container of butter and jar of pickled beets. Resident 56 stated she knew the food items needed to be refrigerated but there was no available refrigerator.

During an interview on 1/14/25 at 2:54 p.m. with Dietary Manager (DM), DM stated residents were encouraged to eat food brought from outside within two hours. DM stated the facility did not have a separate refrigerator to store food for residents.

During an interview on 1/14/25 at 3:21 p.m. with Registered Nurse (RN) 5, RN 5 stated the facility did not have a refrigerator to store perishable foods for the residents, and there should be a refrigerator for residents.

During an interview on 1/14/25 at 4:14 p.m. with Resident 56, Resident 56 stated, I wish they had a fridge for us to use but I know it's not going to happen.

During an interview on 1/15/25 at 8:22 a.m. with Resident 54, Resident 54 stated she would like the facility to have a refrigerator to store food for her. Resident 54 stated approximately a year ago the facility did have a refrigerator for residents but was unsure why it was taken away.

During an interview on 1/15/25 at 8:25 a.m. with Resident 341, Resident 341 stated at home he stored tea in the refrigerator to drink throughout the day. Resident 341 stated he wished the facility had a refrigerator because he had to rely on drinking the tea with ice.

During an interview on 1/16/25 at 10:08 a.m. with Social Services Director (SSD), SSD stated the facility used to have a refrigerator for resident use but was unsure why the facility no longer had one.

During a concurrent interview and record review on 1/16/25 at 10:22 a.m. with the Director of Nursing Services (DON), the facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, dated March 2022, was reviewed.

The P&P indicated, .

Food brought to the facility by visitors and family is permitted .Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable .

Potentially hazardous food that are left out then for the resident without a source of heat or refrigeration longer than 2 hours are discarded .

The DON stated since he had started working at the facility there was no refrigerator for resident use available.

The DON stated residents have the right to store food brought in from outside.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During an interview on 1/15/25 at 3:20 p.m. with MD, MD confirmed Resident 25's Physician Progress

faxed them to the facility at a later date. MD stated the facility requested Physician's Progress Notes for multiple residents for the survey team and she would be faxing them later. MD confirmed she did not have remote access to the progress notes and could not provide them.

During an interview on 1/17/25 at 9:17 a.m. with the Administrator (ADMIN), ADMIN confirmed MD did not document Physician's Progress Notes while at the facility. ADMIN further stated the facility did not have access to Physician's Progress Notes for multiple residents, and staff were unable to review the notes if needed. ADMIN stated if a resident required transfer to a higher level of care, then the facility would need to contact MD and request to fax the progress notes.

During a review of the facility's policy and procedure (P&P) titled, Physician Visits, dated April 2013, the P&P indicated, The Attending Physician must perform all relevant tasks at the time of each visit, including .appropriate documentation.

• During a review of Resident 75's Face Sheet (demographics), the Face Sheet indicated Resident 75

was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (disorder wherein body is unable to regulate blood sugar).

During a concurrent interview and record review of Resident 75's medical record on 1/14/25 at 4 p.m. with the Director of Nursing (DON), the medical record review indicated there were no documented Physician's Progress Notes. DON stated he would request MD to fax the Physician's Progress Notes for the medical record.

During an interview on 1/15/25 at 1 p.m. with the Director of Nursing (DON), DON stated he was waiting for MD to send the progress notes. DON stated, We do not have the progress notes at the facility. MD does not complete her progress notes when she assesses the residents; she faxes them to us- she is old school. DON stated, he expected MD to document progress notes in the chart while she was at the facility so that the notes were readily available.

During an interview on 1/15/25 at 3:20 p.m. with MD, MD confirmed Resident 25's Physician Progress Notes were not in the medical record. MD stated she documented her progress notes at her office and faxed them to the facility at a later date. MD stated the facility requested Physician's Progress Notes for multiple residents for the survey team and she would be faxing them later. MD confirmed she did not have remote access to the progress notes and could not provide them.

During an interview on 1/17/25 at 9:17 a.m. with the Administrator (ADMIN), ADMIN confirmed MD did not document Physician's Progress Notes while at the facility. ADMIN further stated the facility did not have access to Physician's Progress Notes for multiple residents, and staff were unable to review the notes if needed. ADMIN stated if a resident required transfer to a higher level of care, then the facility would need to contact MD and request to fax the progress notes.

