Arbol Healthcare Center of Santa Rosa

Inspectors wroteBased on interview and record review, the facility placed the life of one of three sampled residents (Resident 1) in danger when the facility discharged her from the facility when her insurance coverage ended. The facility did so fully aware Resident 1's family could not provide care at home, and without an appropriate discharge plan, transfer documentation, or follow-up aftercare. In addition, the facility physician discharge orders for Physical therapy (PT, the practice of improving mobility and flexibility through a variety of exercises and other treatments), Occupational Therapy (OT, a therapy that uses everyday life activities to promote health, well-being, and the ability to participate in important activities) and Registered Nursing Services, dated 11/28/25, were not followed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care that respected resident dignity for one out of 13 sampled residents (Resident 34) when: 1. Staff did not close Resident 34's privacy curtain and door when performing a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) and influenza (a respiratory infection caused by influenza virus) swab on Resident 34.2. Staff did not knock on Resident 34's room prior to entering. These failures had the potential for improper care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician obtained informed consents (a process in which residents are given important information of the possible risk and benefits of the use of psychotropic medications-drug affecting mental state) for one of thirteen sampled residents (Resident 38) when Resident 38 received Trazodone HCl (an antidepressant medication) and Escitalopram Oxalate (antidepressant medication) without an informed consent. This failure had the potential in Resident 38 receiving psychotropic medications without being fully informed of the risk and benefits of the medication being administered.

Inspectors wroteBased on interview and record review, the facility failed to complete a Physician Orders for Life Sustaining Treatment (POLST- is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) for one of thirteen sampled residents (Residents 33). This deficient practice had the potential for Resident 33 to receive unnecessary care and/or treatment services against the resident's wishes.

Inspectors wroteBased on interview and record review, the facility failed to provide a written Notice of Medicare Provided Non-Coverage (NOMNC-a notice that informs the beneficiary about the impending end of coverage and their right to appeal the decision) for one of thirteen sampled residents (Resident 42) when Medicare coverage was terminated. This deficient practice resulted in not protecting Resident 42's right to appeal the termination of Medicare Part A and possibly denying Resident 42's needed services.

Inspectors wroteBased on interview, and record review, the facility failed to maintain a safe and comfortable environment for three of 13 sampled residents (Resident 6, Resident 8 and Resident 18) when:1. Resident 6's inventory sheet was not updated and was inaccurately completed. This failure had the potential to result in Resident 16's belongings not being documented in the event of an alleged loss or theft.2. Fire alarm test was conducted without notification to Resident 8 and 18. This failure resulted in Resident 8 and 18 feeling startled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards when oxygen was administered to one of 13 sampled residents (Resident 35), without a physician's order. This failure had the potential to cause harm to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were stored securely and administered according to physician orders for one of 13 sampled residents (Resident 20) when staff left medication at Resident 20's bedside. This failure had the potential for misuse by the resident on unintended areas or for non-approved purposes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in safe and sanitary conditions in the food service department, when the dry storage area contained food items that were undated. This failure had the potential to expose residents to food contamination and food-borne illnesses (sickness by consuming contaminated food or drinks).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain a safe and sanitary environment with an effective infection prevention and control program for two of 13 sampled resident's (Resident 33 and Resident 4) when: 1. Certified Nursing Assistant (CNA) 1 entered a coronavirus (COVID-19- a contagious serious respiratory infection transmitted from person to person) isolation room with a surgical mask.2. Enhanced Barrier Precautions (EBP, an infection control strategy in nursing homes that expands the use of Personal Protective Equipment (PPE), specifically gowns and gloves, for high-contact care activities to prevent the spread of multidrug-resistant organisms), was not followed for one of 13 sampled residents (Resident 4). These failures had the potential to place residents and staff at increased risk for infections.

