Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbol Healthcare Center Of Santa Rosa during CMS and state inspections, most recent first.
A resident with complex medical needs, including a recent abdominal wound and end-stage renal disease, was discharged when insurance coverage ended, despite the family's inability to provide care at home. The facility failed to arrange appropriate aftercare, did not follow physician orders for continued therapies, and provided incomplete discharge instructions. The resident was sent to a hospital with a disconnected wound VAC and required immediate surgery due to inadequate discharge planning and lack of communication with the receiving facility.
A resident with cerebral infarction, apraxia, and aphasia was swabbed for COVID-19 and influenza by an RN while the privacy curtain was open and the room door was wide open, leaving the resident visible from the hallway. The resident indicated discomfort when asked about the lack of privacy. The RN also entered the room without knocking or communicating with the resident and removed items from the room. The DON stated staff must close privacy curtains during swabbing and knock before entering residents’ rooms.
Failure to Obtain Informed Consent for Psychotropic Medications: A resident received Trazodone HCl and Escitalopram Oxalate without informed consent. An LVN confirmed no consent had been obtained for either medication, the MDS nurse stated consent was needed, and the DON reviewed the facility’s informed consent policy and stated it was the nurse’s responsibility to ensure the consent was signed so the resident or family knew the risks and benefits.
Incomplete POLST for a resident: A resident stated she wanted a copy of her POLST but did not receive one. Review of the chart showed the POLST was present but not completed. An LVN stated it was the nurse's responsibility to ensure completion, and the DON confirmed the physician reviews the POLST with the resident while the nurse is responsible for making sure it is completed.
Failure to provide NOMNC when Medicare Part A ended. A resident admitted with sepsis and cancer had skilled coverage terminated, but the facility did not issue the required written notice because days used were miscalculated by prior ownership. The OM confirmed the last covered day and stated the notice was not given, despite the facility policy requiring timely beneficiary notification before non-coverage begins.
A resident’s personal property inventory was inaccurate and did not reflect all hearing aids, while the resident’s family reported misplaced hearing aids and a replacement purchase. In addition, staff conducted fire alarm testing without notifying residents, and two residents stated the loud alarm startled them because they did not know it was only a test.
A resident with emphysema, respiratory failure with hypoxia, and dependence on supplemental O2 was observed receiving continuous oxygen by nasal cannula even though the order summary showed no physician order for oxygen. The MDSN said the order had been overlooked, the MD stated oxygen is a medication that requires a physician order, and the DON said she forgot to enter the oxygen order during admission. The facility policy also required verifying a physician order before oxygen administration.
An unlabeled cup containing a white cream/ointment was found on a resident’s room shelf, and an LVN confirmed there was no MD order allowing bedside medication storage. Facility policy required a written order in the medical record for bedside medication storage.
Undated Food Item in Dry Storage: During a kitchen observation, a food container labeled Polenta was found in dry storage with no expiration date. The CRD stated staff were expected to inspect food deliveries and label and date food items, and the facility P&P required all items to be labeled with the delivery date or a use-by-date.
The facility failed to follow infection control precautions for two residents. A CNA entered a resident’s COVID-19 isolation room wearing a surgical mask instead of the required N95, despite posted droplet/contact precautions and the facility policy requiring N95 use for confirmed COVID-19. In another instance, an RN disconnected a resident’s feeding tube while wearing gloves but no gown, even though EBP signage and facility policy required gown and gloves for feeding tube care.
The facility failed to have a full-time RN as the Director of Nursing (DON), a role essential for overseeing nursing care. Since the previous DON left, the Infection Preventionist, an LVN, has been acting as interim DON. Despite advertising, no candidates have been found, and RNs on staff are unwilling to assume the position. This absence of a full-time RN in the DON role may impact the quality of care provided.
