Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
163% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
85% occupied
Based on a January 2025 inspection.
Occupancy over time
Inspection Report
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding safe transfer and discharge of residents, specifically focusing on the discharge process of Resident 1 after Medicare coverage ended.
Findings
The facility discharged Resident 1 without an appropriate discharge plan, transfer documentation, or follow-up aftercare, despite the resident's complex medical needs. This resulted in Resident 1 being immediately hospitalized with a post-surgical abdominal wound dehiscence requiring surgery. The facility failed to follow physician discharge orders and did not arrange necessary aftercare or referrals.
Deficiencies (1)
Failure to ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Report Facts
Wound size: 14
Wound size: 10
Date of wound care note: Nov 24, 2025
Date of discharge: Nov 28, 2025
Date of hospital admission: Nov 28, 2025
Date of surgery: Nov 28, 2025
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Responsible for discharge planning and signing Notice of Transfer or Discharge |
| Director of Nursing | Director of Nursing | Commented on the importance of discharge planning and facility responsibilities |
| Administrator | Administrator | Provided statements regarding reasons for discharge and clinical appropriateness |
| Operations Manager | Operations Manager | Commented on discharge planning missteps |
| Physician | Facility Physician | Issued discharge orders and provided interview regarding discharge decisions |
| Wound Care Nurse | Wound Care Nurse | Provided hospital wound care information and risks related to wound VAC malfunction |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Nov 18, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey of Arbol Healthcare Center of Santa Rosa to assess compliance with regulatory requirements and quality of care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, informed consent for psychotropic medications, completion of Physician Orders for Life Sustaining Treatment (POLST), notification of Medicare non-coverage, safe and comfortable environment maintenance, professional standards in oxygen administration, medication storage, food safety, and infection prevention and control practices.
Deficiencies (9)
Failure to respect resident dignity and privacy during COVID-19 and influenza swab testing and room entry.
Failure to ensure informed consent was obtained for psychotropic medications for one resident.
Failure to complete Physician Orders for Life Sustaining Treatment (POLST) for one resident.
Failure to provide written Notice of Medicare Provided Non-Coverage (NOMNC) to one resident when Medicare coverage was terminated.
Failure to maintain a safe and comfortable environment including inaccurate inventory of resident belongings and failure to notify residents of fire alarm tests.
Oxygen administered to a resident without a physician's order.
Medications left unsecured at resident bedside without physician order for bedside storage.
Food items in dry storage area were undated, risking food contamination and food-borne illness.
Failure to implement infection prevention and control program including improper use of PPE in COVID-19 isolation and Enhanced Barrier Precautions.
Report Facts
Residents sampled: 13
Fire tests conducted: 3
Oxygen flow rate: 4
Medication cup volume: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Named in findings related to failure to respect resident privacy and dignity during swab testing and room entry |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding facility policies and responsibilities related to multiple deficiencies |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding informed consent and POLST completion deficiencies |
| MDS Nurse | Minimum Data Set Nurse | Interviewed regarding informed consent and oxygen order deficiencies |
| Operations Manager | Operations Manager (OM) | Interviewed regarding Medicare non-coverage notice deficiency |
| Social Service Director | Social Service Director (SSD) | Interviewed regarding inaccurate inventory of resident belongings |
| Certified Nursing Assistant 1 | Certified Nursing Assistant (CNA) | Observed and interviewed regarding infection control PPE use |
| Medical Doctor 1 | Medical Doctor (MD) | Interviewed regarding oxygen administration without physician order |
| Consultant Registered Dietitian | Consultant Registered Dietitian (CRD) | Interviewed regarding food storage and labeling deficiency |
| Registered Nurse 3 | Registered Nurse (RN) | Observed and interviewed regarding failure to follow Enhanced Barrier Precautions |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding PPE use and infection control deficiencies |
Inspection Report
Capacity: 110
Deficiencies: 0
Date: Sep 11, 2025
Visit Reason
The case management inspection was conducted to review a resident incident and death report that the facility Administrator reported to the Department.
Findings
The Licensing Program Analyst reviewed records including care plans, assessments, progress notes, admission documents, medication lists, and medical documentation. No deficiencies were cited during this inspection.
Report Facts
Facility capacity: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karina Tapia | Administrator | Met with during inspection and reported the resident incident |
| Cheyenne Flores | LVN/Health Services Director | Met with during inspection |
| Dina Alviso | Licensing Program Analyst | Conducted the case management inspection |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 10, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to a resident elopement incident and concerns about facility safety and supervision.
