Santa Rosa Care Center

In the surveyor’s words

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

• Actual harm, isolatedF760Aug 9, 2023

  Based on record review, staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#99) was free of any significant medication error. The deficient practice could result in resident having adverse effects and complications. Findings include: Resident #99 was admitted on [DATE] with diagnoses included epilepsy, schizophrenia, heart disease, peripheral vascular disease, macular degeneration, and hypertension. The care plan dated 01/18/2022 revealed the resident had seizure disorder. The goal was that the resident will be free from injury related to seizure activity. […]

• Actual harm, isolatedF684Mar 26, 2021

  Based on staff interviews, clinical record review, facility documentation, and policy review, the facility failed to ensure one resident (#304) received treatment and care in accordance with the resident's choice, regarding full code status. The deficient practice could result in residents' choices regarding code status not being implemented. Findings include: Resident #304 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Advanced Directive dated February 22, 2017 revealed the resident had chosen to be a Full Code, that he wanted his life to be prolonged to the greatest extent possible. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF812Aug 29, 2025

  Based on observations, staff interviews, and review of facility policies, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice has the potential to increase the risk of foodborne illness and compromise resident healthFindings Include:An initial kitchen observation was conducted on August 26, 2025 at 08:26 AM in conjunction with the Dietary Director, (Staff # 116). During observation of the food preparation area, two sanitizer buckets, one containing a dish rag, were observed in the food preparation area where a bowl of pudding/pie mix was being prepared. A portable, blue plastic fan was observed sitting on a metal rack, blowing across the food server's side of the tray line. […]

• No harm, potential for more than minimal, patternF880Aug 29, 2025

  Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that food was served in accordance with professional standards of food service safety. The deficient practices could result in food-borne illnesses.Findings Include:An initial kitchen observation was conducted on August 26, 2025, at 08:26 AM in conjunction with the Dietary Director (Staff # 116). During observation of the food preparation area, two sanitizer buckets, one containing a dish rag, were observed in the food preparation area where a bowl of pudding/pie mix was being prepared. A portable, blue plastic fan was observed sitting on a metal rack, blowing across the food server's side of the tray line. […]

• No harm, potential for more than minimal, patternF600Jun 13, 2025

  Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#235) were free from physical abuse resulting in injury by other residents (resident #205). The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #235 was admitted to the facility on [DATE] with diagnosis that include Diabetes Mellitus type 2, Benign Prostatic hyperplasia, Chronic obstructive pulmonary disease, Dementia, and Hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had severe cognitive impairment. […]