The facility failed to maintain a current and complete facility-wide assessment, which is essential for determining necessary resources to care for residents. The assessment was unavailable, as it was locked in the Administrator's office, and attempts by the Infection Preventionist to compile a new one were incomplete. This deficiency decreased the facility's ability to safely admit residents and meet their care needs.
A resident with dementia and a history of traumatic subdural hemorrhage eloped from the facility and was found injured due to a non-functional Wander Monitoring System (WMS). The system had only one alarm at the front door, while other exits lacked alarms. Staff were unaware of the resident's WMS device, and the facility lacked a policy for maintenance testing. The maintenance supervisor confirmed the system was outdated, and there was no documented evidence of visual checks on certain dates.
The facility failed to maintain sanitary conditions for oxygen therapy equipment, as observed with unsecured oxygen tanks and dusty concentrators with clogged filters. The Maintenance Supervisor had no oversight of the concentrators, and the Infection Preventionist was unaware of maintenance responsibilities. This oversight compromised infection prevention for residents using oxygen therapy.
A facility failed to implement a person-centered care plan with measurable objectives for a resident with an L3 fracture and osteoporosis. Despite therapy and staff awareness, the care plan lacked specific fall prevention measures, and assessments were incomplete. The DON and Charge Nurse acknowledged the absence of interventions, contrary to facility policy.
A resident's choice to refuse end-of-life treatment was not honored due to an outdated POLST in their chart, leading to CPR and mechanical ventilation being administered against their wishes. The error occurred because the most recent POLST was not placed in the chart, and staff were not adequately trained on the facility's policies regarding advance directives.
The facility failed to store dry foods at the recommended temperatures, with the storage area reaching 85°F, above the policy's 50-70°F range. Additionally, a dietary staff member handled both dirty and clean dishes without changing gloves or performing hand hygiene, risking cross-contamination.
Unsafe Discharge Without Adequate Planning or Aftercare
Penalty
Summary
A resident with multiple complex medical conditions, including a recent abdominal surgery with wound dehiscence, end-stage renal disease requiring hemodialysis, and significant mobility and self-care needs, was discharged from the facility when Medicare coverage ended. The facility was aware that the resident's family could not provide adequate care at home, as they lived in an RV that was not accessible for a wheelchair and lacked the necessary resources. Despite this, the facility proceeded with the discharge without ensuring an appropriate discharge plan, transfer documentation, or aftercare arrangements. The resident's care plan had called for coordination with community resources and continued therapies, but these interventions were not implemented. Physician orders for continued physical therapy, occupational therapy, and registered nursing services were not followed at discharge. The discharge instructions were incomplete, lacking scheduled follow-up appointments, special instructions for wound care, and signatures from the resident or family. The wound VAC device, which was facility-owned, was removed prior to discharge, and no replacement was arranged, leaving the resident with an unattached wound dressing. The facility did not communicate with the receiving hospital or provide necessary transfer documentation, despite being informed by the family that the resident would be taken directly to an acute care hospital after discharge. Upon arrival at the hospital, the resident was found with a malfunctioning wound VAC and an open abdominal wound, requiring immediate surgical intervention. Interviews with facility staff, including the Social Services Director, Administrator, Operations Manager, and Director of Nursing, revealed that discharge planning was inadequate and that critical steps, such as arranging aftercare and communicating with the receiving facility, were missed. The facility's own policies required that transfers and discharges be based on the resident's needs and preferences, and that appropriate documentation and communication occur, but these were not followed in this case.