Complaint Details
The complaint investigation was triggered by an incident where Resident 1 eloped from the facility, was found injured outside, and the Wander Monitoring System was found to be non-functional. The investigation included review of clinical records, interviews with staff, and observations of facility safety systems.
Findings
The facility failed to ensure adequate supervision to prevent accidents, resulting in a resident eloping and sustaining injury. Additional deficiencies included lack of a full-time Director of Nursing, absence of a current facility-wide assessment, and failure to maintain oxygen therapy equipment under sanitary conditions.
Deficiencies (4)
Failed to ensure supervision to prevent accidents for one resident who eloped and sustained injury.
Failed to have a Registered Nurse performing the function of Director of Nursing on a full-time basis.
Failed to ensure a facility-wide assessment was available, current, and complete.
Failed to provide and implement an infection prevention and control program ensuring oxygen therapy equipment was clean and maintained.
Report Facts
Residents on oxygen therapy: 6
Date of survey completion: Feb 10, 2025
Date of last maintenance on oxygen concentrator: Mar 25, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist | Interim Director of Nursing (Licensed Vocational Nurse) | Interviewed regarding the non-functional Wander Monitoring System and facility assessment. |
| Licensed Staff A | Reported no Director of Nursing since November and unawareness of WMS device on Resident 1. | |
| Licensed Staff B | Unaware Resident 1 was wearing a WMS device and described alarm testing procedures. | |
| Maintenance Supervisor | Reported on WMS system status and oxygen equipment maintenance. | |
| Administrator | Confirmed no Director of Nursing and interim DON role held by Infection Preventionist. |
Inspection Report
Original Licensing
Census: 94
Capacity: 110
Deficiencies: 1
Date: Jan 10, 2025
Visit Reason
The inspection was a pre-licensing, unannounced visit conducted to evaluate the facility for licensing approval.
Findings
The facility was found to have sufficient furnishings, food supply, emergency supplies, and compliance with posting and fire extinguisher requirements. However, deficiencies were observed during the pre-licensing inspection that will be cited on the current license.
Deficiencies (1)
Deficiencies observed during the pre-licensing inspection to be cited on the current license.
Report Facts
Capacity: 110
Census: 94
Hospice residents approved: 25
Non-ambulatory residents approved: 110
Bedridden residents approved: 30
Hot water temperature: 110.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karina Tapia | Administrator | Met with Licensing Program Analyst during pre-licensing inspection |
| Dina Alviso | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Census: 91
Capacity: 110
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
The visit was conducted as a Change of Ownership evaluation for the Residential Care Facility for the Elderly.
Findings
The applicant and administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 Regulations, including facility operation, admission policies, staffing, health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness.
Inspection Report
Deficiencies: 1
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the development and implementation of a person-centered care plan addressing fall precautions for a resident who sustained an L3 fracture.
Findings
The facility failed to develop and implement a complete, measurable care plan for Resident 1 after an L3 fracture, including fall prevention interventions and monitoring. The care plan lacked specific interventions for fall risk, and assessments were incomplete or missing key data. Staff interviews confirmed the absence of documented fall prevention measures despite the resident's fall and fracture.
Deficiencies (1)
Failure to develop and implement a person-centered care plan with measurable objectives and appropriate interventions for fall precautions after Resident 1 developed an L3 fracture.
Report Facts
Therapy frequency: 5
Fall date: Jun 16, 2024
MDS assessment date: Jun 8, 2024
Fall assessment evaluation date: Jun 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident 1's condition, care plan, and fall monitoring | |
| Director of Rehabilitation | Interviewed about Resident 1's therapy and care planning | |
| Charge Nurse | Interviewed about fall prevention interventions and monitoring for Resident 1 |
Inspection Report
Deficiencies: 1
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to evaluate compliance with residents' rights regarding end-of-life medical treatment, specifically honoring a resident's Do Not Resuscitate (DNR) and comfort care orders.
Findings
The facility failed to honor Resident 1's choice to refuse end-of-life medical treatment, resulting in the resident receiving cardiopulmonary resuscitation and mechanical ventilation against their wishes due to an outdated Physician Orders for Life-Sustaining Treatment (POLST) form being used. The most recent POLST was not placed in the resident's chart, and staff were unaware of the updated orders.
Deficiencies (1)
Failure to honor Resident 1's refusal of end-of-life medical treatment, resulting in unwanted CPR and mechanical ventilation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff C | Primary nurse for Resident 1 who performed CPR based on outdated POLST. | |
| Unlicensed Staff D | Manager of Medical Records Department | Responsible for placing POLST forms in resident charts; was on vacation when latest POLST was not placed. |
| DSD | Director of Staff Development | Aware of POLST policy but did not provide recent in-services on POLST, DNR, or Crash Cart policies. |
| DON | Director of Nursing | Unaware why the latest POLST was not in Resident 1's chart at time of death. |
Inspection Report
Deficiencies: 2
Date: May 30, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards for food service safety, specifically focusing on food storage, preparation, distribution, and serving practices.
