Health inspection·June 3, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview, and record review, the facility failed to protect residents from Resident 1's aggressive behavior when facility staff were not able to verbalize Resident 1's care plan for aggression. This failure resulted in Resident 1 becoming physically aggressive with two residents. Finding: On 5/20/25, the Department received a report from the facility that Resident 1 had hit Resident 2 when their wheelchairs became stuck together while in the hallway. During an observation on 5/27/25 at 9:44 a.m., Resident 1 was in her wheelchair holding a teddy bear and a piece of paper in the room where three male residents resided at the end of a hallway. Immediately outside the door to this room Licensed Nurse A was standing at the treatment cart. Across the hall, a housekeeping cart was in front of the doorway to a resident room. Resident 3, in her wheelchair, approached Licensed Nurse A and asked him to move the housekeeping cart so she could enter her room to use the bathroom. Resident 1 came to the doorway of the room she was in, and Licensed Nurse A asked Certified Nursing Assistant (CNA) B to move Resident 1 so the housekeeping cart could be moved. A second CNA (CNA C) came to help, and Licensed Nurse A told her Resident 3 was waiting to get into her room to use the bathroom. As CNA B pushed Resident 1 past the housekeeping cart, Resident 1 grabbed onto the handle of the cart and would not let go. Licensed Nurse A, CNA B, and CNA C all tried to get Resident 1 to release her grip on the cart. Resident 1 finally let go of the housekeeping cart and as CNA B pushed Resident 1 past CNA C, Resident 1 kicked repeatedly at CNA C's shins. Then, as CNA B pushed Resident 1 past Resident 3, Resident 1 attempted to kick Resident 3. On 5/27/25, the Department received a report from the facility that Resident 1 had struck Resident 3 with a piece of paper as she was passing her in the hallway. During a record review on 5/27/25 at 1:36 p.m., Resident 1's facesheet indicated an admission date of 11/13/24 and multiple diagnoses including Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions; memory loss and confusion are the main symptoms) and dementia with behavioral disturbance (changes in behavior and mood that can manifest as various symptoms, including agitation, aggression, anxiety, depression, and psychosis), among others. Review of Resident 1's care plan revealed a focus area, dated 12/27/24, The resident is experiencing increase in behavior problem manifested by, striking, spitting, grabbing out at others, refusing [medications], [treatment], care, throwing inanimate objects, cups of water, intrusiveness, persistent wandering, behaviors are difficult to redirect. Behaviors tend to escalate in the late afternoon and early evening hours. Further review of this focus area revealed an intervention, dated 3/6/25, Remove from (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 2 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 06/03/2025 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)