Health inspection·April 25, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement its abuse and change of condition policy for two residents (Resident 1 and Resident 2) of four sampled residents when the facility staff did not: Residents Affected - Few Notify the residents' family representatives and physicians, Document an Interdisciplinary Team (IDT- a multidisciplinary team who ensures a comprehensive and coordinated approach to patient care) note, and Initiate care plans to provide person-centered care for both residents for an allegation of resident-to-resident abuse. This failure decreased the facility's potential to prevent recurrence of abuse between Resident 1 and Resident 2. Findings: A review of a investigation summary report sent to the California Department of Public Health (CDPH) on 4/14/25 indicated, On 4/9/25, the [Resident 1] reported to the staff that her roommate [Resident 2], came to her bed around midnight, tore the blankets off the bed, began commanding that she go to the bathroom, and then struck her on the face and chest several times. During an interview on 4/25/25 at 9:10 a.m., the Administrator stated the permanent Director of Nursing (DON) was on leave and not currently working at the facility. A review of an electronic-mail sent to the Surveyor on 4/25/25 at 12:41 p.m. from the Director of Medical Records (DMR) indicated there was no documented evidence of family representative notifications, physician notifications, Special Incident Reports (SIR- a form that documents critical and unexpected events that could impact a patient's health or safety), or IDT notes found in Resident 1 or Resident 2's charts regarding the allegation of abuse on that was reported on 4/9/25. During an interview on 4/25/25 at 2:40 p.m., the Director of Staff Development (DSD) stated licensed staff were expected to notify residents' representatives and physicians of resident-to-resident abuse allegations. The DSD also stated staff were also required to complete a SIR of the allegation and document an IDT note in each residents' chart. During a phone interview on 4/25/25 at 2:48 p.m., Licensed Staff A (LS A) stated Resident 1 notified her of the resident-to-resident abuse allegation on 4/9/25 at around 6 a.m. LS A stated she wrote (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055854 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 04/25/2025 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)