Failure to Protect Resident Privacy and Dignity During Swabbing and Room Entry
Penalty
Summary
The facility failed to protect Resident 34’s dignity during COVID-19 and influenza swab testing when RN 1 performed the nostril swabs with the resident’s privacy curtain open and the room door wide open, leaving the resident visible from the hallway. Resident 34 was admitted with diagnoses of cerebral infarction, apraxia, and aphasia, and during the observation the resident was lying in bed while RN 1 obtained the samples. When asked whether it bothered her that the swabs were done without closing the privacy curtain, Resident 34 nodded yes and showed facial grimacing. The facility also failed to respect Resident 34’s private space when RN 1 entered the room without knocking and without communication, picked up the resident’s things, and left. During interview, the DON stated staff must close residents’ privacy curtains during nostril swab testing and must knock and ask permission before entering residents’ rooms. The facility policy titled Quality of Life - Dignity stated that residents shall be cared for in a manner that promotes dignity, respect, individuality, and privacy, including bodily privacy during personal care and treatment procedures, and that staff will knock and request permission before entering residents’ rooms.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a physician obtained informed consent for one sampled resident, Resident 38, who received Trazodone HCl and Escitalopram Oxalate without informed consent. During a concurrent interview and record review, LVN 1 reviewed Resident 38’s physician orders and confirmed that there was no consent obtained for either medication, stating it was the licensed nurse’s responsibility to ensure the consent was obtained. During an interview, the MDS nurse stated that consent for Escitalopram and Trazodone HCl needed to be obtained. The DON later reviewed the facility’s Informed Consent Policy dated 01/2024, which stated the facility is to involve residents in care decisions by facilitating information and obtaining consent for psychotropic drugs, and stated it was the nurse’s responsibility to ensure the informed consent was signed and that the purpose of the consent was to ensure the resident or family know the risk and benefits.
Incomplete POLST for Resident
Penalty
Summary
The facility failed to complete a Physician Orders for Life Sustaining Treatment (POLST) for one of thirteen sampled residents, Resident 33. During an interview, Resident 33 stated that she wanted a copy of the POLST but had not been given one. During a concurrent interview and record review, LVN 1 reviewed Resident 33's POLST in the chart and stated that it was not completed. LVN 1 stated that it was the nurse's responsibility to ensure the POLST was completed, and noted that a progress note on 9/14/25 indicated a follow-up would be done, but no follow-up was completed. During a later interview and record review, the DON reviewed the facility policy on Advanced Directives and stated that the physician goes over the POLST with the resident and that it was the nurse's responsibility to ensure it was completed.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a written Notice of Medicare Non-Coverage (NOMNC) for Resident 42 when Medicare Part A coverage was terminated. During interview and record review, the Operations Manager reviewed the Skilled Nursing Facility Beneficiary Protection Notification Review and confirmed that Resident 42’s Medicare Part A skilled services episode began on 9/13/2024 and the last covered day of Medicare Part A service was 3/3/2025. The Operations Manager stated that a NOMNC was not provided because the previous ownership miscalculated the days used at start of care on 11/23/2024, recording 49 days used when it should have been 47. Resident 42’s MDS showed admission to the facility with diagnoses including sepsis and cancer. The facility’s policy, Medicare Denial Process Beneficiary Notices dated 11/27/2023, stated that Medicare beneficiaries are to be notified in accordance with CMS Beneficiary Notice guidelines when they do not meet requirements for covered skilled services, and that the notice is to be used a minimum of 2 days prior to the last Medicare Part A covered day. Despite this policy, the required NOMNC was not issued to Resident 42 when Medicare coverage ended.
Inaccurate personal property inventory and unannounced fire alarm testing
Penalty
Summary
The facility failed to maintain an accurate inventory of a resident’s personal belongings. The resident’s Inventory of Personal Effects dated 8/27/25 listed one left hearing aid, but the Social Service Director stated the resident had two hearing aids. The Social Service Director also stated that on 9/6/25 the daughter purchased a new pair of hearing aids that were not inventoried. The resident’s family member stated the facility had misplaced the resident’s hearing aids and that she had to purchase a new set, and she was unaware of the inventory log. The facility also conducted fire alarm testing without notifying residents. A resident stated that a fire alarm test was conducted without informing her and that the alarm startled her because she thought there was an actual fire. Another resident stated the alarm was very loud and that she was unaware it was a test, adding that it startles her when she is sleeping. The Fire Safety Service Invoice showed three fire tests were conducted, and a CNA stated staff were notified of the test but were not instructed to notify residents. The DON stated residents should also be notified so they would not be startled and to keep them comfortable.
