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, Page 1 of 2 555268 555268 04/15/2025 Spring Lake Village 5555 Montgomery Drive Santa Rosa, CA 95409

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few investigation, protection, reporting and response , revised August 2022, indicated: All employees . are mandated reporters. Every employee who . is told by an elder or dependent adult that they have experienced behavior, . constituting physical abuse . shall report the known or suspected instance of abuse . immediately or as soon as practically possible . a report must be sent to the licensing agency .the California Department of Public Health . to report immediately, but not later than two hours (real clock time, not business hours) after forming the suspicion . 555268 Page 2 of 2