Santa Rosa Post Acute
SANTA ROSA POST ACUTE in SANTA ROSA, CA — inspection on December 26, 2025.
Found 3 citations. 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
his or her rights.
(Resident 1) right to communication of three sampled residents, when LN 2 did not use a language
self-determination and the right to a dignified existence among residents.Findings:A review of Resident 1's admission record indicated admission to the facility on 4/23/25 with diagnoses of Type 2 Diabetes Mellitus (DM- a chronic condition in which the body has difficulty in controlling blood sugar levels).
This admission record also indicated Resident 1's primary language was Spanish and that he was his own Responsible Party (a person who is able to make healthcare and financial decisions).A review of Resident 1's Minimum Data Set (an assessment tool) dated 8/5/25 indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident 1 had moderate impairment to his ability to process knowledge and understanding.In an interview in the facility conference room on 11/6/25 at 12:32 p.m., with the use of an interpreter service Resident 1 stated he has had diabetes for over 20 years and was recently started on insulin. Resident 1 stated he has learned that he does not feel well when he was given too much or too little insulin, and how his blood sugar levels are dependent upon what he eats. Resident 1 stated that on Sunday, 11/2/25, he was not feeling well. Resident 1 stated his stomach felt off and he had been vomiting. Resident 1 stated when LN 2 came into his room with his insulin shot, Resident 1 stated he did not want it. Resident 1 stated he told LN 2 he had been vomiting and was not feeling well; however, LN 2 administered the insulin despite Resident 1's refusal. Resident 1 stated when he looked at the syringe that contained the insulin, it appeared like it was too much. Resident 1 stated Spanish was his primary language and LN 2 did not use an interpreter to communicate with him when he came in to give him his insulin.In an interview on 11/6/25 at 3:26 p.m., LN 2 stated he did not speak Spanish and had Certified Nursing Assistant 1 (CNA 1) translate for him that day. LN 2 stated Resident 1 did not refuse his insulin when he went to administer it to him.In a phone interview on 11/6/25 at 5:24 p.m., CNA 1 stated he translated once for Resident 1 and LN 2 on 11/2/25. CNA 1 stated the conversation he translated for that day did not involve insulin.In an interview on 11/6/25 at 4:35 p.m., the Administrator stated staff had options to use for translation which included other staff, their phone, or a website.A review of this facility's policy and procedure (P&P) titled Translation and/or Interpretation of Facility Services revised November 2020 indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility.It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to the staff.
Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English.A review of this facility's P&P titled Resident Rights revised December 2016 indicated, Federal and state laws guarantee certain basic rights to all residents of this facility.
These rights include the resident's right to.self-determination.communication with and access to people and services, both inside and outside the facility.participate in, his.treatment.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
055854 12/26/2025
Santa Rosa Post Acute 4650 Hoen Avenue Santa Rosa, CA 95405
kit- a pre-assembled supply of essential and emergency medications kept in skilled nursing facilities)
care plan goals .shall be documented in the resident's medical record.The medical record shall
response to care .The following information is to be documented in the resident medical record.Objective observations.Treatments or services performed; Changes in the resident's condition; Events, incidents.involving the resident.Documentation in the medical record will be.complete, and accurate.Documentation of procedures and treatments will include care-specific details, including.any unusual findings obtained during the procedure/treatment.A review of the facility's P&P titled Administering Medications revised April 2019 indicated, Medications are administered in accordance with prescriber orders, including any required time frame.The individual administering the medication initials the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication and before administering the next ones.A review of the facility's P&P titled Change in a Resident's Condition or Status revised February 2021 indicated, The nurse will notify the resident's.physician.when there has been a.significant change in the resident's physical condition.need to alter the resident's medical treatment significantly.specific instruction to notify the physician of changes in the resident's condition. A ?significant change' of condition is a major decline.in the resident's status that will not normally resolve itself without intervention by staff.impacts more than one area of the resident's health status.The nurse will record in the resident's medical record information relative to changes in the resident's medical.condition or status.A review of an untitled ADA guideline titled Blood Glucose Meters Can Play an Important Role in Diabetes Care indicated, BGMs [Blood Glucose Meters] provide accurate blood glucose.readings. In fact, the Food and Drug Administration (FDA) required all BGMs to be accurate within about 15-20% above or below the actual reading.BGMs can be the only device you use to track your blood glucose.Blood glucose monitoring is a very important part of diabetes management.A review of the facility's P&P titled Management of Hypoglycemia, revised March 2025, indicated, If a resident has .hypoglycemia and is unresponsive .administer 1 mg of glucagon subcutaneously [a method of administering medications underneath the skin].A review of the American Diabetes Association's (ADA) guideline titled Hypoglycemia for healthcare professionals, dated 2025, indicated, Hypoglycemia is categorized into three levels based on glucose levels and symptom severity.Level 2 Blood glucose less than 54 mg/dL.Level 3 [most severe] Altered mental and/or physical status requiring assistance, irrespective of glucose level.Assess hypoglycemia risks.such as recent episodes, insulin.kidney disease.Reevaluate treatment plan if experiencing level 2 or 3 hypoglycemia.Prescribe glucagon for all on insulin.
Glucagon preparations not requiring reconstitution [to be mixed prior to being used] are preferred.
Glucagon is indicated for hypoglycemia treatment when people are unable to.consume carbohydrates [sugar] by mouth.Non-health care professionals can safely administer glucagon.
any required time frame.The individual administering the medication checks.to verify.the right resident, right medication, right dosage, right time.before giving the medication.A review of the facility's policy titled Charting and Documentation revised July 2017 indicated, The following information is to be documented in the resident medical record.Objective observations; Medications administered; Treatments or services performed; Changes in the resident's condition; Events, incidents, or accidents involving the resident.Documentation in the medical record will be objective.complete, and accurate.Documentation of procedures and treatments will include care-specific details, including.whether the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment; notification or family, physician or other staff.A review of facility policy titled Management of Hypoglycemia, revised 3/25, indicated If a resident has .hypoglycemia and is unresponsive .administer 1 mg [milligram-a unit of measure] of glucagon subcutaneously [a method of administering medications underneath the skin]. A review of the American Diabetes Association's guideline titled Hypoglycemia for healthcare professionals, dated 2025, indicated, Hypoglycemia is categorized into three levels based on glucose levels and symptom severity.Level 2 Blood glucose less than 54 mg/dL.Level 3 [most severe] Altered mental and/or physical status requiring assistance, irrespective of glucose level.Assess hypoglycemia risks.such as recent episodes, insulin.kidney disease.Reevaluate treatment plan if experiencing level 2 or 3 hypoglycemia.Prescribe glucagon for all on insulin.
Glucagon preparations not requiring reconstitution [to be mixed prior to being used] are preferred.
Glucagon is indicated for hypoglycemia treatment when people are unable to.consume carbohydrates [sugar] by mouth.Non-health care professionals can safely administer glucagon.
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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.