Santa Rosa Post Acute

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe smoking environment for six out of six sample residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) when:The outside environment accessible to residents was not free from hazards and the door to the maintenance shed was left open and unattended,Adequate supervision was not provided in the smoking section and safe measures were not monitored for the extinguishing of cigarettes, andSmoking care plans were not initiated for Resident 4 and Resident 6. These deficiencies increased the risk of fire hazards and resident exposure to hazardous materials. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of six sampled residents (Resident 1 and Resident 2) were protected from abuse and remained free from abuse when:A physical altercation occurred between Resident 1 and Resident 2 during which Resident 2 hit Resident 1 on the face,72-hour monitoring was not completed for Resident 1 and Resident 2 following the change of condition (COC), and;Immediate corrective actions were not implemented. This failure presented a risk of harm to Resident 1 and may have resulted in additional abuse or complications affecting both Resident 1 and Resident 2 after their COC. Cross reference F689. [...]

Inspectors wroteBased on interview and record review the facility failed to protect one resident (Resident 1) of two sampled residents from physical abuse when Resident 2 bit Resident 1 on the hand. This failure decreased the facility's potential to ensure residents did not experience abuse.

Inspectors wroteBased on interview and record review, the Licensed Nurse 2 (LN 2) failed to ensure one resident's (Resident 1) right to communication of three sampled residents, when LN 2 did not use a language interpreter to communicate with Resident 1. This failure decreased the facility's potential to support self-determination and the right to a dignified existence among residents.

Inspectors wroteBased on interview and record review, licensed nurses (LNs) did not provide accurate and safe pharmaceutical services to one resident (Resident 1) of three samples residents when:LNs did not ensure Resident 1 had a physician's order for glucagon (emergency treatment injected into a large muscle using a needle to immediately raise blood sugar levels) after Resident 1 had four episodes of hypoglycemia (when a person's blood sugar level drops below 70 milligrams per deciliter [mg/dl, a unit of measurement]) between 7/4/25 and 11/1/25;LN 2 administered insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) to Resident 1 at 11:30 a.m. when it was supposed to be administered at 6:30 a.m.;LN 2 did not ensure accurate documentation in Resident 1's medical chart when: LN 1 documented insulin was administered at 11:07 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete performance reviews (formal meetings where a supervisor evaluates an employee's job performance, providing feedback and setting goals for the future) for more than 12 months for three out of three randomly selected Certified Nursing Assistants (CNAs also known as nurse aides). This failure can prevent identification of skill gaps leading to decline in quality of care.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure sufficient staff members possessed the basic competencies and skills sets to meet the behavioral health needs of residents with mental disorders and those with a history of trauma and/or post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) as reflected in the facility assessment, when: 1. 12 Certified Nursing Assistants (CNAs - also known as nurse aides) did not receive training related to the care of residents with dementia (a progressive state of decline in mental abilities), 2. CNA D was allowed to start work without a competency check (a process that evaluates an individual's knowledge, skills, and abilities to perform a specific role or task effectively) completed, and3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner for a census of 98 residents who received food prepared from the kitchen, when:1. Four containers of spices past their use-by date labels were found available for use on the kitchen shelf;2. Staff cleaning dishes touched cleaned dishes with dirty gloves;3. Dish machine sanitizing solution was not at the required concentration levels. These failures decreased the facility's potential to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure they had an effective pest control program for all residents of the facility when there were flies inside the facility. This failure put the residents at risk for the possible spread of infections. Based on observation, interviews and record reviews, the facility failed to ensure they had an effective pest control program for all residents of the facility when there were flies inside the facility. This failure put the residents at risk for the possible spread of infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a written summary of the baseline care plan (BCP, a document created within 48 hours of a resident's admission, outlining the initial care needed, focusing on basic needs and resident-specific information) was provided to the resident and/or the responsible party (RP, a person who is designated in making decisions about health care and financial matters) for two out of five sampled residents (Residents 31 and Resident 82) when no documented evidence that the BCP summary was provided. This failure could compromise residents' safety, hinder effective communication, and could lead to adverse events, especially during the critical initial days of admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of twenty sampled residents (Resident 28) was provided the Restorative Nursing Assistant Program (RNA-P, a program which provides exercise and a range of motion activities to the residents), when Resident 28's physician's orders, person-centered care plan, and resident's choice to participate in the RNA-P was not being followed. This failure had the potential to result in Resident 28's decline in physical abilities and decreased muscle strength.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure adequate pain relief for one out of 20 sampled residents (Resident 45), when using a numeric pain rating scale where 0 as no pain, 1 to 3 as mild pain, 4 to 6 as moderate pain, and 7 to 10 as severe pain, Resident 45 complained of moderate to severe pain daily. This failure resulted in Resident 45 feeling frustrated and complaining of lack of quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure one resident out of 20 sampled residents (Resident 87) was provided with a safe and sanitary environment when the commode (portable toilet designed for individuals with limited mobility) was covered with a blanket. This failure has the potential to spread germs and cause illness among residents.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the call light (a communication tool used in healthcare settings to allow patients to request assistance from staff) was within reach for one out of five sampled residents (Resident 102), when her call light was found coiled around her lower bed post away from her reach. This failure put Resident 102 at risk for delayed provision of care and accidents.

