A list of the most recent deficiencies for Santa Rosa Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-27 | 2023-12-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-10-27 | 2023-12-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-10-27 | 2023-12-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-27 | 2023-12-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-27 | 2023-12-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-27 | 2023-12-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-27 | 2023-12-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-27 | 2023-12-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-27 | 2023-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-27 | 2023-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-27 | 2023-12-06 | N |
| Dispose of garbage and refuse properly. | Health | 2023-10-27 | 2023-12-06 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-27 | 2023-11-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-09 | 2023-09-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-22 | 2023-05-31 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-01 | 2022-11-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-01 | 2022-11-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-01 | 2022-11-23 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-09-01 | 2022-11-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-01 | 2022-11-23 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-01 | 2022-11-14 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-09-01 | 2022-11-14 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-09-01 | 2022-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-01 | 2022-11-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-01 | 2022-11-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-01 | 2022-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-01 | 2022-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-01 | 2022-11-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-09-01 | 2022-11-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-26 | 2021-04-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-26 | 2021-04-29 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-03-26 | 2021-04-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-03-26 | 2021-04-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-26 | 2021-04-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-26 | 2021-04-29 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-03-26 | 2021-04-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-26 | 2021-04-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-26 | 2021-04-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-26 | 2021-04-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-26 | 2021-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-26 | 2021-04-29 | N |
| Respond appropriately to all alleged violations. | Health | 2021-03-26 | 2021-04-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-26 | 2021-04-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-26 | 2021-04-29 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-26 | 2021-04-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-03-26 | 2021-04-23 | N |
