Health inspection·July 28, 2025

F 0658 Level of Harm - Actual harm Residents Affected - Few skin assessments prior to or after [DATE] for a total of eight missed weekly skin assessments. A review of Resident 1's Progress Notes dated [DATE] at 1:49 p.m., indicated, While in the process of cleaning [Resident 1's] wound to better view base and surrounding area.observed.lifting of the skin. Upon further assessment.there was movement at the lifted spot. When.[Licensed Nurse 1 (LN 1)] wiped the area.saw a small white larvae [sic] looking bug coming up from the tip of the wound.Repetitive motion of cleaning the wound with warm water caused several more small ones to appear. A review of Resident 1's Progress Notes, dated [DATE], at 3:51 p.m., indicated Resident 1 was transferred to the hospital for evaluation of right great toe wound. A review of the hospital document titled Emergency Department [ED] Provider Note dated [DATE], indicated Resident 1 was evaluated and admitted to the hospital for Maggots on right first toe, open chronic wound and necrosis [dead or dying tissue]. A review of Resident 1's hospital document titled Computed Tomography [CT scan-medical imaging procedure using Xray and computers to obtain detailed cross-sectional images of the body] Foot Right with contrast [a substance used to make images clearer and more detailed] dated [DATE] indicated, Findings are concerning for septic arthritis [serious joint infection caused by bacteria] and gangrenous osteomyelitis [tissue death from a severe infection of the bone]. Soft tissue swelling of the great toe. A review of a hospital document titled Surgery Information dated [DATE] at 1:25 p.m., indicated Resident 1 had surgery for Partial First Ray Resection Right Foot [a surgical procedure when part of the first metatarsal [a group of five long bones in the midfoot] and the big toe are removed due to infection or gangrene [dead tissue]. During an interview on [DATE] at 10:44 a.m., LN 2 stated she remembered Resident 1 received wound care with betadine (a topical antiseptic used to prevent and treat minor skin infections). LN 2 stated, For some reason, [Resident 1] was removed from [the Wound Consultant's (WC- a healthcare professional who specializes in the assessment, treatment, and management of acute and chronic wounds)] service, but I don't know why. His [Resident 1] wound was still bad. During a concurrent interview and record review on [DATE] at 12:50 p.m., the Wound Nurse (WN) confirmed there was one weekly skin assessment documented on [DATE] and that it should have been completed and documented every week. She stated she collaborated with the WC during weekly rounds and remembered seeing Resident 1 twice before he was discharged from the WC's service, though the wound was still present. In a further interview at 2:09 p.m., the WN confirmed there were gaps in obtaining doctor orders when the wound treatment orders expired which left Resident 1's wound untreated on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. During an interview on [DATE] at 2:11 p.m., the Director of Nursing (DON) stated the weekly skin assessments should be completed by the WN for any resident with skin issues or wounds. The DON confirmed one weekly skin assessment was completed during Resident 1's entire stay at the facility and stated, It should have been done weekly. During an interview on [DATE] at 1:59 p.m., MD 1 stated, Missed wound treatments would affect wound healing and may attract more flies as compared to a clean wound. During an interview on [DATE] at 3:09 p.m., the DON stated nursing staff must call the doctor about physician orders that cannot be followed, implemented, or need renewal. The DON stated, The ball was dropped by the WN. It [Resident 1's recent maggot infestation] was heartbreaking and hope it never happens again. A review of the facility's document titled Physician Orders dated [DATE] indicated, Physician orders are obtained to provide a clear direction in the care of the resident. A review of The American Nurse's Association's website emphasized the critical role nurses play in implementing.physician orders.while ensuring orders are carried out safely and effectively. https://www.nursingworld.org/A review of the American Medical Directors Association (AMDA) article titled Pressure Ulcers in the Long-Term Care Setting published in 2008 indicated, .Inspect the patient's skin at least once weekly.Assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 2 of 7 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 07/28/2025 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)

F 0658 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete by members of the interdisciplinary team [a group of healthcare professionals from different fields who collaborate to provide comprehensive patient care] can help to distinguish ulcers that are caused by pressure, diabetes, ischemia [reduced blood flow], or venous disease [a condition which causes pooling of blood in the legs], each of which is evaluated and managed differently.weekly reassessment and documentation of ulcer characteristics is recommended. More frequent reassessment may be necessary for ulcers that are not responding to treatment or are worsening despite treatment. Event ID: Facility ID: 056259 If continuation sheet Page 3 of 7 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 07/28/2025 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)