Oxygen Administered Without Physician Order
Penalty
Summary
The facility failed to maintain professional standards of quality when Resident 35 received continuous supplemental oxygen at four liters per minute by nasal cannula without a physician's order. Resident 35 was admitted with emphysema, respiratory failure with hypoxia, and dependence on supplemental oxygen. During observation, the resident was lying in bed receiving oxygen, and a review of the order summary report showed there was no physician order for oxygen. During interviews, the MDS Nurse stated there was no oxygen order from the physician and that it must have been overlooked. The MD stated oxygen is considered a medication and must have a physician's order, and the DON stated she forgot to enter the oxygen order because she was busy with the admission. The facility's policy on oxygen administration stated to verify that there is a physician's order for the procedure.
Unlabeled Medication Left at Resident Bedside Without Order
Penalty
Summary
Medication storage was not maintained securely for one sampled resident, Resident 20. On 9/15/2025 at 3:50 p.m., surveyors observed a 30 mL medication cup containing a white cream/ointment on the shelf in Resident 20's room, and the cup was not labeled. During a concurrent interview and record review at 3:56 p.m., LVN 1 verified that Resident 20 did not have a physician order to keep any type of medication at bedside. Review of the facility's Medication Storage in the Facility policy dated April 2008 showed that bedside medication storage requires a written order in the resident's medical record.
Undated Food Item in Dry Storage
Penalty
Summary
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 a food container labeled Polenta with no expiration date. During a concurrent observation and interview in the kitchen, the Consultant Registered Dietitian stated that staff were expected to carefully inspect all food deliveries and to label and date food items, and stated that labeling and dating food items were necessary to prevent food-borne illnesses to residents. A review of the facility policy and procedure titled, GENERAL RECEIVING OF DELIVERY OF FOOD AND SUPPLIES, dated 2018, indicated that all items were to be labeled with the delivery date or a use-by-date.
Infection Control PPE and EBP Not Followed
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program when a CNA entered Resident 33’s COVID-19 isolation room wearing a surgical mask instead of the required N95 respirator. During observation, a red sign indicating special droplet/contact precautions was posted outside the room, PPE was available on a cart, and the CNA was observed leaving the room after bathing the resident while wearing only a surgical mask. The CNA stated she was supposed to wear an N95 in the droplet isolation room but used a surgical mask because the N95 made it hard to breathe and fogged her glasses. The IP and DON both stated that staff should wear an N95 when caring for a resident on COVID-19 isolation, and the facility policy required an N95 for symptomatic or confirmed COVID-19 positive residents on isolation. The facility also failed to follow Enhanced Barrier Precautions for Resident 4, who was admitted with MS and had a gastrostomy tube. An EBP poster outside the resident’s room indicated staff must wear gloves and a gown for high-contact care activities, including feeding tube care. During observation, an RN was seen wearing gloves and disconnecting the resident’s feeding tube from the stomach without a gown. The RN stated she forgot to put the gown on and did not pay attention, and acknowledged that she should have worn it because the resident was on EBP precautions. The IP stated gowns and gloves were required for disconnecting the feeding tube, and the facility policy required staff to don gown and gloves before feeding tube care.
Facility Lacks Full-Time RN as Director of Nursing
Penalty
Summary
The facility failed to have a Registered Nurse (RN) performing the function of the Director of Nursing (DON) on a full-time basis, which is a requirement for providing oversight and guidance on the care provided by nursing staff. This deficiency was identified through interviews and facility record reviews. Licensed Staff A confirmed that there had been no DON since November, and the facility was actively advertising for the position but had no candidates. The Infection Preventionist (IP), who is a Licensed Vocational Nurse (LVN), was temporarily fulfilling the role of interim DON while also maintaining her full-time IP responsibilities. The Administrator corroborated that the previous DON left on November 27, 2024, and acknowledged the ongoing search for a new DON. Despite having RNs scheduled on all work shifts, none were willing to take on the DON position. The facility's job description for the DON role requires a registered nurse with a current license and a Bachelor of Science degree in nursing. The absence of a full-time RN in the DON role prevented the facility from having the necessary management to adequately assess and meet the residents' needs, potentially impacting the quality of care provided.