Inspectors wroteBased on observation and interview, the facility failed to maintain the kitchen's drain in working order when the sewage drainpipe was observed disconnected and leaking outside the kitchen. This decreased the facility's potential to maintain sewer lines in proper working order and containment.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided by the facility met professional standards of practice for administering medications as ordered by the physician (MD) for three residents (Resident 1, Resident 2, and Resident 3) of three sampled residents when: 1. Resident 1 did not receive her heart failure medication, antidepressant medication, and ointment for skin redness;2. Resident 2 did not receive a dose of his anti-fungal powder; and,3. Resident 3 did not receive her medication to alleviate pain and itching and medication for her thyroid. These failures decreased the facility's potential to ensure residents received medications that prevented a decline in their health status or prolonged discomfort due to their health diagnoses.

Inspectors wroteBased on interview and record review, the facility failed to protect a census of 94 residents from sexual abuse when the facility allowed an alleged perpetrator, Certified Nursing Assistant 1 (CNA 1), to enter the facility on 4/4/25 after conducting an incomplete investigation per facility policy for a census of 94 residents. This failure granted CNA 1 access to Resident 1 and had the potential to place Resident 1 and other residents at risk for further harm. Cross-reference F610. Findings A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of cardiomegaly (a condition when the heart becomes larger than normal) and dementia (a progressive state of mental decline). A review of Resident 1's progress note dated 4/4/25 at 9:38 p.m. indicated, Spoke to this [Resident 1] at approximately 12:40 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of sexual abuse for one resident (Resident 1) of eight sampled residents when Resident 1 alleged a male Certified Nursing Assistant (CNA) matching the identity of CNA 1 exposed himself to Resident 1 and forced Resident 1 to touch his genitals. This failure decreased the facility's potential to protect Resident 1 and a facility census of 94 residents at the facility from harm.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse and change of condition policy for two residents (Resident 1 and Resident 2) of four sampled residents when the facility staff did not: Notify the residents' family representatives and physicians, Document an Interdisciplinary Team (IDT- a multidisciplinary team who ensures a comprehensive and coordinated approach to patient care) note, and Initiate care plans to provide person-centered care for both residents for an allegation of resident-to-resident abuse. This failure decreased the facility's potential to prevent recurrence of abuse between Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for two residents (Resident 1 & Resident 2) of four sampled residents when an allegation of resident-to-resident abuse was reported to the California Department of Public Health (Department) five days later. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement their abuse policy, for one resident out of three sampled residents (Resident 1) when: 1. Resident 1 made an abuse allegation on 3/26/25 but the facility did not report the allegation within two hours to the State (licensing agency), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and law enforcement, and 2.six out of six facility staff did not know the expectation to report any allegation of abuse within two hours to the State, the Ombudsman, and the law enforcement. These failures could put the resident ' s safety at risk due to delayed intervention.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three out of five sampled residents (Resident 2, Resident 3, and Resident 4) were provided with a homelike environment when Resident 1 would wander into their rooms, rummage through their personal belongings and take them. This failure caused emotional distress and feelings of anger for Resident 2, Resident 3, and Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to provide residents a copy of their medical records upon request for six of 15 sampled residents. This failure resulted in the obstruction of the residents' right to access their own medical record.