F 0687 Provide appropriate foot care. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of hemiplegia (a condition characterized by paralysis of one side of the body), expressive language disorder (a communication disorder impacting a person's ability to communicate their thoughts), Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1's History and Physical, dated 11/1/24, indicated Medical Doctor 1 (MD 1) planned for a wound care consult, currently foam dressing to right dorsal [top of foot] foot ulcer every Monday, Wednesday, Friday. MD 1 noted the wound measurement taken on 10/4/24 was, 1 centimeter [cm-a unit of measure] x 1cm x 0.2cm. A review of the Physician's Progress Notes dated 5/16/25, indicated Resident 1 had an infection in his right great toe and was ordered antibiotics, warm compresses as needed and to cleanse the area with normal saline (a solution of salt and water used in medicine to clean wounds), apply betadine (antiseptic used to treat skin infections) and leave wound open to air. A review of a wound consultant document titled Preliminary Wound Report, dated 6/2/25 indicated Resident 1 had, necrotic [tissue that is dead or dying] right great toe with intact black eschar [a thick crust like area of dead tissue that forms on the skin].peripheral pulses [the beats of the heart felt in the extremities when touched ] non-palpable [pulse cannot be felt]. Extremities cold to touch. Great toe nail [sic] is almost detaching. Referral to podiatrist [a doctor specializing in treatment of the foot]. A review of Resident 1's Order Summary Report, dated 6/6/25, indicated a podiatry consult was ordered. A review of a wound consultant document titled Preliminary Wound Report, dated 6/9/25 indicated, Black eschar stable and dry. Paint wound with betadine and leave open to air. Follow up with Podiatrist.to [discharge from services] today. A review of Resident 1's Progress Notes dated 6/13/25 at 11:09 p.m., indicated Resident 1's right great toenail came off. A review of Resident 1's Progress Notes dated 6/14/25 at 10:05 p.m., indicated, Wound to [Resident 1's] right great toe is worsening.Will notify [Wound Consultant ((WC) a healthcare professional who specializes in the assessment, treatment, and management of acute and chronic wounds)] with further information. A review of Resident 1's Progress Notes, dated 7/21/25, at 1:49 p.m., indicated, While in the process of cleaning [Resident 1's] wound to better view base and surrounding area.observed.lifting of the skin. Upon further assessment.there was movement at the lifted spot. When.[Licensed Nurse 1-LN 1] wiped the area.saw a small white larvae [sic] looking bug coming up from the tip of the wound.Repetitive motion of cleaning the wound with warm water caused several more small ones to appear. A review of Resident 1's Progress Notes, dated 7/21/25 at 3:51 p.m., indicated Resident 1 was transferred to the hospital for evaluation of right great toe wound. A review of the hospital document titled Emergency Department (ED) Provider Note dated 7/21/25, indicated Resident 1 was evaluated and admitted to the hospital for, Maggots on right first toe, open chronic wound and necrosis [death of cells and living tissue]. A review of hospital document titled Computed Tomography [CT scan-medical imaging procedure using Xray and computers to obtain detailed cross-sectional images of the body] Foot Right with contrast [a substance used to make images clearer and more detailed], dated 7/21/25, indicated, Findings are concerning for septic arthritis [serious joint infection caused by bacteria] and gangrenous osteomyelitis [tissue death from a severe infection of the bone]. Soft tissue swelling of the great toe. A review of a hospital picture of Resident 1's right great toe wound, taken on 7/22/25, at 9:43 a.m., depicted Resident 1's right great toe with approximately 3.5 cm of black eschar. A small amount of light-yellow discharge was seen oozing from the center of the wound. Resident 1's toenails to healthy digits were yellowed, stained and long. A review of a hospital document titled Surgery Information, dated 7/25/25 at 1:25 p.m., indicated Resident 1 had Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 4 of 7 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 07/28/2025 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)

