Santa Rosa Post Acute
Inspection Findings
F-Tag F0658
F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
orders:a. Lidocaine (medication used to alleviate pain) external patch, 4%, apply to effected area topically one time a day for pain with a start date of 8/27/25 at 9 a.m. The MAR indicated Resident 3 had not been given the medication on 8/27/25 nor 8/28/25 at 9 a.m. b. Betamethasone Dipropionate external cream 0/05%, apply to affected area topically every 8 hours for psoriasis with a start date of 8/26/25 at 5 p.m. The MAR indicated Resident 3 had not been given the evening dose on 8/26/25 at 5 p.m., the morning and mid-day dose on both 8/27/25 and 8/28/25 at 1 a.m. and 9 a.m.c. Levothyroxine Sodium oral tablet, 50 micrograms (mcg. - a unit of measurement), give 50 mcg by mouth in the morning for hypothyroidism (when
the thyroid gland is unable to meet the body's needs) with a start date of 8/31/25 at 6 a.m. The MAR indicated Resident 3 had not been given the medication on 8/31/25 at 6 a.m. During a concurrent interview and record review on 9/2/25 at 11:24 a.m., the Infection Preventionist (IP) reviewed Resident 1's, Resident 2's, and Resident 3's August 2025 MARs and confirmed all three residents had missed doses of their medications.During a second interview and concurrent record review on 9/2/25 at 12:10 p.m., the IP stated licensed nurses are expected to check the facility's emergency medication stock for the ordered medication.
The licensed nurses are also expected to call the pharmacy to confirm a delivery date and time, then call
the physician to notify him of the issue. The physician can then decide whether to order a substitute or confirm that the delay of medication administration is okay. Lastly, the licensed nurses are then expected to document what they did and any instructions they were given in the resident's chart. The IP also stated the pharmacy was located close by so most medications could be delivered the same day; however, if the order is placed at night, the medication would be delivered the following morning. The IP reviewed Resident 1, Resident 2, and Resident 3's progress notes and confirmed there was no documented evidence the pharmacy nor the physician was called. The IP also reviewed the list of medications available in the facility's emergency medication stock and found only the lidocaine patch was available. The IP stated the nurse could have administered the lidocaine from the facility's emergency medication stock.During an interview with the acting Director of Nursing (DON) and the Administrator (ADM) on 9/2/25 at 2:36 p.m., the DON confirmed if a medication was missed then it is considered a medication error and could have negatively affected the health of the residents. A review of the facility's policy titled, Administering Medications, revised April 2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame.
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SANTA ROSA POST ACUTE in SANTA ROSA, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SANTA ROSA, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SANTA ROSA POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.