Health inspection·July 25, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm resident he stated Yes. When asked how the plan of care was communicated to the staff, he stated the CNAs were shown and told what to do. Review of Resident 1's care plan indicated Resident 1 had an unwitnessed fall in her room on 6/16/24 and did not show specific interventions or monitoring to prevent falls from occurring. This fall could have potentially caused the L3 fracture and pain, but there was no documemtation to support this finding. Residents Affected - Few During an observation and concurrent interview on 7/22/24 at 11:30 a.m., Resident 1 was observed sitting in a wheelchair in the activity room. When attempting to interview Resident 1 she could not verbalize or form words or sentences to questions asked; movement was weak to her right side. When asking the resident if she had pain, she attempted to answer the question, but words were scrambled and incomprehensible. She shook her head No. A review of Resident 1's Minimum Data Set 3.0 (MDS- a standardized assessment and screening tool) dated June 8, 2024, did not show a complete assessment for level of cognition (mental process of thinking and understanding) was conducted the assessment form was missing data points and did not include a Brief Interview for Mental Status (BIMS) summary score in-order to confirm if Resident 1 was able or unable to make herself understood or if she was able to understand others. A review of Resident 1's fall assessment evaluation dated June 9, 2024, was also incomplete with missing data points and showed no risk level for falls or interventions to assist the resident with ambulation and transfers. During an interview on 7/22/24 at 11:45 a.m. the Charge Nurse was assigned to take care of Resident 1 and was asked what interventions were in place to help prevent falls for the resident. She stated all residents had gait belts that Physical Therapy (PT) used when walking residents, we bring fall risk residents to the nurse's station or to the activity room to keep a watch on them. When asked if the interventions were care planned, she stated she would have to look at the care plan. Review of the care plan did not show specific interventions for fall risk were listed in the care plan nor were any updates made to the care plan post hospitalization. When asking the charge nurse how she kept residents safe from falls she stated we do frequent checks and keep the residents at the nurse's station. When asked if the monitoring of falls was documented in the progress notes or on the Treatment Administration Record (TAR), she stated it usually was. When reviewing the TAR and care plan no interventions or monitoring was listed for Resident 1. During an interview on 7/22/24 at 12:00 noon, the DON was asked how residents were kept safe from falls. She stated we post signs at the bedside that lets staff know how to move residents out of bed. When asked what interventions were put in place to monitor Resident 1 for falls, she stated she would have to look at the care plan. Review of Resident 1's care plan showed no specific interventions were listed on the care plan to prevent falls for Resident 1. The DON stated to the charge nurse that monitoring interventions for falls should be added to the care plan for Resident 1. The DON showed a copy of the Safety-First sign posted on the wall next to Resident 1's bed with instruction that indicated, resident transfers required, moderate and maximum assist and when standing pivot transfer to the left, right side is weak. A review of the facility's policy and procedure titled, Care Plans- Comprehensive Person-Centered with a revision date of December 2016, indicated: 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; h. Incorporate risk factors associated with identified problems; . m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels .13. Assessment of residents are ongoing and care plans are revised as (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 07/25/2024 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 0656 information about the resident and the resident's condition change. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 3 of 3