Inspectors wroteBased on interview, and facility record review, the facility failed to have a Registered Nurse (RN) performing the function of the Director of Nursing (DON) on a full-time basis to provide oversight and guidance on the provision of care provided by nursing staff. This failure prevented the facility from having the required management, to adequately assess and meet the needs of residents in a timely manner and had the potential to negatively impact the quality of care delivered by licensed and non-licensed nursing staff to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a facility-wide assessment (a review of a facility's infrastructure, resident population, and services to determine needed resources to provide care) was available, current, and complete. This deficient practice decreased the facility ' s potential to safely admit residents and ensure their care needs were met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure supervision to prevent accidents for one resident (Resident 1) when: 1. Resident 1 eloped from the facility and was found face down on the pavement; and, 2. The Wander Monitoring System (WMS, an alarm system compromised of a monitor placed on the resident and placed on facility exits used to prevent residents from wandering or seeking to leave the facility) ordered by the physician to be implemented for Resident 1 was not functional. These failures resulted in Resident 1 ' s obtaining trauma to the right eyebrow and a laceration which required stiches and decreased the facility ' s potential to ensure the safety of residents at risk of elopement to leave the facility undetected placing the resident at risk for injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure patient care equipment was functioning and maintained under sanitary conditions when oxygen therapy equipment provided to facility residents was dirty and not maintained. This failure decreased the facility ' s potential to prevent infections among respiratory compromised residents who used oxygen concentrators for medical treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan with measurable objectives and appropriate interventions for one resident (Resident 1), that addressed fall precautions when the resident developed an L3 fracture (a fracture of the third vertebra in the lumbar spine) of unknown origin. This failure put Resident 1 at risk for additional injuries and falls and had the potential to cause pain and Resident 1's safety to go unmonitored.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor (Resident 1) choice for the refusal of end-of-life medical treatment. This failure resulted in Resident 1 receiving Cardiopulmonary conversion (chest compressions) and mechanical ventilation (assisted breaths with a medical device) against Resident 1's decision. During a review of Resident 1's medical record, Physician Orders for Life-Sustaining Treatment (POLST) form, dated [DATE], indicated in box A, Do Not Attempt Resuscitation / (DNR) (Allow Natural Death), Box B indicated, Comfort -Focused Treatment - primary goal of maximizing comfort. Relieve pain and suffering with medication by any route as needed, use oxygen, suctioning, and manual treatment of airway obstruction. [...]

Inspectors wroteBased observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards of food service safety when: 1) the facility failed to store dry foods (staples; mixes and packaged foods; canned and dried foods; spices, herbs, condiments, and other foods not requiring refrigeration) in the optimum temperature between 50°and 70°Fahrenheit (F); and 2) the facility failed to prevent cross-contamination of kitchen dishes when dietary staff operating the dishwasher handled dirty and clean dishes without changing gloves or performing hand hygiene. These failures had the potential for residents to consume degraded food and had the potential to expose residents to gastro-intestinal diseases.

Inspectors wroteBased 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.

Inspectors wroteBased on dietary staff observations, dietary staff interviews and dietary document review, the facility failed to ensure staff competency in relationship to dietary staff position as evidence by dietary staff not 1) knowing how to test the quaternary (quat ammonium compounds designed to kill germs) sanitizer solution used to sanitize the kitchen countertops and sanitize the pots and pans in the manual three-compartment sink process (wash, rinse, and sanitize), 2) using the correct Cool Down Process for hot foods, 3) follow therapeutic diets when portion sizes were not plated correctly and meat needing to be pureed (texture-modified diet with the consistence of pudding for people who have difficulties with chewing and swallowing) was not weighed prior to being pureed, 4) serving pasteurized (heat treated to kill harmful bacteria such as salmonella) eggs, and 5) thawing meat according to [...]

Inspectors wroteBased on kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) meat not thawed according to the facility's policy and procedure, 2) the correct Cool Down Process for cooked meats was not followed per the facility's policy and procedure, 3) dietary staff did not know how to test the quaternary (quat ammonium compounds designed to kill germs) sanitizer solutions, 4) non-pasteurized eggs were being used, 5) the kitchen floors and counter appliances looked dirty, 6) garbage cans in the prep food areas were not covered with lids and the garage bens outside were open and there was garbage surrounding the garbage bins, 7) opened dried food products were not labeled with an open date and use by date, 8) fresh produce located in bins in the refrigerator were not labeled with a received by date, 9) [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an effective infection prevention and control program when: 1. Staff were not following the facility's guidelines for Contact Precautions, donning and doffing of Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), and appropriate hand hygiene with a resident who was positive for Clostridium Difficile infection (C. diff, also known as Clostridioides difficile or C. difficile, is a bacteria that causes diarrhea and inflammation of the colon. It is a contagious infection that is estimated to cause almost half a million infections in the United States each year. - Centers for Disease Control and Prevention), 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it had a medication error rate of less than 5%, when three of 30 medications were not given according to the physician's orders. This failure resulted in a 10% error rate and caused one unsampled resident (Resident 183) to be upset and have a bowel movement immediately after her meal, potentially losing the opportunity to absorb the nutrients from her food.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor the food preferences for two of three residents sampled for food (Residents 1 and 4). These failures resulted in Residents 1 and 4 to feel ignored and frustrated as they were served food they disliked, which may lead to poor nutritional intake and unplanned weight loss.

