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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 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.