Findings
The facility failed to store dry foods within the optimum temperature range and failed to prevent cross-contamination of kitchen dishes due to improper glove use by dietary staff. These deficiencies posed potential risks of degraded food consumption and exposure to gastrointestinal diseases for residents.
Deficiencies (2)
Failed to store dry foods in the optimum temperature between 50 and 70 degrees Fahrenheit.
Failed to prevent cross-contamination of kitchen dishes when dietary staff handled dirty and clean dishes without changing gloves or performing hand hygiene.
Report Facts
Temperature in dry foods storage: 85
Optimum storage temperature range: 50
Optimum storage temperature range: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Services Manager | Interviewed regarding dry foods storage temperature and facility policy | |
| Dietary Staff A | Observed operating dishwasher and handling dishes without changing gloves |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an incident of resident abuse to authorities within the required two-hour timeframe after the allegation was made.
Complaint Details
The complaint investigation was triggered by an alleged abuse incident on 12/30/23 involving a contracted vendor staff sitter who allegedly hit a resident. The facility reported the abuse verbally on 12/31/23 and in writing on 1/1/24, which was beyond the required two-hour timeframe. The investigation outcome was unsubstantiated due to lack of sufficient evidence.
Findings
The facility failed to report one incident of resident abuse within the federally mandated two-hour requirement, potentially resulting in ongoing resident harm and preventing timely investigation. The abuse allegation was ultimately deemed unsubstantiated due to insufficient evidence.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Date of alleged abuse: Dec 30, 2023
Date of verbal report: Dec 31, 2023
Date of written report: Jan 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding the abuse incident and reporting |
| Administrator | Administrator | Interviewed regarding abuse reporting and training |
| Certified Nursing Assistant A | Certified Nursing Assistant | Reported alleged abuse to Director of Staff Development |
| Director of Staff Development | Director of Staff Development | Received abuse report from CNA A and reported to Administrator and DON |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 27, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to honor resident choices, specifically concerning forced showers and denial of medication self-administration requests.
Complaint Details
The complaint investigation found substantiated issues where Resident 8 was forcibly given a shower despite refusal, causing distress and potential psychological harm, and Resident 20 was denied the right to self-administer medications without assessment, contrary to facility policy.
Findings
The facility failed to honor resident self-determination for two residents: Resident 8 was given a shower despite refusal, resulting in distress and potential psychological harm, and Resident 20 was not permitted to self-administer medications without assessment, contrary to facility policy. Interviews and record reviews confirmed these issues.
Deficiencies (2)
Failure to honor resident choice by giving Resident 8 a shower despite refusal.
Failure to permit Resident 20 to self-administer medications without prior assessment as required by policy.
Report Facts
BIMS score: 6
Annual MDS date: Jul 15, 2023
Social Service Progress Note date: Jul 28, 2023
Five Day Follow-up Report date: Aug 3, 2023
Care plan initiation date: Aug 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding communication gaps and policies on resident showers and medication self-administration |
| Licensed Staff N | Involved in transferring Resident 8 to shower chair and showering despite refusal | |
| Unlicensed Staff L | Involved in transferring Resident 8 to shower chair and forcefully changing brief | |
| Unlicensed Staff M | Assisted in transferring Resident 8 to shower chair and stated healthcare staff should not force showers | |
| Licensed Staff Q | Interviewed about shower refusal protocol and honoring resident wishes | |
| Admissions Coordinator | Interviewed about medication self-administration requests and facility policy |
Inspection Report
Routine
Deficiencies: 9
Date: Oct 27, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident rights, care and services, dietary services, infection prevention and control, and overall facility operations.
Findings
The facility was found deficient in honoring resident self-determination, providing appropriate care and services including restorative nursing programs, medication administration, dietary services, infection prevention and control. Specific issues included failure to honor resident choices, expired restorative nursing orders, medication errors, dietary staff competency and sanitation failures, and lapses in infection control practices.
Deficiencies (9)
Failure to honor resident self-determination regarding shower refusal and medication self-administration.
Failure to reassess residents for Restorative Nursing Assistant (RNA) programs and obtain new physician orders after RNA orders expired for three residents.
Failure to reposition and float heels of Resident 8 per physician's order and facility policy.