Facility-Wide Assessment Unavailable and Incomplete
Penalty
Summary
The facility failed to ensure that a facility-wide assessment was available, current, and complete, which is necessary to determine the resources required to care for residents competently. During an interview, the Director of Staff Development (DSD) stated that the facility assessment was not available as it was locked in the Administrator's office. Further interviews revealed that the Infection Preventionist (IP), who was also serving as the interim Director of Nursing (DON), could not locate the facility assessment and was attempting to compile one over the weekend, but it was incomplete. The document provided to the surveyor did not adhere to the facility's policy and procedure for conducting, reviewing, and updating the facility assessment. The Administrator confirmed the inability to find the facility assessment. The facility's policy, revised in October 2018, mandates an annual facility assessment to evaluate and update the facility's capacity to meet residents' needs. The team responsible for this assessment includes the Administrator, a representative of the governing body, the medical director, and the director of nursing services. The absence of a current and complete facility assessment decreased the facility's potential to safely admit residents and ensure their care needs were met.
Resident Elopement Due to Non-Functional Wander Monitoring System
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for a resident who eloped from the facility and was found face down on the pavement. The resident, who had a history of traumatic subdural hemorrhage and unspecified dementia, was at high risk for falls and wandering. Despite having a care plan in place to prevent injury, the resident sustained trauma to the right eyebrow, resulting in a laceration that required stitches. The Wander Monitoring System (WMS) ordered for the resident was not fully functional. The system had only one alarm located at the front door, while two other exit doors lacked alarms. The Infection Preventionist confirmed the system's malfunction and the absence of a policy for maintenance testing. Additionally, staff members were unaware of the resident's WMS device, indicating a lack of communication and training regarding the system's use. The facility's maintenance supervisor acknowledged the outdated WMS and the cancellation of its update. The supervisor tested the front door alarm weekly but did not change the device's batteries or know who was responsible for it. The facility lacked a policy and procedure for the WMS, and there was no documented evidence of visual checks on specific dates. The elopement evaluation form for the resident was incomplete, further highlighting the facility's failure to ensure the safety of residents at risk of elopement.
Failure to Maintain Sanitary Conditions for Oxygen Therapy Equipment
Penalty
Summary
The facility failed to maintain patient care equipment under sanitary conditions, specifically concerning the oxygen therapy equipment provided to residents. During an interview, the Maintenance Supervisor (MS) admitted to periodically checking the oxygen storage room to ensure the security of the oxygen tanks but stated he had no oversight or maintenance responsibilities for the oxygen concentrators. The Infection Preventionist (IP) confirmed that six residents were on oxygen therapy using concentrators provided by the facility. However, during an observation, it was noted that multiple oxygen tanks were unsecured, and three oxygen concentrators were covered in dust, with one having filters full of lint and debris. The last maintenance service for one concentrator was recorded as being performed in March 2020. The IP acknowledged the lack of a maintenance contract for the oxygen concentrators and was unaware of who was responsible for their cleaning and maintenance. Additionally, there was no policy or procedure available for the maintenance of the oxygen concentrators, despite the manufacturer's instructions indicating the need for routine maintenance and cleaning. This oversight decreased the facility's ability to prevent infections among residents who were respiratory compromised and relied on oxygen concentrators for medical treatments.
