Health inspection·March 24, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure three out of five sampled residents (Resident 2, Resident 3, and Resident 4) were provided with a homelike environment when Resident 1 would wander into their rooms, rummage through their personal belongings and take them. This failure caused emotional distress and feelings of anger for Resident 2, Resident 3, and Resident 4. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of polyneuropathy (a condition in which multiple nerves throughout the body are damaged), vascular dementia (type of brain damage caused by reduced blood flow to the brain causing a progressive state of decline in mental abilities), and Alzheimer ' s Disease (a disease characterized by a progressive state of decline in mental abilities). A review of a facility document titled Order Summary Report, dated 2/20/25, indicated a Psych Referral PRN [as needed]. A review of a facility document titled Care Plan Report, dated 3/4/25, indicated Resident 1 was at risk to wander throughout the facility attempting to enter other resident ' s rooms without permission. Constantly grabbing other belongings from staff and nurse station. A review of facility physician notes, dated 3/21/25, indicated Resident 1 was previously in locked-down memory care unit .pt is anxious .also intermittently wander and result in aggressive interaction with other patients/residents. During a phone interview, on 3/24/25, at 9:10 a.m. with the complainant (CMP), the CMP stated multiple family members attended the last meeting held on 3/17 and complained about the lack of action the facility has taken to prevent Resident 1 from entering other resident rooms and taking their belongings. CMP stated other residents are getting pissed at her [Resident 1] for taking their stuff. Most of the time, they are not getting anything back. CMP further stated [Resident 1] was witnessed swinging at another resident recently. When CMP met with the Administrator (ADM) about her concerns with the lack of facility action to subdue the behavior of Resident 1, the ADM stated, What would you like me to do? During a phone interview, on 3/24/25, at 9:21 a.m., the Ombudsman (OM) stated she had received Page 1 of 3 055854 055854 03/24/2025 Santa Rosa Post Acute 4650 Hoen Avenue Santa Rosa, CA 95405

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 055854 Page 2 of 3 055854 03/24/2025 Santa Rosa Post Acute 4650 Hoen Avenue Santa Rosa, CA 95405

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 . 055854 Page 3 of 3