Pruitthealth - Santa Rosa
PRUITTHEALTH - SANTA ROSA in MILTON, FL — inspection on March 27, 2026.
Found 6 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
for psychotropic medication for 3 out 3 consents reviewed. (Resident #13, # 60 and #128)The findings
without a date of completion.
The consent form contained only the resident's representative typed name in the designated signature line, with no handwritten or authenticated signature present.
Additionally, the consent form lacked a witness signature to the facility representative.
Furthermore, the consent form did not include documentation of the date and time the consent was obtained, or the relationship to the resident. (Photographic evidence obtained)A review of Resident #60's medical record revealed a psychotropic medication consent form without a date of completion.
The consent form contained only the resident's typed name in the designated signature line, with no handwritten or authenticated signature present. (Photographic evidence obtained)A review of Resident #128's medical record revealed a psychotropic medication consent form without a date of completion.
The consent form contained only the resident's typed name in the designated signature line, with no handwritten or authenticated signature present. (Photographic evidence obtained).On 03/25/2026 at approximately 12:30 PM, an interview was conducted with the Director of Nursing.
She explained that the psychotropic consents are not printed and are directly completed on the computer.
She added that the name of the resident/responsible party is typed in the designated signature line.
She acknowledged that there are no signatures for authentication.On 03/25/2026 at approximately 12:35 PM, an interview was conducted with Staff R, Social Worker.
She acknowledged that psychotropic medication consents were not validated with a handwritten signature.
She explained that she called Resident #13's representative, listed as the primary contact, over the phone to obtain the consent.
She explained that the consents are not printed and instead the name of the resident and/or representative is typed in lieu of a signature.
She further stated that when consent is obtained via telephone, there is no witness to verify or validate the authorization.
She acknowledged that this process lacks accountability and credibility, as there is no evidence to support that the consent was reviewed, that risks and benefits were explained, or that informed consent for the administration of psychotropic medications was obtained.On 03/25/2026 at approximately 12:40 PM, a phone interview was conducted with Resident #13's representative and primary contact.
She stated that she is not aware of the type of medications the resident is receiving and is not involved in the resident's medication management.
She further stated that she has never been contacted by the facility to provide consent for the administration of medications.On 03/26/2026 at approximately 12:35 PM, an interview was conducted with the Interim Administrator.
She explained that, for authentication of the consent, she expects the consent form to be printed and signed.
She added that, when consent is obtained over the phone, a witness signature should be present to validate it.The consent form for use of psychotropic was reviewed.
Under the section Additional information it describes that the resident/responsible party have been informed of available alternatives, benefits of medication use, potential side effects of medication use, right to refuse treatment, the need for continued use will be reviewed quarterly, consent can be withdrawn at any time, questions about medications can be asked at any time.
With the resident/family signature: My signature indicates my informed consent for use of the medications listed above and that I understand the reason for use and potential risks and benefits.
Per the Senior Nurse Consultant, the facility does not have a policy for informed consents.
106048 03/27/2026
Pruitthealth - Santa Rosa 5530 Northrop Road Milton, FL 32570
bipolar disorder and schizoaffective disorder were not added until 03/25/2026, after staff interviews
106048 03/27/2026
Pruitthealth - Santa Rosa 5530 Northrop Road Milton, FL 32570
reason.
observation, interviews, and record review, the facility failed to ensure that a resident received
affected 1 of 1 residents reviewed. (Resident #7) The findings include:On 03/23/2026 at approximately 11:57 AM, Resident #7 was observed asleep in his room.
Record review confirmed the resident is a quadriplegic with two ostomies, a feeding tube, a catheter, and is totally dependent for care.On 03/24/2026 at 9:57 AM, Resident #7 reported ongoing difficulty obtaining assistance to replace the battery for the motorized wheelchair, which has been nonfunctional since 2020.
The resident stated there have been multiple emails to the corporate office, and that they informed the resident that it is the resident's responsibility to find help.
The wheelchair was observed beside the bed with personal belongings stored on it.
The resident stated not having been out of bed since an appointment a month ago and shared that the facility-provided highˆback manual wheelchair is not comfortable.At approximately 12:45 PM on 03/24/2026, a review of a binder containing the resident's printed emails showed repeated requests for assistance with wheelchair repair, leg pumps, and preferred ostomy supplies. An email dated 12/01/2025 showed the resident requested a reference letter from the corporate office for a foundation that donates wheelchairs or batteries; the corporate representative denied the request, stating they do not assist with donations for residents.At approximately 4:20 PM on 03/24/2026, the Social Services Director (SSD) stated awareness that the resident has been requesting help finding a new motorized wheelchair since before the SSD was hired one year ago.
