Health inspection·June 13, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm [DATE] indicated DNR with Full Treatment (mechanical ventilation and cardioversion). Licensed Staff C stated this is why she performed the CPR on Resident 1. Licensed Staff C queried what the risk to resident safety are if an outdated POLST is left on the front of Resident 1's Chart. Licensed Staff C stated, she thinks that the latest wishes of the resident and / or Resident representative would not be honored as they should. Residents Affected - Few During an observation and record review of Resident 1's medical record, indicated there was a prior POLST dated, [DATE], for Resident 1 that indicated in Box B, DNR with Full Treatment. Box D of the POST was signed by Legally recognized decision maker 1 and MD 1. During an interview with Unlicensed Staff D, on [DATE] at 2:15 p.m., Unlicensed Staff D stated, she is the manager of the facilities Medical Records Department whose job it is to place the resident's POLST form in the front of the hard copy of the chart where it is easily accessible. Unlicensed Staff D stated, she was on vacation at that time and the most recent version of the POLST never made it into Resident 1's chart. Unlicensed Staff D then stated, she was not on vacation, but doesn't understand how the most recent POLST did not make it to Resident's 1 Hard copy of the chart. During an interview with the DSD, on [DATE] at 2:25 p.m., DSD queried if she was aware of the POLST policy. DSD stated, she was aware of the POLST policy. DSD queried for the in-services that she performed for the nursing staff in the last 3 months. No in-services for nurses were completed by the DSD for the facility's POLST Policy, DNR policy or Crash Cart policy and procedures. During an interview with the DON on [DATE] at 2:40 p.m., DON was queried why the latest POLST was not in the front of the chart for Resident 1. DON stated, she knows it is the facility's policy to keep the latest POLST in the front of the hard copy of the chart. DON stated, she is unaware as to how the latest POLST for Resident 1 was not in the front of the hard copy of the chart when Resident 1 expired. During a review of the DSD's job description, titled, Director of Staff Development, updated 2015, indicated, Essential Duties and Responsibilities, 5. Assists in the planning and coordination of training programs for all departments within the facility to respond to identified problem areas, service quality or to teach procedures or methods. 7. Provide-specific orientation to Health Center nursing staff including completion of the clinical skills checklist. 20. Assumes a proactive role in resolving resident issues & concerns related to assigned areas of responsibility. During a review of the facility's policy and procedure titled, Do Not Resuscitate Order Revised [DATE], indicated, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a DO NOT Resuscitate Order in effect. 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident' medical record. 6. The Interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. 7. The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. 8. Inquiries concerning do not resuscitate orders / requests should be referred to the administrator, director of nursing services, or to the social services director. During a review of the facility's policy and procedure titled, Resident Rights Guidelines for All Nursing Procedures Revised 2010, indicated, 1. Prior to having direct-care responsibilities for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 2 of 3 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 06/13/2024 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete residents, staff must have appropriate in-service training on resident rights, including: C. Resident notification of rights, services and health/medical condition, F. Resident right of refusal (medication and treatments), H. Resident freedom of choice, I. Resident/Family participation in care planning. During a review of the facility's policy and procedure titled, Advance Directives Revised [DATE], indicated, H. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form-a form designed to improve patient care by creating a portable medical order from that records patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patients current medical condition into consideration. Refusing or Requesting Treatment 1. The resident has the right to refuse medical or surgical treatment, whether or not he or she has an advance directive. A. A resident will not be treated against his or her own wishes. B. Residents who refuse treatment will not be transferred to another facility unless all other criteria for transfer are met. C. The resident's refusal does not absolve facility staff from providing other care that allows him/her to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. 2. Depending on the state requirements, the legal representative may also have the right to refuse or forego treatment. 3. If the resident or representative refuses treatment, the facility and care provider will: C. Document specifically what the resident/representative is refusing. 7. The Staff Development Coordinator is responsible for scheduling training regarding advance directives for newly hired staff members as well as scheduling annual advance in-services to ensure that the staff remains informed about the residents' rights to formulate advance directives and facility policy governing such rights. Event ID: Facility ID: 555836 If continuation sheet Page 3 of 3