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide resident-centered care to one resident (Resident 1) of four sampled residents when Licensed Nurses administered Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions combined with artificial breathing in an effort to manually preserve brain function to restore blood circulation and breathing in a person whose heart unexpectedly stops beating) against Resident 1 ' s decision not to be resuscitated (rescued). This failure resulted in physical, psychosocial (involving both psychological and social aspects), and financial harm to Resident 1 after she had survived the medical emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately respond to a scabies (a burrowing mite that causes an itchy rash; it can spread from person to person in crowded living situations such as nursing homes) outbreak that resulted in 41 out of 95 residents developing an itchy rash when the infection preventionist did not implement surveillance for potential cases of scabies when rashes began appearing, did not identify the scabies outbreak, and did not report the scabies outbreak to the local health department (LHD) per Centers for Disease Control and Prevention (CDC) guidance. This failure potentially delayed additional resources and assistance from the local health department to prevent scabies from spreading to all 95 residents and delayed the LHD from investigating potential exposures and further spread in the community.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a reliable communication channel to one of three sampled residents (Resident 1), when phone calls to the facility were not picked up in a timely manner. These multiple unanswered phone calls resulted in difficulties in establishing communication between Resident 1 and her family, causing frustration and distrust.

Inspectors wroteBased on interviews and record reviews, the facility failed provide pharmaceutical services that meet the needs of the residents when one of four sampled residents (Resident 1) did not receive Lyrica (a medication used to treat It is used to treat painful nerve diseases) twice, over a seven-day period, contrary to the physician ' s orders. This failure was not in alignment with facility policy and procedures and resulted in Resident 1 to experience unrelieved pain which prompted her subsequent transfer to the emergency room.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to: Ensure residents were consistently able to communicate with their Responsible party (RP, the individual who directs someone else's care) and loved ones via the facility phone after 5 p.m., and on the weekends, for two out of two sampled residents (Resident 4 and Anonymous Resident 5 (AR 5). In addition, two out of two Anonymous family members 6 and 7 (A FM 6 and 7) complained of staff not picking up the facility phone at the nursing station and not being able to talk to their loved ones after 5 p.m., at nighttime, and on the weekends, and Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) stated receiving complaints from family members and residents in general, about how they were not able to communicate with each other when they called the facility phone after 5 p.m., and on the weekends. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate nutrition and weight monitoring for (Resident 1) when (Resident 1) lost 7.8 pounds (5.3%) within the first week of the Resident's admission. This failure had the potential for Resident 1 to be at risk for malnutrition, dehydration, and electrolyte imbalance.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure: 1. Staff were aware of what Baseline Care Plan (BCP, a plan that promotes continuity of care and communication among nursing home staff to increase resident safety) was, or its completion time frame. 2. BCP was completed timely for five out of five sampled residents (Residents 1, 2, 4, 7 and Anonymous 5). These failures had the potential to put residents' safety at risk and for residents not receiving the care that they need.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure food served to seven out of seven sampled residents (Residents 1, 2, 4, 6, 7, Anonymous 3 and 5) were palatable, and at an appetizing temperature. These failures could lead to Gastrointestinal Disease such as Diarrhea and vomiting and could result in residents not eating their meal, feeling frustrated and upset.

