Sonoma Post Acute

In the surveyor’s words

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

• Immediate jeopardy, widespreadF695Mar 30, 2022

  Based 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . (Portable oxygen tanks are steel cylinders filled with concentrated oxygen; they can be put on the back of wheel chairs, allowing residents to move about and prevent residents from being confined to their rooms or bed) This failure prevented Resident 10 and Resident 48 from receiving their oxygen as ordered by their physicians and caused potential for Resident 10 and Resident 48 to experience shortness of breath, harm, and possible death from [CONDITION(S)] (an… […]

• Actual harm, isolatedF689Apr 22, 2026

  Based 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… […]

• Actual harm, isolatedF689Mar 10, 2023

  Based on observation, interview and record review, the facility failed to ensure that the Policy and Procedure for using a bed alarm, (A device to alert staff when resident was moving or getting out of bed) was implemented for one resident, Resident 1 when: 1) On 9/26/22, the bed alarm pad with sensor was not placed directly under Resident 1, in between sheets. Certified Nursing Assistant (CNA) placed the bed alarm pad with sensor in between two mattresses of Resident 1 ' s bed. 2) The staff reported that they did not hear the bed alarm sound off when Resident 1 moved or got out the bed on 3/15/2022, 5/17/2022 and 9/25/2022. Resident 1 was found on the floor during rounds (an act of visiting) on dates 3/15/2022, 5/17/2022 and 9/25/2922. […]

• Actual harm, isolatedF687Jan 25, 2022

  Based on interview and record review the facility failed to ensure Healthcare Personnel (HCP) provided the necessary foot care per the physician's orders, and nursing assessments, for one of two sampled residents (Resident 1), who had been admitted to the facility for physical therapy post surgery of a fractured left ankle and was at risk for poor circulation (blood flow) because of comorbidities (two or more diseases), diabetes (high blood sugar) and on [CONDITION(S)] (a procedure to divert blood to a machine to remove waste products and excess fluid from the blood when the kidneys stop working properly). […]

• No harm, potential for more than minimal, widespreadF812Apr 16, 2026

  Based 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.A colander was found in the ready to use area with dried food stuck to the base and inside openings and 3 pans were found with peeling/flaking of cooking surfaces.10 Plastic… […]