The SSD stated uncertainty about who is responsible for providing the resident with resources.On 03/25/2026 at approximately 3:58 PM, the Administrator stated that the Activities Director would be appointed to assist the resident with finding resources for wheelchair repair or replacement.
The Activities Director acknowledged awareness that the resident has been seeking such assistance for years.Observations from 03/23/2026 through 03/25/2026 showed the resident did not leave the bed or his room.Review of Activities of Daily Living (ADL) documentation dated 03/23-03/25/2026 showed Activity did not occur for mobility off the unit on all shifts.A review of Progress notes documented longstanding wheelchair malfunction concerns: 11/10/2020 (Nursing): Motorized wheelchair not charging; administration notified. 03/05/2025 (NP): Resident assessed for power mobility device; current wheelchair nonfunctional.
Resident physically and mentally able to use powered mobility and cannot selfˆpropel manual chair. 03/25/2025 (NP): Resident continued requesting updates on new powered wheelchair. 04/15/2025 (NP): Assessment reiterated need for powered wheelchair; manual wheelchair not feasible due to contracture and weakness.
Review of the Minimum Data Set (MDS) dated [DATE] documented that going outside and having fresh air is very important to the resident.
106048 03/27/2026
Pruitthealth - Santa Rosa 5530 Northrop Road Milton, FL 32570
Federal health inspectors cited PRUITTHEALTH - SANTA ROSA in MILTON, FL for a deficiency under regulatory tag F-F0694 during a standard health inspection conducted on 2026-03-27.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 6 deficiencies cited during this inspection of PRUITTHEALTH - SANTA ROSA.
Correction Status: Deficient, Provider has no plan of correction.
assessed and deemed safe and competent to selfˆadminister medications.
In an interview with Employee Y, Registered Nurse (RN), on 03/24/2026 at approximately 2:59 PM, she confirmed that medications may only be left at a resident's bedside if there is a physician's order and the resident has been evaluated and approved to take medications independently.
On 03/25/2026, a review of the facility's policy, Self Administration, last reviewed on 12/11/2025, stated that a resident may selfˆadminister medication only if the licensed nurse and physician determine the practice is safe for the resident and others in the facility.
The policy also applies to family members who wish to administer medications.
Bedside storage of medications is allowed only when it does not pose a risk to residents who may wander into rooms.
Locked drawers or cabinets are required if unlocked storage is not effective.
The attending physician must enter an order for bedside medication storage and selfˆadministration.
On 03/23/2026 at approximately 11:45 AM, observation revealed that nebulizer tubing was present in
were not labeled with the date (Photographic evidence obtained).
On 03/24/2026 at approximately 4:15 PM, an interview was conducted with Staff L, RN.
She explained that both shifts are responsible for changing respiratory items on a weekly basis and indicated that all residents have physician orders for these changes.
She further stated that the facility does not require respiratory equipment to be dated to reflect when items are changed.
Additionally, she reported that the storage bag used for respiratory items, such as tubing/masks is not routinely replaced.
On 03/25/2026 at approximately 8:35 AM, a follow up interview was conducted with Staff L, RN.
Upon entering Resident #15's room to assess the oxygen tubing, she was unable to determine the last respiratory equipment change by visually inspecting the tubing and was unable to state when it had been changed, as the tubing was not dated.
On 03/25/2026 at approximately 8:40 AM, an interview was conducted with Staff O, RN.
Upon entering Resident #100's room to assess the oxygen tubing and nebulizer tubing/mask, she was unable to determine the last respiratory equipment change by visually inspecting the tubing and was unable to state when it had been changed, as the tubing was not dated.
A facility policy titled Oxygen administration, dated 12/01/2008 and last reviewed 11/17/2025, stated that oxygen humidifier bottles are disposable bottles and are for single resident use only and changed weekly.
All oxygen tubing should be changed when there is visible soiling with the respiratory secretions/mucus and weekly.
106048 03/27/2026
Pruitthealth - Santa Rosa 5530 Northrop Road Milton, FL 32570