Medication left unattended at resident's bedside (Resident 1).
Medication error rate of 10% due to late administration of three medications to Resident 183.
Dietary staff lacked competency in sanitizer testing, cool down processes, portion control, use of pasteurized eggs, and thawing meat according to policy.
Facility failed to maintain clean kitchen environment including dirty floors, unclean appliances, uncovered garbage cans, unlabeled food products, spoiled produce, dishwasher not meeting temperature standards, and structural damage in kitchen.
Failure to maintain effective infection prevention and control program including improper PPE use, failure to disinfect glucometers between uses, failure to perform hand hygiene before and after meals and resident care, and unlabeled suction tubing.
Failure to honor food preferences for residents resulting in serving disliked foods.
Report Facts
Medication error rate: 10
Distance: 83.5
RNA program expiration: 12
Dishwasher wash cycle temperature: 142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff K | Observed wearing gloves while preparing glucometer and donning isolation gown without changing gloves, violating PPE protocol. | |
| Licensed Staff H | Observed failing to disinfect glucometer between resident uses. | |
| Director of Nursing | DON | Provided interviews regarding infection control practices and RNA program deficiencies. |
| Infection Preventionist | IP | Provided interviews on infection control lapses including hand hygiene and PPE use. |
| Food and Beverage Manager | Provided interviews regarding dietary service deficiencies and kitchen sanitation. | |
| Dietary Manager | Provided interviews regarding dietary staff competency and kitchen sanitation. | |
| Certified Dietary Manager | CDM | Provided interviews regarding dietary staff hand hygiene and kitchen sanitation. |
| Registered Dietician | RD | Provided interviews regarding dietary service deficiencies and infection control oversight. |
Inspection Report
Routine
Deficiencies: 11
Date: Dec 6, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, grievance process, transfer and discharge notifications, care planning, medication administration, food safety, infection control, and staff competencies.
Findings
The facility failed to ensure medication self-administration assessments, proper grievance process awareness, timely transfer notifications, complete and updated care plans, appropriate medication administration including suctioning and medication for oral secretions, safe medication storage and handling, food safety practices, infection prevention and control measures, and staff competency evaluations. These deficiencies posed risks of medication errors, delayed grievance resolution, inadequate resident care, potential foodborne illness, and increased risk of communicable disease transmission.
Deficiencies (11)
Failed to ensure medication self-administration assessment was provided for a resident with dementia who self-administered eye drops.
Failed to ensure residents and staff knew the complaint and grievance process and failed to post complaint and grievance notices accessibly.
Failed to provide timely notification of hospital transfers to residents' responsible parties and ombudsman for two residents.
Failed to provide notices of bed hold policy to two hospitalized residents.
Failed to implement person-centered care plans including respiratory assessments and preferred activities for two residents.
Failed to review and revise care plan quarterly for a resident, including inappropriate gastric residual checks and conflicting feeding instructions.
Failed to provide appropriate treatment and care including respiratory assessments pre- and post-suctioning and administration of medication to reduce excessive oral secretions for a resident.
Failed to provide competent nursing staff including lack of competency evaluations, holding medication without physician orders, failure to administer ordered medication, and inappropriate gastric residual assessments.
Failed to ensure safe and secure medication administration and storage; medication carts left unlocked with insulin pen accessible and expired medications present in storage.
Failed to ensure food safety including lack of accurate labeling/dating of thawing meats, unsanitary kitchen conditions, and lack of staff training and operational process review related to food safety.
Failed to implement infection prevention and control practices including delayed transmission-based precautions, incomplete COVID-19 symptom monitoring documentation, improper PPE use and disposal, and failure to offer hand hygiene prior to medication self-administration.
Report Facts
Medication held: 12
Hospital transfers: 5
Gastric residual volume threshold: 250
Bed hold charge: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff I | Observed administering medication and leaving medication cart unlocked with insulin pen on top; did not offer hand hygiene to Resident 7. | |
| Management Staff J | Stated Resident 7 did not have medication self-administration assessment. | |
| Management Staff M | Responsible for grievance forms and transfer notifications; verified ombudsman was not notified for Resident 8 transfers. | |
| Licensed Staff O | Stated licensed nurses notified responsible parties for hospital transfers; did not administer Atropine to Resident 8. | |
| Physician C | Physician | Stated Resident 8 had multiple hospitalizations due to aspiration pneumonia and was not aware Atropine was not administered. |
| Executive Chef | Responsible for kitchen operations; acknowledged lack of labeling/dating and cleaning logs. | |
| Licensed Staff R | Observed doffing PPE incorrectly and leaving medication cart unlocked. |
Report
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