Health inspection·December 9, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a unit used to measure pressure] continuous pressure.A review of Resident 1's wound care note titled, SNF Wound Care @ [at] [Facility name], dated 11/24/25, indicated Resident 1's abdominal wound measured 14.0 cm (centimeters-a unit of measure) x 10.0 cm x UTD [unmeasurable] after debridement (a medical procedure to remove dead, damaged, or infected tissue), with light serosanguineous drainage (a normal, watery, pale pink or reddish fluid from a healing wound, a mix of clear serum and a small amount of blood, indicating healthy healing).A review of Resident 1's facility Progress Notes, dated 11/25/25, indicated Social Services Director (SSD) presented Resident 1 and spouse (FM) with a Notice of Medicare Non-Coverage (NOMNC-a form Medicare providers must give beneficiaries when their Medicare-covered services are ending, informing them of their right to appeal the decision) on 11/27/25 for impending discharge on [DATE]. This note indicated when FM received this form, he stated, if she [Resident 1] discharges on 11/28/25 I will be bringing her straight back to the hospital and that's that.A review of Resident 1's facility document titled, Notice of Transfer or Discharge, dated 11/28/25, indicated Resident 1 was notified on 11/28/25 about impending discharge home on that same date. According to this document, the facility determined the reason for discharge was, The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by this facility. The form was signed by the SSD.A review of Resident 1's facility Progress Notes, dated 11/28/25, indicated SSD documented, this writer was approached by residents' [Resident 1's] spouse, resident and resident's spouse requesting transportation to be arranged for discharge, this writer arranged transportation for resident to discharge to home.During a phone interview on 12/04/25 at 2 p.m., FM stated the facility attempted to send Resident 1 home on [DATE], but he called an ambulance to take Resident 1 directly to [General Acute Care Hospital-GACH] instead because they lived in a recreational vehicle (RV). FM explained the RV had stairs and the doors/insides could not safely accommodate Resident 1's wheelchair. FM stated Resident 1 was initially informed of discharge because Medicare insurance coverage was ending on 11/20/25 but was granted a few more days after an appeal. FM stated he also appealed the next discharge date of 11/27/25 (Medicare coverage was ending on that date), however it was denied by the Medicare insurance company. FM stated the facility did not inform him of an opportunity of a second level appeal (when a Qualified Independent Contractor (QIC), contracted by CMS (Centers for Medicare and Medicaid Services) conducts a reconsideration in Medicare eligibility and coverage) for Resident 1's continued skilled nursing care after 11/27/25. FM also stated the facility did not try to find any alternatives for Resident 1's aftercare or offer any alternative means of staying in the facility, other than private pay options which FM stated he could not afford. FM stated he informed the facility of these difficulties each time the facility attempted to discharge Resident 1, including FM's inability to get after-care for Resident 1, and that he did not have the money to pay for Resident 1's continued stay at the facility without Medicare payments. At no time prior to Resident 1 or FM receiving the facility Notice of Transfer of Discharge on 11/28/25 had Resident 1 accumulated any unpaid facility charges.During a concurrent interview and record review on 12/04/25 at 2:31 p.m. with SSD, he stated Resident 1's Medicare insurance coverage would initially end on11/20/25, but an appeal for continued care and coverage was granted. A review of Resident 1's NOMNC, signed by Resident 1 on 11/25/25, indicated a new Medicare insurance end-date of 11/27/25, for which another appeal was filed for continued skilled nursing services. A review of a document titled, Beneficiary and Family Centered Cared Quality Improvement Organizations (BFCC-QIO-designed to help Medicare beneficiaries who have a complaint about clinical quality or want to appeal a healthcare provider's decision to discharge them from the hospital or discontinue other types of services) Determination Letter, from [Insurance company], dated 11/27/25, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 2 of 4 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 12/09/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated Resident 1's last day of paid skilled nursing services would be 11/27/25. The denial reason documented indicated Resident 1 had not shown any further progress with therapy, and no skilled nursing services were needed to maintain function or prevent decline. The SSD stated a second level appeal would have allowed Resident 1 to remain in the facility during the second level appeal process, but he, may have missed offering Resident 1 that option. SSD stated Resident 1 would have benefited from additional skilled nursing services, but FM did not or could not afford to pay for this care on his own. SSD stated he did not arrange aftercare services or referrals for Resident 1, because FM told SDD that Resident 1 would be taken directly to an acute care hospital after discharge instead of home.A review of Resident 1's facility Prescriber Order Note, dated 11/28/25, indicated the facility physician (PHY) documented the following order, May D/C [discharge] home with meds [medications] PT/OT/RN on 11/28/25.A review of Resident 1's facility Progress Notes, dated 11/28/25, indicated [Resident 1] left the facility at 1230 [12:30 p.m.] via comfort care transport accompanied by husband.During an interview on 12/04/25 at 12:30 p.m., with PHY, he stated because of the difficulties surrounding Resident 1's discharge environment and the issues regarding Resident 1's after care, he considered it was a