Failure to Implement Person-Centered Care Plan for Fall Prevention
Penalty
Summary
The facility failed to develop and implement a person-centered care plan with measurable objectives and appropriate interventions for a resident who developed an L3 fracture of unknown origin. Despite the resident's medical history of osteoporosis and a recent unwitnessed fall, the care plan did not include specific interventions or monitoring to prevent falls. This oversight put the resident at risk for additional injuries and falls, potentially causing pain and leaving the resident's safety unmonitored. Interviews with the Director of Nursing (DON) and the Director of Rehabilitation revealed that the resident had no documented falls in the facility, yet the care plan lacked specific interventions for fall prevention. The resident was receiving therapy five times a week, and staff were informed about the care plan, but there was no documentation of specific fall prevention measures. The resident's Minimum Data Set (MDS) assessment and fall risk evaluation were incomplete, missing crucial data points and risk level assessments. The Charge Nurse and DON acknowledged the absence of specific fall prevention interventions in the care plan. The facility's policy on comprehensive person-centered care plans emphasized the need for measurable objectives and risk factor incorporation, but these were not reflected in the resident's care plan. The DON indicated that monitoring interventions for falls should be added, but at the time of the survey, these were not documented.
Failure to Honor Resident's DNR Wishes
Penalty
Summary
The facility failed to honor a resident's choice to refuse end-of-life medical treatment, resulting in the resident receiving cardiopulmonary resuscitation (CPR) and mechanical ventilation against their documented wishes. The resident had a Physician Orders for Life-Sustaining Treatment (POLST) form indicating Do Not Attempt Resuscitation (DNR) and a focus on comfort care, which was not followed due to an outdated POLST being present in the resident's chart. The outdated POLST indicated DNR with full treatment, leading to the initiation of CPR by Licensed Staff C when the resident was found with no vital signs. Licensed Staff C, who was the primary nurse for the resident, checked the chart and found the outdated POLST, which led to the misunderstanding and subsequent actions. The staff member was unaware of a more recent POLST that had been updated to reflect the resident's wishes for comfort-focused care. The error was compounded by the absence of the most recent POLST in the resident's chart, which was supposed to be placed there by the Medical Records Department manager, Unlicensed Staff D, who was either on vacation or unaware of the oversight. The Director of Staff Development (DSD) had not conducted any in-services for the nursing staff regarding the facility's POLST policy, DNR policy, or crash cart procedures in the last three months, which may have contributed to the lack of awareness and adherence to the resident's documented wishes. The facility's policies and procedures clearly state the importance of honoring residents' advance directives and ensuring that staff are trained on these policies, but these were not effectively implemented in this case.
Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food service safety by not storing dry foods at the recommended temperatures. During an observation, it was noted that the dry foods storage area felt warm, and there was no thermometer present to monitor the temperature. The Dietary Services Manager confirmed the absence of a thermometer and acknowledged that dry foods should be stored between 68 and 75 degrees Fahrenheit. However, the surveyor's thermometer registered a temperature of 85 degrees Fahrenheit in the storage area, which is above the facility's policy recommendation of 50 to 70 degrees Fahrenheit. This discrepancy indicates a failure to maintain the appropriate storage conditions for dry foods. Additionally, the facility did not prevent cross-contamination in the kitchen. During an observation, Dietary Staff A was seen handling both dirty and clean dishes without changing gloves or performing hand hygiene. The staff member loaded dirty dishes into the dishwasher and then removed clean dishes using the same gloves, which could lead to cross-contamination. These actions demonstrate a lack of adherence to proper hygiene practices in the kitchen, potentially exposing residents to gastro-intestinal diseases.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 211 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Rosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blue Oak Post-acute | 2.7 mi | ★★★★★ | 32 | 0 |
| Park View Post Acute | 3.6 mi | ★★★★★ | 13 | 0 |
| Northvine Postacute Care | 3.7 mi | ★★★★★ | 4 | 0 |
| Santa Rosa Post Acute | 4 mi | ★★★★★ | 29 | 0 |
| Summerfield Health Care Center | 4.3 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Arbol Healthcare Center Of Santa Rosa.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.