Spring Lake Village: Infection Control Gaps Found - CA
That's what inspectors found in February at the 47-resident skilled nursing facility in Santa Rosa.
Enhanced Barrier Precautions, known as EBP, are a specific infection control protocol developed by the Centers for Disease Control and Prevention to reduce the spread of multidrug-resistant organisms inside nursing homes. Multidrug-resistant organisms, sometimes called MDROs, are bacteria that have become resistant to the antibiotics typically used to treat them. They spread easily in facilities where people share caregivers, live in close quarters, and often have open wounds or medical devices that create a direct pathway into the body.
The CDC published its EBP recommendations in April 2024. The California Department of Public Health followed with a memo to all skilled nursing facilities in June of that same year, directing them to put the precautions in place.
Eight months later, the infection preventionist at Spring Lake Village had never heard of them.
When inspectors sat down with the facility's Infection Preventionist Registered Nurse and its Director of Staff Development on February 12, both told investigators they did not know what EBP was. Because they didn't know what it was, no policy had been written. Because no policy had been written, no training had been given. The staff caring for residents, including those with wounds or indwelling medical devices, had never been instructed to follow the protocol.
What the protocol actually requires is specific. During high-contact care activities — helping a resident with personal hygiene, changing bed linens, administering medications, changing a wound dressing — staff are supposed to wear gowns and gloves when working with any resident known to be colonized or infected with a drug-resistant organism, and also when working with residents considered at elevated risk of acquiring one. Residents with wounds qualify. Residents with indwelling medical devices qualify. In a skilled nursing facility, that description covers a significant portion of the people living there on any given day.
The precautions exist because contact is how these organisms move. A caregiver's hands or clothing can carry bacteria from one resident to the next in the time it takes to walk down a hallway. Gowns and gloves, used correctly and discarded between residents, interrupt that chain. Without them, the chain stays intact.
Spring Lake Village had no mechanism in place to interrupt it.
Inspectors cited the failure under F880, the federal infection control tag, and noted the lapse had the potential to affect all 47 residents in the building.
The timeline matters here. The CDC guidance came out in April 2024. The state health department sent its memo in June 2024. By February 2025, when inspectors arrived, the facility's own infection control nurse still couldn't define the term. That's not a case of a policy being written but poorly implemented, or training being conducted but not retained. The people responsible for knowing had simply never encountered the information.
There is no indication in the inspection report that any resident had been diagnosed with a drug-resistant infection as a direct result of the gap. But the nature of MDRO transmission is that the damage is often invisible until it isn't — until a resident develops an infection that doesn't respond to standard treatment, and the question becomes how long the exposure had been happening and how many people it touched.
The 47 residents at Spring Lake Village spent those eight months in a facility where the staff responsible for their protection from drug-resistant organisms didn't know the protection existed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spring Lake Village from 2025-02-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
SPRING LAKE VILLAGE in SANTA ROSA, CA was cited for violations during a health inspection on February 13, 2025.
That's what inspectors found in February at the 47-resident skilled nursing facility in Santa Rosa.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.