Santa Rosa Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF760Dec 26, 2025

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) out of three sampled residents was free from a significant medication error when:Resident 1 did not have a person-centered care plan that included the administration of glucagon (emergency treatment to raise blood sugar levels) during a hypoglycemic episode (when a person's blood sugar level drops below 70 milligrams per deciliter (a unit of measurement)) nor one for Resident 1's risk for refractory hypoglycemia;Licensed Nurse 2 (LN 2) documented that insulin was administered at 11:30 a.m. […]

• Actual harm, isolatedF678Jan 28, 2025

  Based on interviews and record reviews, the facility failed to provide resident-centered care to one resident (Resident 1) of four sampled residents when Licensed Nurses administered Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions combined with artificial breathing in an effort to manually preserve brain function to restore blood circulation and breathing in a person whose heart unexpectedly stops beating) against Resident 1 ' s decision not to be resuscitated (rescued). […]

• Actual harm, isolatedF684Mar 1, 2023

  Based on observation, interviews and records review, the facility failed to assess and provide necessary treatment and services for two of two sampled residents (Resident 1, and Resident 2) when: 1. Resident 1 was not properly assessed for symptoms of scabies (an itching skin irritation caused by the microscopic human itch mite, which burrows into the skin's upper layers and eventually causes itching, tiny irregular red lines just above the skin and an allergic rash) when she developed skin rashes to her arms, legs, and abdomen and the facility did not administer Permethrin cream (medication used to treat scabies) and Ivermectin (an anti-parasitic drug) to Resident 1 according to the dermatologist ' s order. This failure resulted in: a. […]

• No harm, potential for more than minimal, widespreadF607May 2, 2025

  Based on interview and record review, the facility failed to protect a census of 94 residents from sexual abuse when the facility allowed an alleged perpetrator, Certified Nursing Assistant 1 (CNA 1), to enter the facility on 4/4/25 after conducting an incomplete investigation per facility policy for a census of 94 residents. This failure granted CNA 1 access to Resident 1 and had the potential to place Resident 1 and other residents at risk for further harm. Cross-reference F610. Findings A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of cardiomegaly (a condition when the heart becomes larger than normal) and dementia (a progressive state of mental decline). A review of Resident 1's progress note dated 4/4/25 at 9:38 p.m. […]

• No harm, potential for more than minimal, widespreadF610May 2, 2025

  Based on interview and record review, the facility failed to thoroughly investigate an allegation of sexual abuse for one resident (Resident 1) of eight sampled residents when Resident 1 alleged a male Certified Nursing Assistant (CNA) matching the identity of CNA 1 exposed himself to Resident 1 and forced Resident 1 to touch his genitals. This failure decreased the facility's potential to protect Resident 1 and a facility census of 94 residents at the facility from harm. Findings: A review of CNA 1's employee file indicated he was hired at the facility on 8/31/21. […]