F 0687 Level of Harm - Actual harm Residents Affected - Few surgery for, Partial First Ray Resection Right Foot [a surgical procedure when part of the first metatarsal (a group of five long bones in the midfoot)] and the big toe are removed due to infection or gangrene [dead tissue]. During an interview on 7/28/25 at 10:15 a.m., the Wound Nurse (WN) remembered the last orders placed for Resident 1's wound care was to, wash with soap and water then leave open to air. During an interview on 7/28/25 at 10:44 a.m., LN 2 stated she remembered Resident 1 had initially received wound care with betadine, then it was changed to soap and water. LN 2 stated, For some reason, Resident 1 was removed from [WC's] service, but I don't know why. [Resident 1's] wound was still bad. During an interview on 7/28/25 at 2:11 p.m., the Director of Nursing (DON) stated the WN should complete the weekly skin assessments for any residents with skin issues or wounds. The DON stated if assessments were completed weekly, the deterioration of the wound might have been caught and addressed. During an interview on 7/30/25 at 1:59 p.m., MD 1 stated he was worried about bacteria forming in Resident 1's wound when it was covered, so he ordered a different treatment with instructions to leave the wound open to air. MD 1 decided to change the treatment to soap and water on 7/3/25 and continue to leave the wound open to air. MD 1 stated he wanted the wound dry, thinking it would heal better. MD 1 stated he wrote two orders for a podiatry consult for Resident 1, as wound care was not his area of expertise. MD 1 also stated he had concerns about the wound healing knowing Resident 1 had poor circulation, which was another indication for a podiatry consult. MD 1 further stated Resident 1's insurance plan required a primary physician change to the same county to facilitate a podiatry consult for Resident 1's toe. MD 1 asked for assistance from the DON and the Social Services Director (SSD) to complete this task, but they were unsuccessful in doing so. MD 1 stated, There are always flies [in the facility], but I can't send every resident out who has a wound because of the flies. During an interview on 7/30/25 at 2:47 p.m., the SSD stated she became aware of the order to obtain a podiatry consult for Resident 1's right foot in early June. The SSD stated Resident 1's primary physician through his insurance provider was in a different county. The SSD stated Resident 1's insurance provider wanted Resident 1 to call them to change his primary physician to a local physician where he currently resided to facilitate a podiatry consult. The SSD stated she tried to call, but the insurance provider wanted to speak to Resident 1. The SSD stated Resident 1 then asked Family Member 1 (FM 1) to try and call him, but FM 1 reported she was told the same thing. The SSD stated Resident 1 refused to call the insurance provider himself because he was planning on returning to his residence up north. The SSD confirmed she did not inform MD 1 of Resident 1's refusal to call and she did not document this in Resident 1's medical record. During an interview on 7/31/25 at 9:18 a.m., MD 1 stated he became aware of the insurance barrier which prevented a podiatry consult on 7/11/25. MD 1 stated he spoke with Resident 1 and urged him to call the insurance provider to make the necessary changes. MD 1 stated Resident 1 agreed to call. During an interview on 7/31/25 at 1:54 p.m., FM 1 stated the facility notified FM 1 a change needed to be made with Resident 1's insurance provider at approximately the beginning of June 2025. FM 1 stated when FM 1 called the insurance provider, FM 1 was told there was no need to change physicians. FM 1 stated the insurance provider notified FM 1 that a bill for consulting services could be sent to Resident 1's documented county of residence. FM 1 denied the insurance provider told her they needed to speak with Resident 1. FM 1 then stated FM 1 called the SSD to inform her of this information, and the SSD became argumentative and told FM 1 this was incorrect. FM 1 stated FM 1 was unsure what happened after that and was distressed the podiatry consult never happened. FM 1 stated, Because of this lack of attention, six weeks later [Resident 1] had a toe amputation. During an interview on 7/31/25 at 2:31p.m., the Wound Consultant (WC) stated each resident in her service was endorsed to the WN, who rounded with the WC (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 5 of 7 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 07/28/2025 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)

F 0687 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete during her weekly treatment visits. After each visit, a treatment summary note is sent to the facility. The WC acknowledged she saw Resident 1 twice. The first visit was on 6/2/25 and a second time on 6/9/25, at which point Resident 1 was discharged from her services. The WC stated there was no need for her to continue following as the wound was stable as long as the wound was monitored closely and the eschar remained dry. The WC stated, If the wound gets wet or moist, the eschar would soak up the fluid, open up and cause an infection. My recommendation upon discharge from my service was to paint the wound with betadine and leave it open to air. Betadine has antiseptic properties and adds an additional layer of protection to wounds. During a concurrent interview and record review on 8/1/25, at 10:13 a.m., the DON stated the Interdisciplinary Team (IDT- a group of healthcare professionals