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1. Ensure dietary staff were aware the facility had a vegan (strict vegetarian, vegan diet completely excludes anything that comes from an animal) menu. 2. Ensure one out of two sampled residents (Resident 1) was receiving a vegan meal per his and his responsible party (RP, someone who is able to act on behalf of the resident) preference. These failures led to Resident 1 to not receive a vegan meal per his preference. This failure also had the potential for Resident 1 to not meet the recommended daily intake (RDI, the average daily dietary intake level that is sufficient to meet the nutrient requirements of nearly all (97-98 per cent) healthy individuals in a particular life stage and gender group) for certain nutrients like protein or vitamins which could further compromise his medical status.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure there was a qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services when a dietary manager (DM) who was not certified was put in place to oversee dietary services when the Registered Dietician (RD) was not employed full-time (staff that works 35 or more hours per week).

Inspectors wroteBased on observation, interview, and record review, the facility failed protect the residents ' right to be free from sexual abuse by a resident when one resident, Resident 1, who had a known history of touching a female resident inappropriately, did not have a plan in place to prevent further abuse. This failure resulted in sexual abuse of two additional residents.

Inspectors wroteBased on interview and record review, the facility failed to initiate a care plan for the behavior of one of four sampled residents (Resident 1) when Resident 1 was witnessed touching a female resident inappropriately. This failure resulted in Resident 1 continuing to touch female residents inappropriately with no plan in place to manage or prevent the behavior.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled certified nurse assistants (CNA [CNA 1]) had a valid nursing assistant certificate. This deficient practice placed all 94 residents at risk for receiving improper patient care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the care and services needed for one of two sampled residents (Resident 1) when: 1. Resident 1 ' s change in condition was not addressed timely, 2. Resident 1 missed his scheduled tube feedings, 3. Resident 1 ' s pressure injury was not documented according to nursing standards and Resident 1 was not placed on a low-air loss mattress, 4. Resident 1 missed multiple doses of his medications, and 5. Resident 1 was not weighed daily per physician ' s order. These multiple failures to carry out Resident 1 ' s physician orders resulted in care and services not provided to a vulnerable resident totally dependent on nursing staff to meet his needs.

Inspectors wroteBased on observation, interview, and record review, the facility ' s pharmacy failed to deliver timely the medications for one of two sampled residents (Resident 1). This failure resulted in Resident 1 missing doses of medications he needed for his multiple comorbidities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedure on infection control practices during a COVID-19 outbreak when: 1) Two unlicensed staff were observed not wearing the correct Personal Protective Equipment (PPE - typically gown, mask, gloves) when entering a COVID positive room. 2) One unlicensed staff was observed in a room with no facemask or PPE that housed a resident on contact precautions (involves the use of PPE appropriately, including gloves, gown, mask to protect against exposure and cross contamination of certain illnesses) for Clostridioides difficile (C-difficile - a contagious bacteria that causes an infection of the colon, the longest part of the large intestine. [...]

