Health inspection·April 15, 2025

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. Based on interviews and record reviews, the facility failed to implement their policy to immediately report an allegation of abuse, for one resident out of three sampled residents (Resident 1), when Resident 1 notified staff of an allegation of abuse on 4/13/25 but was not reported to California Department of Public Health (the Department) until 4/15/245. This failure had the potential to leave Resident 1 vulnerable to further harm or abuse, delay the investigation and corrective actions to address the allegation of abuse. Findings: On 4/15/25, the Department received a report from the facility which indicated Resident 1 accused Certified Nursing Assistant A (CNA A) of sexually abusing her. During an interview on 4/15/25, at 1:45 PM, the Administrator stated the incident was reported to him sometime around 4 PM on 4/14/25. During an interview on 4/15/25, at 3:10 PM, CNA A stated while he was taking care of Resident 1 with CNA C on 4/13/25, Resident 1 accused him of raping her. CNA A stated he reported the incident to Licensed Nurse B (LN B) but was not aware if LN B reported the allegation of abuse to anyone. A review of staffing assignment indicated both CNA A and CNA C worked the afternoon shift on 4/13/25. During a follow-up interview on 4/15/25, at 3:33 PM, CNA A on speaker phone and in the presence of the Director of Nursing (DON) stated, on 4/13/25 Resident 1 had accused him of raping her. CNA A stated he reported the incident to stated LN B who removed Resident 1 from his resident assignment. During an interview on 4/15/25 at 3:54 PM, CNA C stated Resident 1 had a violent reaction to CNA A when he joined her to care for Resident 1on 4/13/25. Resident 1 had told CNA C that he , indicating CNA A, had raped her and was going to kill her. CNA C stated CNA A also heard Resident 1's allegation. CNA C added she heard CNA A report the incident to LN B on 4/13/25 and LN B then removed Resident 1 from CNA A's assignment. During an interview on 4/15/25 at 4:01 PM, the DON confirmed, LN B was supposed to report to her or to the Administrator immediately after the incident was reported to her but had not. A review of the facility's policy titled, Elder and dependent adult abuse prevention, (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: 555268 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 555268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spring Lake Village 5555 Montgomery Drive Santa Rosa, CA 95409 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)