Petaluma Post-Acute Rehabilitation

In the surveyor’s words

From the most serious findings on record at Petaluma Post-Acute Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF685Dec 19, 2025

  Based on observation, interview and record review, the facility failed to ensure two of two residents (Resident 36 and Resident 92) had access to devices needed for sensory impairment when,1. Resident 36 reported broken glasses, needed for distance, on admission, and the glasses remained unaddressed a month later. And,2. Resident 92 reported needing hearing aids to hear people clearly, on admission, and Social Services did not respond to his request.This failure affected both residents' ability to actively engage in their care, their overall functionality, and their sense of well-being. Findings:1. A review of Resident 36's clinical record indicated she was admitted in 11/2025, with a diagnosis of a fracture of her left patella and a large contusion over her left eye after a fall. […]

• No harm, potential for more than minimal, patternF761Dec 19, 2025

  Based on observation, interview and record review, the facility failed to ensure safe medication labeling and storage practices were followed when,1. A loose Lantus Solostar Insulin Pen (A disposable prefilled injection device for long-acting insulin administration for diabetic residents) was found in the medication refrigerator with no label, no resident name, no instructions, no open date. And,2. Medication tablets and pills intended for wasting, were collected and filled in an unlabeled urine specimen cup that was stored inside a medication cart.These failures had the potential to contribute to unsafe medication use and administration and medication diversion.Findings: 1. […]

• No harm, potential for more than minimal, patternF880Dec 19, 2025

  Based on observation, interview, and record review, the facility failed to ensure infection control procedures were followed for two of two Residents (Resident 62 and Resident 64), when Licensed Nurse 1(LN 1) did not disinfect the blood pressure cuff between use on these residents.This failure had the potential to spread infection between residents.Findings:During an observation on 12/17/25 at 8:09 a.m., in Hall A, LN1 checked the blood pressure of Resident 64 and did not disinfect the blood pressure cuff afterwards.During an observation on 12/17/25 at 8:26 a.m., in Hall A, LN1 proceeded to check the blood pressure of Resident 62 and did not disinfect the blood pressure cuff prior to using.During an interview on 12/17/25 at 8:43 a.m., with LN 1, LN1 stated she should have cleaned the blood… […]

• No harm, potential for more than minimal, patternF563Mar 11, 2022

  Based on observation, interview and record review, the facility failed to ensure residents could receive visitors outside of regular working hours for one (Resident 64) of 17 sampled residents. This failure did not ensure Resident 64's rights, and had the potential to negatively affect residents' psychosocial outcomes due to restricted visitation of families and friends who may want to visit and cheer-up residents in the morning or evening, outside of business hours. Findings: A review of Resident 64's Admission Record indicated she was admitted to the facility on [DATE], with a history of bleeding between the brain and tissue covering the brain, high blood pressure, insulin dependent diabetes and generalized muscle weakness. […]

• No harm, potential for more than minimal, patternF679Mar 11, 2022

  Based upon observation, interview and record review the facility failed to provide individualized activities for three of 17 sampled residents (Resident 43, 58, and 64). This deficient practice had the potential to affect the quality of life of residents by placing them at risk of sensory deprivation and decreased cognitive functioning. Findings: 1. During a review of Resident 43's, Admission Record, dated 2/10/22, indicated she had been admitted to the facility on [DATE] following a hip replacement surgery (surgery to implant an artificial hip joint), muscle weakness and low blood pressure when standing or sitting. A review of Resident 43's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 1/31/22, indicated the resident exhibited no cognitive deficits. […]