During a review of the facility's policy and procedure (P&P) titled, Physician Visits, dated April 2013, the P&P indicated, The Attending Physician must perform all relevant tasks at the time of each visit, including .appropriate documentation.

During a review of the facility's QAPI Minutes (a written record of a QAPI meeting that documents topics discussed, decisions made, and actions taken), dated January to December 2024, the minutes indicated that for January and February of 2024, Medication Administration Audits by the Pharmacist (PHARM) were planned to be completed monthly and reported to QAPI.

The minutes indicated the audits were not completed for February.

During an interview on 1/15/25 at 12:47 p.m. with the Director of Nursing (DON), the DON stated PHARM was responsible for conducting monthly medication administration audits.

During an interview on 1/16/25 at 3:26 p.m. with PHARM, PHARM denied being responsible for conducting medication administration audits.

During an interview on 1/17/25 at 9:17 a.m. with the Administrator (ADMIN), the ADMIN stated his start of employment was June 2024.

The ADMIN stated he had no knowledge of the medication administration audits to be completed by PHARM and declined to discuss any further issues identified and addressed by QAPI prior to his start of employment because those issues were before my time.

The facility was unable to provide documentation that medication administration was audited by PHARM monthly during February to December 2024.

During a review of the facility's policy and procedure (P&P) titled, QAPI Plan, dated 10/24/24, the P&P indicated, The facility QAPI program is ongoing, comprehensive and addresses all care and services provided by the facility.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review of the facility's QAPI Agenda and Minutes, dated October 2024, the documents indicated the following PIPs were assigned/ongoing: Call Lights, Care Conferences, and Falls, but did not include any evaluation or discussion regarding the PIPs.

During a review of the facility's policy and procedure (P&P) titled, QAPI Plan, dated 10/24/24, the P&P indicated, The QAPI program is designed to address all systems and practices in this facility that affect residents .

Information is collected, evaluated and monitored by the QAPI committee .

Facility will conduct performance improvement projects that are designed to take a systemic approach to revise and improve care or services in areas that we identify as needing attention . An important aspect of our PIPs is a plan to determine the effectiveness of our performance improvement activities and whether the improvement is sustained . the QAPI committee will review data and input on a monthly basis to look for potential topics for PIPs .The facility will use the QAA log to include listing of current projects and outcomes .

Quality deficiencies that are identified through feedback and data will undergo appropriate corrective action .

The QAPI program, overseen by the QAPI committee, is designed to identify and address quality deficiencies through the analysis of underlying cause and actions targeted at correcting systems at a comprehensive level.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During an interview on 1/15/25 at 3:20 p.m. with Infection Preventionist (IP), IP stated if one resident was on contact isolation and they shared a room with other residents, staff must wear gown and gloves regardless upon entering the room.

During a review of Resident 63's Medication Administration Record (MAR), dated 1/15/24, the MAR indicated, CONTACT PRECAUTIONS every shift for r/t [related to] MRSA positive on the wound culture .

During a review of the facility's policy and procedure (P&P) titled, Isolation- Categories of Transmission-Based Precautions (TBP), dated September 2022, the P&P indicated, .Staff and visitors wear a disposable gown upon entering the room . 4c.

During an observation on 1/17/25 at 9:58 a.m. in room [ROOM NUMBER], Registered Nurse (RN) 5 entered Resident 344's room wearing a surgical mask. An Enhanced Barrier Precaution sign was posted outside the door with a personal protective equipment (PPE) cart.

During a concurrent interview and record review on 1/17/25 at 10:07 a.m. with RN 5, Resident 344's Medication Administration Record (MAR), dated 1/17/25 was reviewed.

The MAR indicated, on 1/15/25 Resident 344 had Droplet Precaution related to influenza and Enhanced Barrier Precaution related to foley catheter. RN 5 confirmed there was not a Droplet Precaution sign posted.

During an interview on 1/17/25 at 10:25 a.m. with Infection Preventionist (IP), IP stated if there was an order, there should have been a sign posted on the door.