Inspectors wroteBased on observations, and interviews the facility failed to maintain a consistently operable telephone communication system in operating condition that had an established answering system when it was observed there was no efficient communication system to contact the facility by calling the facility ' s main contact phone number during hours of operation and after hours when the front desk receptionist was not in the facility to answer phone calls. This failure caused stress, anxiety, and lack of communication between resident ' s responsible parties, and family members who were unable to contact staff members at the facility creating a safety concern that had the potential to result in delayed or non-delivery of care and services to its residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing professional standards of practice were followed for one of three sampled residents (Resident 1) when: 1. Licensed Staff A, the admitting nurse, felt Resident 1 needed a higher level of care upon arrival to the facility based on her nursing assessment, but did not notify or share her concerns with the attending physician. In addition, she documented Resident 1's cognition was alert and oriented, when the discharging facility indicated he was nonresponsive and unable to follow commands due to a traumatic brain injury, 2. No baseline or comprehensive care plans were created for Resident 1 until after he passed away at the facility approximately 36 hours after admission, even though, according to the facility physician, he was a critically ill resident, 3. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure one out of three sampled residents (Resident 1) was provided the needed care, assessment and treatment in a timely manner and in accordance with professional standards of practice when Resident 1 A. did not receive a timely assessment for complaints of eye irritation and coughing. B. there were no nurse documentation for the eye infection and coughing C. did not receive the ophthalmic antibiotic order for the eye infection until 2 days later. 4. there were no care plan created for the eye infection or the coughing that would have guide staff on how to care for Resident 1 safely. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the Office of the State Long-Term Care Ombudsman (a public advocate [official] who is charged to provide valuable assistance to residents, their families and/or friends, in the resolution of quality of care and quality of life issues) when five of five sampled residents (Residents 74, 15, 45, 23 and 84) were transferred out, and eventually admitted to acute care. This failure had the potential for all five sampled residents to not have protection from being discharged or transferred inappropriately, and limit residents' access to an advocate who can inform them of their options and rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with dignity and respect when a staff member did not knock on the door before entering five of five residents' rooms (Resident 41, Resident 34, Resident 67, Resident 24 & Resident 66). This failure had the potential to cause residents to feel disrespected and an invasion of privacy when staff did not knock and request permission before entering resident rooms.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the contact information for the Office of the State Long-Term Ombudsman (the Ombudsman) in a form and manner accessible to residents. This failure resulted in four of four residents (Residents 3, 4, 31 and 44) not knowing how to contact the Ombudsman.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan that met the needs of three of three residents (Residents 28, 35, and 232). For Resident 28, the facility did not create a care plan for use of supplemental oxygen. For Resident 232 the facility did not create a care plan for a PICC (Peripherally Inserted Central Catheter) line, an intravenous catheter. For Residents 35 and 232, the facility did not create a care for use of indwelling urinary catheters (drainage tubes for urine). These failures placed Residents 28, 35 and 232 at risk of not having their care needs met, including the prevention of urinary, respiratory, skin and blood infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the activities care plan for one of two residents (Resident 35). This failure resulted in Resident 35 not enjoying his favorite activity of being outdoors for fresh air and sun.

Inspectors wroteBased on observation, interview and record review, the facility and their pharmacist failed to ensure that the instructions on the label of the medication (Prednisone - an anti-inflammatory) container were correct for one of three residents (Resident 80). The discrepancy in the instructions, on the medication container, the eMAR (electronic medication administration record), and the doctor's order for the administration of Resident 80's Prednisone included with lunch, at 8:30 a.m., and one time a day. This failure of uncorrected administration instructions for the Prednisone had the potential to cause a medication error when dispensing the Prednisone leading to possible adverse effects for Resident 80.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate labeling of medications for safe administration, for safe and proper storage of medication in the correct temperature, for discarding expired medication, and for labeling food items in the refrigerator located in the Medication Room. These failures had the potential to result in licensed nurses administering wrong medication or the wrong dose of medications which may have a significant adverse effect on residents that may lead to serious harm or death.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain accurate medical records for one of 18 sampled residents (Resident 50) when her signature was entered on the wrong line in the medication consent form. This failure had the potential to misrepresent a resident's care experience, and assented plan of care goals and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all staff to practice infection control prevention when: A housekeeper did not change gloves after cleaning each resident's rooms, and, A housekeeper did not wash hands or use alcohol based hand rub (ABHR) after cleaning each resident's room, and, Licensed nurses did not change the dressing (bandage) on the PICC line (Peripheral Inserted Central Catheter - an intravenous line). These failures had the potential to spread infections (such as Covid19) to vulnerable residents, staff, and visitors, or skin and blood infections due to unchanged PICC line dressing.