Santa Rosa Post Acute
SANTA ROSA POST ACUTE in SANTA ROSA, CA — inspection on September 2, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.