During an interview on 1/17/25 at 10:21 a.m. with the Director of Nursing (DON), the DON stated the expectation was to post the correct sign in accordance with the order for isolation precautions.

During a review of the facility's policy and procedure (P&P) titled, Isolation- Categories of Transmission-Based Precautions (TBP), dated September 2022, the P&P indicated, .When a resident is placed on transmission-based precautions appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for the type of precaution .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a review of Resident 84's Face Sheet (demographics), the Face Sheet indicated Resident 17 was admitted on [DATE] with diagnoses to include a UTI.

During a review of Resident 84's Physician Orders, dated 10/27/24, the Physician Order indicated, Amoxicillin-Pot Clavulanate tablet 875-125 milligram (unit of measurement), give 1 tablet by mouth two (2) times a day for urinary tract infection for 14 days.

During a concurrent interview and record review on 1/15/25 at 10:48 a.m. with Infection Preventionist (IP), the facility's binder of Monthly Infection Control Log, dated 2024 was reviewed. IP stated there was no documentation that the antibiotic stewardship monitored the effective use of Amoxicillin-Pot Clavulanate for urinary tract infection in October 2024 and November 2024 for Resident 84. IP also stated the IPs should have monitored for the effective use of antibiotics monthly.

During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated 2001, the P&P indicated, The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents .

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a concurrent observation and interview on 1/13/25 at 9:03 a.m. with Resident 54 in room [ROOM NUMBER], the room had three residents residing in it.

Bed C's individual living space was visibly smaller than Bed A and B's living spaces. Resident 54 in Bed C, stated, Look how small this is; I can't even get by. Resident 54 used a walker for an assistive device.

During a concurrent observation and interview on 1/15/25 at 4:06 p.m. with Maintenance (MAIN) in room [ROOM NUMBER], MAIN measured Bed C's individual living space, the result was 11.5 feet by 6.5 feet, the Maintenance Director calculated living space was 74.75 square footage (sqft.). MAIN stated, Oh, too small! She needs at least 80.

During a concurrent observation and interview on 1/15/25 at 6:01 p.m. with the Administrator (ADMIN), in room [ROOM NUMBER], the ADMIN had the MAIN measure Bed C's individual living space, 11.5 feet by 6.5 feet, the ADMIN calculated living space was 74.75 sqft.

The ADMIN confirmed Bed C's individual living space was under 80 sqft.

During a concurrent interview and record review on 1/16/25 at 12:01 p.m. with the ADMIN, [facility name] Resident Room Measurements, was reviewed.

The [facility name] Resident Room Measurements indicated rooms labeled 1-24, in red ink, had three residents in one room.

The ADMIN stated all 24 rooms with a Bed C had an individual living space below 80 sqft.

Facility was unable to provide policy and procedure for adequate resident living space.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a concurrent interview and record review on 1/16/25 at 6:49 p.m. with the DSD, the SSD's Employee Files, dated 10/25/24 was reviewed.

The abuse training post-test indicated the SSD selected the incorrect answer that mandated reporters must report known or suspected instances of physical abuse, abandonment, isolation, financial abuse, or neglect by telephone to the long-term care ombudsman or law enforcement within 24 hours, instead of the correct answer to report immediately, or as soon as possible.

The abuse training post-test also indicated that the post-test was incomplete.

The DSD confirmed that SSD's abuse training post-test was not completed.

During an interview on 1/16/25 at 6:52 p.m. with the DSD, the DSD stated, the facility did not have a tracking system for staff that are struggling with the information from the abuse trainings.

The DSD stated wrong answers on the abuse training post-test were corrected verbally, but education was not re-evaluated afterwards .

During an interview on 1/16/25 at 6:53 p.m. with the Administrator (ADMIN), the ADMIN stated the questions on the abuse post-test seemed confusing and may need to be fixed.

The ADMIN stated staff should be required to rewatch the abuse training video and complete the post-test until they get all the answers correct.

During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, the P&P indicated, Provide staff orientation and training orientation programs that include topics such as . reporting of abuse .

Implement measures to address factors that may lead to abusive situations, for example: adequately prepare staff for caregiving responsibilities .

