Health inspection·December 5, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure an abuse allegation was reported to the appropriate agencies within 2 hours after an allegation was made for one out of two sampled residents (Resident 1). This failure could put the resident's safety at risk and potentially hinder the ability to properly investigate and protect the resident due to a lack of time to intervene effectively. Findings: A review of Resident 1's face sheet (demographics) indicated he was admitted to the facility on [DATE] with a diagnoses of Muscle Weakness and Anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). Resident 1's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 10/7/24 indicated Resident 1 had intact cognition (memory). Resident 1's MDS also indicated he was dependent on staff with his care except for eating and oral hygiene on which needed substantial assistance from staff. A review of the facility initial report dated 11/14/24 indicated this verbal abuse allegation occurred on 11/12/24. A review of Resident 1's Progress note dated 11/12/24 at 8:00 p.m. indicated Resident 1's brother-in-law approached Licensed Staff D to complain about Unlicensed Staff B working with Resident 1 of using vulgar words. During an interview on 12/4/24 at 11:15 a.m., Unlicensed Staff A stated, using vulgar words on residents or telling resident to f--- off or f--- you was a verbal abuse and should have been reported right away. Unlicensed Staff A stated all abuse allegations had to be reported within 2 hours after learning about the allegation. Unlicensed Staff A stated not reporting abuse allegations timely could put the resident's safety at risk. During an interview on 12/4/24 at 11:32 a.m., Licensed Nurse (LN) B stated using vulgar or swear words or telling a resident to f--- off or f---you were considered a verbal abuse and should be reported to the Ombudsman (assist in the resolution of problems and advocate for the rights of residents of long-term care facilities), the state and local police department (PD) within 2 hours after an allegation was made. LN B stated not reporting abuse allegation within 2 hours put residents' safety at risk. LN B stated not reporting an abuse allegation timely could also result to resident feeling nobody believed their complaint and could be distrustful to staff. LN B stated reporting the abuse allegation timely within 2 hours not only protect the resident involved but the rest of the facility's (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: 056259 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 056259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northvine Postacute Care 446 Arrowood Dr Santa Rosa, CA 95407 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)