Inspectors wroteBased on interview and record review, the facility failed to honor the choices for two of two (Residents 20 and 8) sampled residents when: 1. Resident 8 was given a shower despite her refusal, and 2. Resident 20 was not permitted to self-administer medications without being assessed first, contrary to the facility's policies and procedures on medication self-administration. These failures resulted in Resident 8 to lash out in anger at the staff, and had the potential for Resident 8 to experience feelings of decreased self-worth, both of which could negatively impact their psychological well-being.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide care and services in accordance with standards of practice when: 1. A licensed therapist did not reassess a resident for a Restorative Nursing assistant (RNA) program (focused on nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) and obtain a new physician order for an RNA program after an RNA order had expired for three out of three sampled residents (Residents 5, 13 and 17), 2. Nursing staff were not repositioning and floating bilateral (both sides) heels of Resident 8 per physician's order and per facility policy, and 3. A dispensed medication was left unattended at a resident's bedside (Resident 1). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents and staff knew the complaint and grievance process and failed to post complaint and grievance notices in a manner accessible to all residents. This failure did not ensure residents rights to file a grievance and had the potential to delay the facility's identification and response to residents' needs or complaints.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide competent nursing staff when providing care and services for two of 8 residents when: 1. The facility did not evaluate competencies and skills of all licensed nurses and CNAs (Certified Nursing Assistant); 2. Nursing staff held Resident 16's blood pressure medication without a physician order; 3. Nursing staff did not administer medication to reduce excessive oral secretion per physician order; 4. Nursing staff assessed Resident 8's residual (volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding) when the resident had a gastro-jejunosstomy tube (a feeding tube with its distal end placed within the small intestine). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety in accordance with standards of practice when 1) there was a lack of accurate labeling/dating of thawing meats; 2) lack of sanitary conditions in the food preparation area 3) lack of staff training and review of operational processes, related to food safety within food and nutritional services. Failure to follow safe food practices put all facility residents at risk for contracting foodborne illness and compromise the health of residents who eat prepared food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed provide assessment and treatment for one of 8 sampled residents (Resident 8) when the nurses did not assess Resident 8 before and after oral suctioning and did not administer medication to reduce excessive oral secretion. This failure may have contributed to Resident 8 developing pneumonia (infection in the lungs).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and secured medication administration and storage were practiced when: 1. Medication carts (Med Cart) A and B were left unlocked and unattended, with one insulin pen left on top of one of the medication carts. 2. One expired allergy medication and three wound gel were in the medication room ready for use These failures could have resulted to resident access to insulin, ingestion of medications inside the med cart and administration of expired medicines and had the potential for adverse consequences needing hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection prevention and control practices when: 1) Transmission based precautions were not implemented timely for one resident (Resident 16) that was being tested for possible COVID-19. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication self-administration assessment was provided to one of seven residents (Resident 7) who were observed for medicine administration and had a diagnosis of dementia (a condition characterized by impairment of brain functions, such as memory loss and judgement). This failure could have resulted in expired and wrongful administration of medicine.

Inspectors wroteBased on interview and record review, the facility failed to ensure transfer notices were provided for two of 8 residents (Resident 18 and 8) when: 1. Resident 18 was transferred to the hospital without notifying the resident's responsible party (RP); 2. Resident 8 was transferred to the hospital without notifying the Long-term Care Ombudsman Program. These failures did not ensure necessary parties were duly notified, to advocate for residents' best interest during transfers from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure notices of the bed hold policy were provided to two (Resident 18 and 8) of the two hospitalized residents. This failure could have resulted in residents being unaware that they could return to the facility after hospitalization, and if they needed to submit payment to reserve a bed.

Inspectors wroteBased on interview and record review, the facility failed to implement a person-centered care plan for two of eight sampled residents (Residents 8 and 6) when: 1) The nurses did not perform pre- and post-respiratory assessments to monitor Resident 8 for improvement. This failure resulted in Resident 8 developing recurrent aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach) and multiple hospitalizations. 2) The staff did not follow the activity care plan to provide opera music. This failure resulted in Resident 6 not receiving her preferred activity.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the Care Plan quarterly for one of 8 sampled residents (Resident 8) when: 1) One nurse was checking gastric residual when Resident 8 had Gastrojejunostomy (A tube placed into the stomach that passes from the stomach into the small intestine to give liquid nutrition, medications, and other fluids directly into the small intestine). This failure had the potential for disrupting the tube patency. 2) The care plan indicated for staff to offer thickened liquid to Resident 8 who was NPO (Nothing by mouth - a medical instruction meaning to withhold food and fluids by mouth). This failure had a potential for staff to give Resident 8 a thickened liquid that may lead to choking.