Report any allegations within time frames required by federal requirements.

056120 01/17/2025

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During an interview on 1/13/25 at 9:03 a.m. with Resident 54, Resident 54 stated she was involved in a resident-to-resident altercation on 12/13/24 and has been trying to leave the facility. Resident 54 stated, I don't feel safe here.

During an interview on 1/16/25 at 9:26 a.m. with Resident 54, Resident 54 stated she did not feel safe at the facility and still wanted to transfer to a different facility. Resident 54 stated she had not heard any update in a month.

During an interview on 1/16/25 at 10:01 a.m. with the Social Services Director (SSD), the SSD stated she did not call any facilities to follow-up on transferring Resident 54 since 12/18/24.

The SSD stated it was very important for residents to feel safe at the facility, and she should have seen her more frequently and followed up with transferring Resident 54 to a different facility.

During an interview on 1/16/25 at 11:06 a.m. with the Director of Nursing (DON), the DON stated after Resident 54 stated she did not feel safe, the SSD should have followed up daily to address any psychosocial needs.

During a review of Resident 54's Summary- Resident-to-Resident Incident, dated 12/13/24, Resident 54's Summary- Resident-to-Resident Incident indicated, When asked if [Resident 54] feels safe in the facility, [Resident 54] stated, 'No.' .When asked if [Resident 54] would like to be place in another facility . [Resident 54] stated, 'Yes.'

During a review of Resident 54's Social Services Note, dated 12/17/24, the note indicated Resident 54 did not feel safe at the facility and discussed other facility options with the SSD.

The note indicated the SSD faxed a referral.

056120

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056120 B.

Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During an interview on 1/15/25 at 12:55 p.m. with the Director of Nursing (DON), the DON stated nurses were evaluated for medication administration competency upon hire and if there were any errors with competency during medication administration audits (observations to help identify potential and actual medication errors at different stages).

The DON further stated medication administration audits were completed by the Pharmacist (PHARM).

During an interview on 1/16/25 at 3:26 p.m. with the PHARM, the PHARM stated he has not completed medication administration audits and that was not his responsibility.

During a review of Duties and Responsibilities (job description), for RN 3, 4, 5, 6 and LVN 2, the Duties and Responsibilities indicated, Implement and maintain established nursing objectives and standards .

Ensure that established departmental policies and procedures are followed .

Prepare and administer medications as ordered by the physician .

During a review of [facility name] Facility Assessment, dated 1/6/25, the Facility Assessment indicated, .Staff Training/Education & Competencies .

Upon hire skills checks are completed through competency evaluations and are reviewed annually thereafter or as needed.

Performance evaluations are performed annually to ensure staff are meeting the facility standards of performance and conduct .

During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices .

Medications are administered in accordance with written orders .

056120

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056120 B.

Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During an interview on 1/15/25 at 12:47 p.m. with the Director of Nursing (DON), the DON stated PHARM was responsible for conducting monthly medication administration audits.

During an interview on 1/16/25 at 3:26 p.m. with PHARM, PHARM denied being responsible for conducting medication administration audits.

During an interview on 1/17/25 at 9:17 a.m. with the Administrator (ADMIN), the ADMIN stated his start of employment was June 2024.

The ADMIN stated he had no knowledge of the medication administration audits to be completed by PHARM and declined to discuss any further issues identified and addressed by QAPI prior to his start of employment because those issues were before my time.

The facility was unable to provide documentation that medication administration was audited by PHARM monthly during February to December 2024.

During a review of the facility's policy and procedure (P&P) titled, QAPI Plan, dated 10/24/24, the P&P indicated, The facility QAPI program is ongoing, comprehensive and addresses all care and services provided by the facility.

056120

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056120 B.

Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

During a follow-up interview on 1/17/25 at 9:20 a.m. with the ADMIN, the ADMIN stated he was unaware of the existence of the QAA Log (Quality Assessment and Assurance Log, a record of data and current PIPs to be reviewed as part of QAPI).

056120

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056120 B.

Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Bay Post Acute 300 Douglas Street Petaluma, CA 94952

F-F943)

4.

Incomplete Resident's Records (Cross-reference