Santa Rosa Post Acute: Medication Safety Failures - CA
The December 26 complaint inspection revealed the facility failed to follow its own policies for medication administration and medical record documentation. Under federal regulations, staff must verify the right resident, right medication, right dosage, and right time before giving any medication.
The facility's policy requires complete documentation of all medications administered, treatments performed, and changes in resident condition. Staff must record whether residents tolerated procedures, refused treatment, and any notifications to family or physicians.
During the incident, the nursing home failed to properly manage a severe hypoglycemia case. The facility's own policy states that unresponsive residents with hypoglycemia should receive 1 milligram of glucagon administered underneath the skin.
According to American Diabetes Association guidelines, hypoglycemia has three severity levels. Level 2 occurs when blood glucose drops below 54 mg/dL. Level 3, the most severe, involves altered mental or physical status requiring assistance, regardless of glucose level.
The guidelines recommend prescribing glucagon for all residents on insulin and using preparations that don't require mixing before administration. Glucagon treats hypoglycemia when people cannot consume sugar by mouth, and non-healthcare professionals can safely administer it.
Inspectors noted the facility must reassess treatment plans after Level 2 or 3 hypoglycemia episodes and evaluate risks including recent episodes, insulin use, and kidney disease.
The violation resulted in actual harm to few residents, according to the inspection report. The facility received citations for failing to ensure proper medication administration procedures and adequate medical record documentation during the emergency response.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Santa Rosa Post Acute from 2025-12-26 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: June 13, 2026 · Our methodology
SANTA ROSA POST ACUTE in SANTA ROSA, CA was cited for violations during a health inspection on December 26, 2025.
The December 26 complaint inspection revealed the facility failed to follow its own policies for medication administration and medical record documentation.
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.
Frequently Asked Questions
- What happened at SANTA ROSA POST ACUTE?
- The December 26 complaint inspection revealed the facility failed to follow its own policies for medication administration and medical record documentation.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SANTA ROSA, CA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from SANTA ROSA POST ACUTE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 055854.
- Has this facility had violations before?
- To check SANTA ROSA POST ACUTE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.