safe decision to send Resident 1 back to [GACH] rather than home. Yet, his discharge note (above) dated 11/28/25 indicated, May D/C home with meds.A review of a facility document for Resident 1 titled, Discharge Instruction, dated 11/28/25, indicated no appointments were listed as scheduled with Resident 1's primary care physician or in-home care services. Sections of the discharge instructions regarding special training/instructions for dressing changes, wounds, current treatments/therapies, and special observations were left blank. The skin condition section indicated Wound vac is disconnected on discharge and MD is aware. Resident 1 or FM's signature was not on this discharge document.A review of Resident 1's General Acute Care Hospital (GACH) document titled, Acute Care Surgery Consultation, dated 11/28/25, indicated Resident 1, had a wound VAC in place which is not connected to anything, this was removed and there is an underlying open wound about 15 x 10 cm with pink granulation [the new, healthy, pinkish-red tissue that fills a wound during healing] tissue. This document was from the GACH that received Resident 1 after discharge from the nursing facility.A review of Resident 1's GACH document titled, Hospitalist History and Physical, dated 11/29/25, indicated Resident 1 was admitted to [GACH] on 11/28/25. This document indicated, .Patient [Resident 1] had bowel resection [surgery to remove part of the small or large intestine] on 10/20/2025 with skin dehiscence and wound VAC was in place. She [Resident 1] does not remember when it started malfunctioning. She says that her wound VAC was replaced earlier today. Surgery was consulted apparently wound VAC was not connected.During an interview on 12/04/25 at 1:20 p.m., with the facility Administrator (ADM) and Operations Manager (OPM), ADM stated the reason Resident 1 was discharged from the facility was because Medicare insurance was ending. ADM and OPM both stated it would have been clinically appropriate for Resident 1 to remain in the facility had Medicare insurance coverage continued.During an interview on 12/04/25 at 1:21 p.m. with the ADM and the OPM, the ADM stated Resident 1's wound vacuum was removed just prior to discharge on [DATE] at 12:30 p.m., because it was a facility-owned medical appliance, and a new one should have been ordered for replacement by the SSD as part of discharge planning. When it was discussed that the SSD did not make any post-discharge arrangements for Resident 1, OPM stated, that was a misstep on [SSD's] part.During a phone interview on 12/10/25 at 3 p.m., with the facility's Director of Nursing (DON), the DON stated discharge planning was crucial for residents because it prevented harm. The DON stated the facility should have ensured Resident 1 was discharged to a safe environment, and the facility was responsible for making referrals or appointments for ongoing medical/nursing care for discharged Residents. The DON stated in cases where a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555836 If continuation sheet Page 3 of 4 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 12/09/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident was transferred to another facility or a GACH, the facility should send thorough documentation and make a verbal nurse-to-nurse report from the facility to the receiving hospital to communicate routine and special instructions. The DON stated the SSD was primarily responsible for ensuring discharges were made appropriately and completely. When asked why transfer paperwork was not sent to [GACH] for Resident 1, the DON replied, everyone thought that [Resident 1] was discharging home, yet FM had clearly communicated to SSD on multiple occasions that Resident 1 would go directly to a GACH from facility upon discharge.During an interview on 12/11/25 at 1:50 p.m. with a GACH (to which Resident 1 was sent on 11/28/25) Wound Care Nurse (WCN), the WCN stated he had cared for and had personal knowledge of Resident 1's wound care hospital course. The WCN stated Resident 1 came to the GACH on 11/28/25 with a wound vac dressing which was not hooked up to suction, and per Resident 1's statement, was malfunctioning prior to this. The WCN stated surgery was performed on 11/28/25 at 9:20 p.m. to remove Resident 1's 3M foam dressing (key component for VAC Therapy to promote healing by removing fluid, reducing swelling, and encouraging tissue growth in various wounds) that should never have been left unattached to suction for more than two hours. The WCN stated because many hours had passed between when Resident 1 left the facility and when the dressing was surgically removed, Resident 1 was at risk for harm from delayed wound healing and infection. The WCN stated an attempt to restart wound Vac therapy on 12/8/25 was unsuccessful, thus another possibly slower healing type of wound care was immediately initiated for Resident 1.A review of the facility's current Policy and Procedure (P & P) titled, Transfer and Discharge Documentation, dated 1/2019, indicated, When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider.Each resident will be permitted to remain in the facility, and not be transferred or discharged unless b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility. e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at this facility.A review of the facility's current P & P titled, Transfer or Discharge Notice, dated 2001, indicated, In determining the transfer location for a resident, the decision to transfer to a particular location will be determined by the needs, choices and best interests of that resident.A review of a document provided by the facility, titled, Patient guide for 3M™ V.A.C.(R) Therapy with 3M™ V.A.C.(R) Peel and Place Dressing, copyrighted 2024, indicated Keep the therapy unit on. If off for more than two hours, the dressing will need to be changed. Event ID: Facility ID: 555836 If continuation sheet Page 4 of 4