Healdsburg Hospital D/P SNF

In the surveyor’s words

From the most serious findings on record at Healdsburg Hospital D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Jul 9, 2026

  Based on interview and record review, the facility failed to develop activity care plans for the residents when three of five residents sampled for activities (Residents 7, 9, 13) did not have an activities care plan. This failure had the potential to result in activities that do not meet the needs of the residents.During a record review and concurrent interview on 7/8/26 at 10:52 a.m., when asked for the location of the activity care plan in the electronic medical record, Nurse Manager navigated to a flow sheet in Resident 13's chart for documentation of activities and stated the flow sheet was considered the care plan for activities. […]

• No harm, potential for more than minimal, patternF812Aug 16, 2024

  Based on observation and interview and facility policy review, the facility failed to ensure food items were stored in a manner that complied with food handling practices to prevent food-borne illness (illness caused by the ingestion of contaminated food or beverages), when two bowls of prepared food were in the walk-in refrigerator without any labeling and several food items were opened and without labels in the dry storage area. This failure had the potential to result in the rapid growth of pathogenic (capable of causing disease) microorganisms (e. g. bacteria, virus etc.) that could cause food-borne illnesses and could affect the residents of the facility. Findings: During an observation on 8/12/24 at 9:15 a.m., food items in the freezers were labeled with the arrival date. […]

• No harm, potential for more than minimal, isolatedF636Jul 9, 2026

  Based on interview and record review, the facility's staff failed to complete comprehensive assessments of residents when two of five residents sampled for activities (Residents 9 and 13) did not have completed activity assessments through family interview. This failure had the potential to result in activities that are not personalized for residents who are no longer able to communicate their preferences.During a record review and concurrent interview on 7/8/26 at 1:30 p.m., MDS Coordinator reviewed Resident 9's activity assessments dated 3/23/26 and 3/22/25 and verified they had not been completed. […]

• No harm, potential for more than minimal, isolatedF732Jul 9, 2026

  Based on observation, interview and record review, the facility did not ensure the posted daily staffing information included the required elements: 1. Facility name 2. The current date 3. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides. 4. Resident census. This failure resulted in residents, visitors and staff not having access to the required information and had the potential for the facility not to meet the required daily nurse staffing hours per patient day. […]

• No harm, potential for more than minimal, isolatedF656Aug 16, 2024

  Based on observation, interviews and records review, the facility failed to develop a person-centered individualized care plan for 1 of 8 sampled residents (Resident 7.) This failure had the potential for facility staff to not provide adequate care to Resident 7's eyes which could cause further damage to his eyes and/or blindness. Findings: During on observation on 8/13/24 at 10:25 a.m., in Resident 7's room, Resident 7 had his right eye covered with a gauze dressing. Resident 7's left eye was open and seemed to be looking at the HFEN. During an interview on 8/13/24 at 2:57 p.m., Licensed Nurse C stated Resident 7 has his eye covered because his medical condition causes the eye to be swollen preventing the eye lids from closing. […]