Health inspection·March 24, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some several complaints from the facility residents about the behavior of Resident 1. OM stated she spoke to the ADM regarding the distress and anger the residents and family members were feeling about Resident 1 ' s behavior on 3/17/25, 3/19/25 and 3/21/25. OM stated the ADM told her We don ' t provide 1:1 sitters. During an interview on 3/24/25, at 10:27 a.m., Resident 2 stated everyone has had it with her .we have had it with watching our doors, she just comes in and takes our stuff. She will sometimes go when you tell her but most of the time, she flips you off or says ' fuck you ' .it ' s hard to relax and enjoy reading a book, watching TV or enjoy relaxing because you are just waiting for her to come in. One time, when I woke up from a nap, a whole bowl of candy that I had out on my dresser was completely gone .They [the Administrator] are just not doing anything about this. During an interview on 3/24/25, at 10:35 a.m., Resident 3 stated I have C Diff (Clostridium Difficile-a highly contagious bacteria that causes severe diarrhea) and she [Resident 1] comes in here touching my stuff. I don ' t want her spreading my germs all over the place getting everyone else sick .It makes me mad that she is allowed to do this. During an observation, on 3/24/25 at 10:47 a.m., Resident 1 attempted to enter room [ROOM NUMBER] when one of the residents in the room loudly yelled Get out of here! A staff member quickly approached Resident 1 and wheeled her away from the room. During a concurrent observation and interview, on 3/24/25, at 10:52 a.m., Resident 4 stated She [Resident 1] has taken 3 pairs of my glasses. They [administration] have only returned one, and I have no more left. Resident 4 stated the glasses are prescription and without them, he will be unable to read or watch TV. Resident 4 further stated She [Resident 1] also took my expensive razor . I am worried that she will find my black pouch with other valuables and take them too or other things like my cell phone. During the interview, Resident 4 became upset and was crying while he stated She ' s got me worried to the point I can ' t sleep for fear that she will come in and take my things. She has taken so much from me and everybody. During an observation, on 3/24/25, at 11:10 a.m., Resident 1 wheeled herself into room [ROOM NUMBER], left, and wheeled into room [ROOM NUMBER]. Residents within that room were yelling at Resident 1 to get out! A visitor was witnessed wheeling Resident 1 out of room [ROOM NUMBER] and down the hall towards her room. During an interview, on 3/24/25, at 11:15 a.m., Certified Nursing Assistant A (CNA A) stated Resident 1 was confused and likes to roam all the hallways of the facility but will get lost and thinks other residents ' rooms are hers. CNA A further stated Resident 1 .takes other residents ' items. If it ' s food, we let her have it because she normally has started eating it. If it is glasses or something else, we have to wait until she puts it down, otherwise she will get aggressive. We return things when they know who they belong to. During an observation, on 3/24/25, at 11:29 a.m., Resident 1 wheeled herself into room [ROOM NUMBER]. A CNA wheeled her out of the room immediately and left her in the hallway. Resident 1 then went in room [ROOM NUMBER], followed by room [ROOM NUMBER]. A CNA attempted to remove Resident 1, but she resisted stating This is my room and my stuff. During an interview, on 3/24/25, at 11:35 a.m., Licensed Nurse B (LN B) stated As far as I know, [Resident 1] has always wandered into others rooms .she does tend to take others items claiming they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055854 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055854 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Rosa Post Acute 4650 Hoen Avenue Santa Rosa, CA 95405 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 are hers .I have seen things in her room that I know are not hers. Level of Harm - Minimal harm or potential for actual harm During an observation, on 3/24/25, at 12:48 p.m., Resident 1 wheeled herself into room [ROOM NUMBER] which was unoccupied at the time, and opened the dresser drawers but did not take anything. She turned her wheelchair around and took a folded personal blanket from the foot of the bed and placed it on top of the pillow. Resident 1 then wheeled herself to room [ROOM NUMBER] and started picking up the items left on the bedside tray. Residents Affected - Some During an interview, on 3/24/25, at 1:08 p.m., the DON stated she was not made aware of Resident 1 ' s wandering and behavioral issues until she arrived at the facility. The DON stated she was aware the residents and family members were unhappy, but she was not sure how to address their concerns. I told the staff [Resident 1] needed to be watched. We are working on a plan to move her to a different facility, but she is [insurance type] pending . so we have to find a way for others to be tolerant of her behaviors. When asked about the psychiatric referral found in Resident 1 ' s physician orders, the DON stated that psych referrals are for all the admitted residents, not sure it would help in this case. I do not know if a psychiatrist has seen her. The DON stated a meeting was held on 3/21 and I know other residents are getting angry .not sure what to do .I told the family members we would reimburse for any missing items, just to contact me or the [ADM]. During a concurrent observation and interview on 3/24/25, at 2:23 p.m., LN C was observed removing Resident 1 out of room [ROOM NUMBER] and wheeling her back to her room. When asked about the frequency of removing Resident 1 from other residents ' rooms, she stated All day, every day .I understand how it makes the other residents upset. It would upset me too. During an interview, on 3/24/25, at 2:26 p.m., LN D was asked about the behaviors of Resident 1 to which she stated Our little wanderer? It would bother me if she kept coming in my room, especially if she was taking my stuff. During an interview, on 3/24/25, at 2:31 p.m., LN E stated I would be upset if she [Resident 1] kept coming in my room. It ' s not so much that she ' s going in the room, it ' s that she ' s grabbing things. I am always after her all day long to retrieve items she has taken, and you have to wait until she puts things down otherwise, she will hit you . It ' s not like we have eyes on her 24-7 .I have a lot of residents that she has taken things from. A review of the facility policy titled Resident Rights, dated 2001, indicated Employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to .be free from .misappropriation of property . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055854 If continuation sheet Page 3 of 3