A list of the most recent deficiencies for Sonoma Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-10 | 2023-04-06 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Establish methods for sharing information. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Use approved construction type or materials. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-04-11 | 2022-04-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-30 | 2022-04-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-30 | 2022-04-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-30 | 2022-04-24 | N |
| Provide activities to meet all resident's needs. | Health | 2022-03-30 | 2022-04-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-30 | 2022-04-24 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-03-30 | 2022-04-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-30 | 2022-04-24 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-30 | 2022-04-24 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-03-30 | 2022-04-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-30 | 2022-04-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-30 | 2022-04-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-30 | 2022-04-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-30 | 2022-04-24 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-03-30 | 2022-04-24 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-03-30 | 2022-04-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-30 | 2022-04-24 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-03-30 | 2022-04-24 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-03-30 | 2022-04-24 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-03-30 | 2022-04-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-30 | 2022-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-02 | 2022-03-30 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-02 | 2022-03-30 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-02-04 | 2022-03-30 | Y |
| Provide appropriate foot care. | Health | 2022-01-25 | 2022-03-23 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-02 | 2022-03-02 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-02 | 2022-03-02 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-07 | 2022-02-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-24 | 2022-02-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-25 | 2021-12-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-29 | 2021-06-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-08 | 2021-04-27 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-16 | 2019-10-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-16 | 2019-10-15 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-18 | 2019-10-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-18 | 2019-10-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-18 | 2019-10-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-18 | 2019-10-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-18 | 2019-10-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-09-20 | 2018-10-08 | N |
| Develop a communication plan. | Fire Safety | 2018-09-20 | 2018-10-08 | N |
| Use approved construction type or materials. | Fire Safety | 2018-09-20 | 2018-10-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-20 | 2018-10-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-09-20 | 2018-10-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-09-20 | 2018-10-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-09-20 | 2018-10-08 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-09-20 | 2018-10-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-09-20 | 2018-10-08 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-07-16 | 2018-09-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-07-16 | 2018-09-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-16 | 2018-09-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-07-16 | 2018-09-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-07-16 | 2018-09-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-16 | 2018-09-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-07-16 | 2018-09-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-07-16 | 2018-09-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-07-16 | 2018-09-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-07-16 | 2018-09-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-16 | 2018-09-05 | N |
