Inspection Reports for
Arbol Residences in Santa Rosa

The facility was generally compliant with regulations including approved dementia care plans, safe environment, and proper food handling. However, deficiencies were found related to staff fingerprint clearance, health screening, CPR/first aid certification, training hours, and unlocked maintenance and laundry rooms posing potential safety risks.

The facility was generally compliant with regulations including approved dementia care plans, safe environment, and proper food handling. However, deficiencies were found related to staff fingerprint clearance, health screening, CPR/first aid certification, training hours, and unlocked maintenance and laundry rooms posing potential safety risks.

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.

The complaint alleging untimely response to call bells was substantiated based on record reviews, staff and related party interviews, and alarm event reports. The preponderance of evidence standard was met.

The investigation substantiated the allegation that staff failed to respond promptly to call pendants, with documented response times ranging from 15 to over 24 minutes on multiple occasions in October 2025. This failure poses a risk to residents' personal rights and health and safety.

The complaint was substantiated based on record reviews, staff interviews, and alarm event reports showing delayed staff responses to call pendants. The cited regulation is CCR 87468.2(a)(4) regarding Additional Personal Rights of Residents in Privately Operated Facilities.

The investigation substantiated the allegation that staff failed to respond timely to call pendants, with documented response times ranging from 15 to over 24 minutes on multiple occasions in October 2025. This failure poses a risk to residents' personal rights, health, and safety.

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.

The visit was complaint-related, reviewing incidents involving resident R1 and R3 regarding reported abuse by R3, and incidents involving resident R2 leaving the memory care unit unsupervised. The abuse reports were substantiated and appropriately addressed. The incidents involving R2 resulted in a cited deficiency.

The facility appropriately addressed reported incidents of abuse and resident safety concerns. However, a deficiency was cited related to insufficient staffing and supervision for residents with dementia using delayed egress devices on exterior doors, which led to a resident leaving the memory care unit unsupervised on two occasions.

The complaint investigation was substantiated for the allegation that staff violated a resident's personal rights by taking and sharing photos without consent. The allegations that staff did not assist with incontinent care needs and made inappropriate comments were unsubstantiated due to insufficient evidence.

The allegation that staff violated a resident's personal rights by taking and sharing humiliating photos was substantiated, resulting in a deficiency citation. The allegations that staff did not assist with incontinent care and made inappropriate comments were unsubstantiated due to lack of evidence.

The visit was complaint-related involving reports of abuse by resident R3 and incidents of resident R2 leaving the memory care unit unsupervised. The abuse reports were substantiated and addressed appropriately. The wandering incidents led to a cited deficiency.

The facility appropriately addressed the reported incidents of abuse and resident wandering; however, a deficiency was cited related to insufficient staffing and supervision for residents with dementia using delayed egress devices on exterior doors, posing a health and safety risk.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.