Santa Rosa Center for Rehabilitation and Healing

In the surveyor’s words

From the most serious findings on record at Santa Rosa Center for Rehabilitation and Healing, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF758Apr 20, 2023

  Based on interview and record review, the facility failed to ensure that orders for as needed (PRN) psychotropic medications (other than antipsychotics) indicated a duration for order for 6 of 8 residents reviewed for psychiatric medications. (Residents #398, #399, #56, #68, #73, and #66) The findings include: Resident #389 A review of Resident #389's physician orders revealed an order for Lorazepam (a psychotropic mediation used to treat anxiety) 0.5 milligrams (mg) every two hours as needed for anxiety, with no end date. […]

• No harm, potential for more than minimal, patternF695Nov 18, 2021

  Based on record review and staff interview the facility failed to provide respiratory care in accordance with the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #137 Review of Resident #137's record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] = Clear; 2= Rales; 3= Rhonchi; 4= Wheeze; 5= Rub; 6= Diminished. Document Location: A= Anterior; P= Posterior, R= Right; L=Lower; B= Bilateral. Review of the Medication Administration Record (MAR) for November 2021 revealed the area for documenting lung sounds (LS) was blank from 11/11/2021 through 11/16/2021. On 11/17/2021 at approximately 10:06 AM, an interview was conducted with Staff A, Registered Nurse (RN). […]

• No harm, potential for more than minimal, isolatedF686Jun 2, 2026

  Based on a record review, interviews, and review of facility policy, the facility failed to prevent new skin breakdown from occurring for 1 of 3 residents reviewed for pressure ulcers (Resident #3).The findings include:Review of Resident #3's medical record revealed he had been admitted to the facility on [DATE] for respite services. Resident #3 had a medical history significant for Alzheimer's, dementia, and a stroke in 2024 which caused him to have left sided weakness. Review of Resident #3's Baseline Care Plan revealed the section for skin breakdown was left blank. A Skin Risk Assessment performed on 04/24/26 identified that Resident #3 was at moderate risk for skin breakdown. […]

• No harm, potential for more than minimal, isolatedF554Dec 4, 2025

  Based on observation, resident interview, staff interviews, record review, and policy review, the facility failed to ensure the interdisciplinary team assessed and determined residents were capable of self-administration of medications prior to allowing 1 of 20 sampled residents to self-administer medications. (Resident #2) The findings include: An observation of Resident #2 was conducted on 12/1/25 at 11:41 AM. The resident was in bed and a green, round pill was observed in a medication cup on top of the overbed table. The resident stated the medication was a Tums (a medication used for upset stomach and nausea) and that the nurse brought it in a while ago. […]

• No harm, potential for more than minimal, isolatedF656Dec 4, 2025

  Based on observations, record review, staff interview, and policy review, the facility failed to implement the plan of care for 1 of 1 sampled resident reviewed for edema. (Resident #103)The findings include:Observations of Resident #103 were conducted on 12/2/25 at 12:05 PM and 12/3/25 at 11:35 AM. During both observations, the resident was sitting in his wheelchair with no compression stockings on his lower extremities. A review of Resident #103's electronic medical record revealed the resident had a current diagnosis of edema and a current physician order dated 11/13/25 for compression stockings to bilateral lower extremities when out of bed as tolerated. A review of the current medication and treatment records revealed no indication of the use of compression stockings. […]