Santa Rosa Care Center

Inspectors wroteBased on the facility observation, staff and resident interviews, and policy review, the facility failed to report to state agencies a serious injury to a resident within the required timeframe for 1 of 3 (Resident #1) residents. Failure of reporting could result in delay in investigation of possible abuse by the appropriate agencies.

Inspectors wroteBased on clinical record review, interviews, and review of facility policy and procedures, the facility failed to ensure one resident (#87) was free from abuse from another resident (#16). The deficient practice resulted in one resident (#87) sustaining injuries. Based on clinical record review, interviews, and review of facility policy and procedures, the facility failed to ensure one resident (#87) was free from abuse from another resident (#16). The deficient practice resulted in one resident (#87) sustaining injuries.

Inspectors wroteBased on observations, staff interviews, and review of facility policies, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice has the potential to increase the risk of foodborne illness and compromise resident healthFindings Include:An initial kitchen observation was conducted on August 26, 2025 at 08:26 AM in conjunction with the Dietary Director, (Staff # 116). During observation of the food preparation area, two sanitizer buckets, one containing a dish rag, were observed in the food preparation area where a bowl of pudding/pie mix was being prepared. A portable, blue plastic fan was observed sitting on a metal rack, blowing across the food server's side of the tray line. The blades of the fan were noted to be caked with thick, brownish-gray colored dirt. [...]

Inspectors wroteBased on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that food was served in accordance with professional standards of food service safety. The deficient practices could result in food-borne illnesses. Findings Include:An initial kitchen observation was conducted on August 26, 2025, at 08:26 AM in conjunction with the Dietary Director (Staff # 116). During observation of the food preparation area, two sanitizer buckets, one containing a dish rag, were observed in the food preparation area where a bowl of pudding/pie mix was being prepared. A portable, blue plastic fan was observed sitting on a metal rack, blowing across the food server's side of the tray line. The blades of the fan were noted to be caked with thick, brownish-gray colored dirt. [...]

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I screening was accurately completed for one resident (#41). The sample size was #21. The deficient practice could potentially lead to residents not receiving appropriate placement and services to identified mental health needs.

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that necessary respiratory care was provided for one resident (#2). Sample size was 23. The deficient practice could lead to residents not receiving appropriate respiratory care. Findings Include:Resident # 2 was admitted to the facility on [DATE], with diagnoses that included: acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. A review of the comprehensive Minimum Data Set (MDS), dated [DATE] revealed that the resident had adequate levels of hearing and the ability to make himself understood and to understand others. However, the resident had a moderate visual impairment that permitted him to identify objects, but not to read newspaper headlines. [...]

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policy review, the facility failed to ensure that one resident (#16) had a physician's order for dialysis. The sample size was 23. This deficient practice has the potential to result in residents receiving dialysis without appropriate medical authorization.

Inspectors wroteBased on clinical record reviews, staff interviews, and facility observations, the facility failed to ensure that medications were stored in accordance with professional standards for one resident (#66) out of a sample of 23. This deficient practice has the potential to compromise medication safety. Findings Include:Resident # 66 was admitted on [DATE], and readmitted on [DATE], with diagnoses that included: [...]

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#235) were free from physical abuse resulting in injury by other residents (resident #205). The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on clinical record review, interviews, facility documentation, and review of facility policy, the facility failed to ensure resident #1 was free from abuse from resident #2. The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that four residents (#11, #111, #22, #3) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on clinical record review, interviews, facility documentation, facility surveillance video, and policy review, the facility failed to ensure two residents (#1 and #4) were free from abuse from other residents (#2 and #5). The census was 123. The deficient practice can result in additional incidents of staff to resident abuse.

Inspectors wroteBased on clinical record review, interviews, and policy review, the facility failed to ensure one resident's (#3) rights were honored related to refusing medications. This deficient practice could result in further violations of resident's rights.

Inspectors wroteBased on observation, staff and resident interviews, clinical record review, facility records and facility policy, the facility failed to ensure that one resident (#28) was free from abuse. This deficient practice could lead to further incidents of resident abuse.

Inspectors wroteBased on staff and resident interviews, clinical record review, facility documents, and facility policies, the facility failed to ensure that residents do not abuse other residents. This deficient practice could result in physical and psychosocial harm to the residents.

Inspectors wroteBased on record review and interviews, the facility failed to protect the rights of two residents (#4 and #1) to be free from abuse by other residents (#6 and #5). The deficient practice could result in further resident abuse.

Inspectors wroteBased on observations, staff interviews and facility policy, the facility failed to ensure that proper food safety measures were implemented. Failure to meet this requirement could result in the spread of food borne illness.

Inspectors wroteBased on review of resident council minutes, resident and staff interviews, and policy and procedures, the facility was unable to demonstrate that concerns brought forth at resident council were responded to by the facility. The facility census was 80. The deficient practice could result in the concerns, views, grievances or recommendations by residents not being considered or acted upon by facility staff.

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I was sent to the state for determination for a PASARR level II for one resident (#19). The deficient practice could result in residents not receiving the appropriate service they need.

Inspectors wroteBased on observations, clinical record reviews, staff interviews, and policy review, the facility failed to ensure the medication error rate was not more than 5%, by failing to administer medications as ordered to one resident (#44). The medication error rate was 20%. The deficient practice could result in further medication errors.

Inspectors wroteBased on observations, staff interviews and facility policy, the facility failed to ensure that refuse was stored in a manner consistent with professional standards. Failure can result in pest infestations.

Inspectors wroteBased on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that infection control standards were maintained during wound care. The deficient practice could result in the spread of infection to residents. An observation during wound care was conducted on October 26, 2023 at 8:49 AM with a Licensed Practical Nurse (LPN/staff #72). Staff #72 gathered the necessary supplies, donned gloves at the nurse's station in the hallway and then proceeded with supplies in hand to the resident's room. Staff #72 set up her wound supplies, removed the resident's socks and conducted wound care. Removed the old dressing, applied wound cleanser to a gauze, cleansed the wound site and replaced the dressing with a fresh hydrofera dressing. [...]

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure that maintenance and housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior were consistently provided. The deficient practice could result in resident rooms not having a homelike environment.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure 5 residents (#s 65, 54, and 114) receiving psychotropic medications were consistently monitored for adverse effects and target behaviors. The sample size was 5. The deficient practice could result in residents receiving psychotropic medications not being monitored for adverse effects and target behaviors. Regarding resident #65 -Resident #65 was admitted on [DATE] with diagnoses that included vascular dementia with behavioral disturbances, major depressive disorder, and anxiety disorder. Review of physician orders revealed the following: -Risperidone (antipsychotic medication) tablet 0.25 milligrams by mouth daily for vascular dementia with behavioral disturbances dated April 27, 2021; [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that one resident (#43) was free from physical abuse by another resident (#122). The sample size was 6. The deficient practice could result in other residents being abused.

Inspectors wroteBased on clinical record review, staff interviews, review of facility documentation, and policy reviews, the facility failed to ensure one sampled resident (#72) was free from restraint. The deficient practice may result in other residents being improperly restrained.

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy and procedure, the facility failed to ensure an allegation of abuse involving two residents (#'s 43 & #122) was thoroughly investigated. The deficient practice could result in abuse investigations not being conducted.