Pruitthealth - Santa Rosa

In the surveyor’s words

From the most serious findings on record at Pruitthealth - Santa Rosa, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 23, 2021

  Based on observation, staff interview and record review, the facility failed to ensure 2 of 2 vulnerable residents at risk for elopement (Resident #40 and #48) were not able to exit the building unsupervised. Resident #40 was found unattended in the facility parking lot by a staff member on 3/7/21 and Resident #48 was able to exit the building unsupervised through a fire door on 3/9/21. The facility's failure to prevent an elopement and eliminate potential hazards placed 2 residents at a likelihood of serious injury and death. […]

• Immediate jeopardy, isolatedF867Apr 23, 2021

  Based on observation, staff interview and record review, the facility Quality Assurance and Performance Improvement (QAPI) process failed to develop appropriate plans of action to correct quality deficiencies related to resident elopement that occurred on 3/7/21 (Resident #40) and 3/9/21 (Resident #48). The facility's failure to follow the QAPI process may prevent the facility from correcting and improving their systems to ensure resident safety and prevent serious harm for residents at risk for elopement (Resident #40 and #48). Resident #40 was found unattended in the facility parking lot by a staff member on 3/7/21 and Resident #48 was able to exit the building unsupervised through a fire door on 3/9/21. This failure has the potential to affect 28 residents at risk for elopement. […]

• No harm, potential for more than minimal, patternF880Mar 27, 2026

  Based on observation, interviews, and record and policy reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment for 12 of 25 people reviewed. (Residents #66, #52, #33, #105, #102, #60, #93, #100, #128, #15, #21, and #101)The findings include:Resident #66 A review of medical recordS for Resident #66 revealed the resident was admitted on [DATE]. Resident #66's quarterly Minimum Data Set (MDS) (a standardized, mandatory assessment tool in long-term care (LTC) nursing homes, used to evaluate resident functional capabilities, health status, and care needs) dated 2/6/26 reveals resident's Brief Interview for Mental Status (BIMS) of 01, (a cognitive assessment tool) indicating severe cognitive… […]

• No harm, potential for more than minimal, isolatedF552Mar 27, 2026

  Based on interviews and record review, the facility failed to ensure the resident's right to be fully informed and to participate in care decisions, including the provision of a properly executed consent for psychotropic medication for 3 out 3 consents reviewed. (Resident #13, # 60 and #128)The findings include:A review of Resident #13's medical record revealed a psychotropic medication consent form 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. […]

• No harm, potential for more than minimal, isolatedF645Mar 27, 2026

  Based on interviews and record reviews, the facility failed to ensure the accuracy and completeness of Preadmission Screening and Resident Review (PASRR) documentation for 3 of 4 residents reviewed for PASRR compliance. (Residents #3, #72 and #95) The findings include:Resident #95 Resident #95 was admitted to the facility on [DATE] with diagnoses which included a primary diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms, and secondary diagnoses of anxiety disorder, bipolar disorder, and other disorders of psychological development. Further review of Resident #95's medical record reveals a Psychiatric Periodic Evaluation dated 1/15/26, which revealed the resident has a past history of involuntary inpatient psychiatric care and outpatient psychiatric care. […]