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: August 5, 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.