from various disciplines who collaborate to provide comprehensive and coordinated care to residents) meetings for skin occurred on a weekly basis. Residents discussed at the IDT meetings are brought forth by the WN who assessed all residents with skin issues in the facility. The DON confirmed the first documented skin meeting to discuss Resident 1's great right toe was on 6/11/25. The recommendations from this meeting indicated, .continue with treatment per MD order, continue with weekly wound visit, RD [Registered Dietitian] consult and recommendation, monitor for signs/symptoms of infection and notify MD if any noted. The recommendations for the week of 6/18/25 were identical to the previous week. The DON acknowledged there was no evidence of an IDT meeting documented for 6/25/25. The DON further acknowledged the IDT meetings dated 7/3/25, 7/10/25 and 7/17/25 all indicated a treatment of soap and water to the wound to be continued in addition to the previously documented recommendations. The DON confirmed there was no documented evidence of Resident 1's wound worsening, and no documented evidence of a podiatry consult in the IDT skin meetings. On 8/1/25 a request for the facility's policy and procedure regarding IDT meetings was submitted to the DON. The DON stated there was no existing policy on IDT function.A review of a facility document titled Facility Assessment, undated, indicated the intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the resident require. The document further indicated wound care and wound care dressings are competency practices the facility offered.A review of recommendations titled Diabetic Wound Care from the American Podiatric Medical Association (APMA) dated 2025 indicated, Diabetes is the leading cause of non-traumatic lower extremity amputations in the United States.Foot ulceration precedes 85 percent of diabetes-related amputations.Once an ulcer is noticed, seek podiatric medical care immediately. Foot ulcers in patients with diabetes should be treated to reduce the risk of infection and amputation, improve function and quality of life, and reduce health-care costs.The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.To keep an ulcer from becoming infected, it is important to.keep the ulcer clean and bandaged.cleanse the wound daily, using a wound dressing or bandage.The old thought of ‘let the air get at it' is now known to be harmful to healing.The use of full-strength betadine.and soaking are not recommended, as these practices could lead to further complications. Event ID: Facility ID: 056259 If continuation sheet Page 6 of 7 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 07/28/2025 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)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an effective pest control program when flies were observed in common hallways and three resident rooms and four resident rooms had torn window screens.This failure decreased the facility's potential to prevent vector (an insect or rodent that transmits bacteria and viruses) borne illnesses for a census of 54 residents.During a concurrent observation and interview on 7/28/25 at 10:30 a.m., Resident 3 was lying in bed. Upon observation a half full and open urinal and partially eaten personal food items had been placed on Resident 3's bedside table. In addition, a strip of fly paper with 3 dead flies attached and a live fly was seen on Resident 3's curtain Resident 3 stated he had seen flies in his room, all the time. Upon inspection, Resident 3's window screen was torn.During a concurrent observation and interview on 7/28/25 at 10:51 a.m., Resident 4 was sitting on the edge of his bed. Resident 4 stated flies had randomly been entering his room throughout the day and made him annoyed. Resident 4 stated, They land on your head and buzz around. A dead fly was observed on his windowsill.During an observation on 7/28/25 at 10:55 a.m., a torn window screen was found in resident room [ROOM NUMBER].During an observation on 7/28/25, at 10:56 a.m., a fly was seen flying around in resident room [ROOM NUMBER].During a concurrent observation and interview on 7/28/25 at 10:58 a.m., in Resident 5's room, holes were observed in the window screen. Resident 5 stated, Flies come in here all the time. I told them about this.During an observation on 7/28/25 at 11:02 a.m., a torn window screen was found in resident room [ROOM NUMBER].During an interview on 7/28/25 at 1:30 p.m., the Maintenance Worker (MW) reviewed the maintenance binder and could not locate a work order to repair any window screens. The MW confirmed he did not proactively work on pest prevention.During an observation on 7/28/25 at 1:40 p.m., at the nurse's station, a fly was persistently buzzing around this surveyor.During an interview on 7/28/25 at 2:51 p.m., the Administrator (ADM) stated he was not aware of a fly problem in the facility. The ADM stated flies in the facility, pose a significant problem.A review of the facility's policy titled Pest Control, dated 1/18, indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056259 If continuation sheet Page 7 of 7