Health inspection·January 19, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 observation, interview, and record review, the facility failed to report one incident of resident abuse to authorities within the required two-hour time frame after the allegation was made. This failure to report an allegation of abuse within the Federally mandated requirement of two hours, had the potential to result in ongoing resident abuse and physical, mental, and /or emotional harm, and prevented the State Agency from conducting a timely investigation into the allegation. Findings: During a review of a report titled State of California Report of Suspected Dependent/Elder Abuse (SOC 341) dated 1/1/24, the SOC 341 indicated alleged abuse occurred on 12/30/23 with exact time unknown. The SOC 341 indicated telephone report made to the State Agency and Local Ombudsman on 12/31/23 at 12:15 p.m. and written report was faxed 1/1/24 at 10:49 a.m. During a review of a document titled SOC 341 General Instructions, dated 8/22, Instructions indicated, If the abuse occurred in a Long-Term Care (LTC) facility, was physical abuse, but did not result in serious bodily injury .send the written report to the local law enforcement agency, the local Long term Care Ombudsman Program (LTCOP), and the appropriate licensing agency within 24 hours of observing, obtaining knowledge of, or suspecting physical abuse. During a review of a document titled Abuse Allegation Follow-Up Report, dated 1/3/24, the Follow-Up Report indicated, On Sunday, December 31st, verbally reported this allegation to CDPH, and the local Ombudsman, and faxed the SOC 341 on Monday, January 1st, 2024. During an interview on 1/10/24 at 9:00 a.m., the Director of Nursing (DON) stated abuse incident occurred when alleged perpetrator (contracted vendor staff) sitter (a non-licensed staff hired to provide companionship and did not provide direct patient care) allegedly hit Resident 1 (R1). DON stated the alleged victim, R1, had a 1:1 sitter for safety reasons due to impulsivity and throwing things. The DON stated the alleged perpetrator no longer worked at the facility. The DON stated the Certified Nursing Assistant A (CNA A) reported the alleged abuse to the Director of Staff Development (DSD) on 12/31/23. During an interview on 1/10/24 at 9:45 a.m., the Administrator stated verbal report of abuse was made to the California Department of Public Health (CDPH) and the Ombudsman on 12/31/23. The Administrator was unable to provide time or documentation of verbal reporting. (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: 555836 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 555836 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbol Healthcare Center of Santa Rosa 300 Fountaingrove Parkway Santa Rosa, CA 95403 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)