A list of the most recent deficiencies for Santa Rosa Post Acute. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-24 | 2024-02-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-24 | 2024-02-16 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2024-01-03 | 2024-01-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-22 | 2024-01-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-22 | 2024-01-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-15 | 2023-12-31 | Y |
| Keep all essential equipment working safely. | Health | 2023-12-14 | 2023-12-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-02 | 2023-11-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-28 | 2023-10-13 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-20 | 2023-08-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-20 | 2023-08-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-22 | 2023-07-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-24 | 2023-05-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-24 | 2023-05-11 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-12 | 2023-04-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-01 | 2023-04-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-01 | 2023-04-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-14 | 2023-03-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-14 | 2023-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-28 | 2023-03-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-14 | 2023-02-28 | Y |
| 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 | 2022-12-23 | 2023-02-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-19 | 2023-01-31 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-12-19 | 2023-01-31 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-04 | 2023-01-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-04 | 2023-01-18 | Y |
| 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 | 2022-12-21 | 2023-01-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-21 | 2023-01-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-05 | 2022-11-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-05 | 2022-11-18 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-05 | 2022-11-18 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-10-05 | 2022-11-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-13 | 2022-11-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-23 | 2022-10-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-03 | 2022-10-12 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-03 | 2022-08-17 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-08-03 | 2022-08-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-16 | 2022-06-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-03 | 2022-05-10 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-03 | 2022-05-10 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-02-22 | 2022-03-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-31 | 2022-03-07 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-02-07 | 2022-02-28 | Y |
| Provide or obtain dental services for each resident. | Health | 2022-02-07 | 2022-02-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-18 | 2022-01-17 | Y |
| Post nurse staffing information every day. | Health | 2021-11-18 | 2022-01-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-02 | 2021-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-18 | 2021-09-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-27 | 2021-09-15 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-04-29 | 2021-07-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-04-29 | 2021-07-01 | N |
| Use approved construction type or materials. | Fire Safety | 2021-04-29 | 2021-07-01 | 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 | 2021-04-29 | 2021-07-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-04-29 | 2021-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-29 | 2021-07-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-29 | 2021-07-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-29 | 2021-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-29 | 2021-07-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-29 | 2021-07-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-17 | 2021-05-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-23 | 2021-05-25 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2021-04-23 | 2021-05-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-04-23 | 2021-05-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-23 | 2021-05-25 | N |
| Provide activities to meet all resident's needs. | Health | 2021-04-23 | 2021-05-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-23 | 2021-05-25 | 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 | 2021-04-23 | 2021-05-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-23 | 2021-05-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-23 | 2021-05-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-28 | 2019-07-24 | 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 | 2019-03-28 | 2019-07-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-28 | 2019-07-24 | 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 | 2019-03-28 | 2019-07-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-28 | 2019-07-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-28 | 2019-07-24 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-03-28 | 2019-07-24 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-03-28 | 2019-07-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-03-28 | 2019-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-28 | 2019-07-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Use approved construction type or materials. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-05-28 | 2019-06-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-28 | 2019-06-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-28 | 2019-06-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-03-28 | 2019-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-28 | 2019-06-03 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-03-28 | 2019-06-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-03-28 | 2019-06-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-28 | 2019-06-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-03-28 | 2019-06-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-28 | 2019-06-03 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-03-28 | 2019-06-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-04-10 | 2018-04-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-04-10 | 2018-04-27 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-04-10 | 2018-04-27 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-04-10 | 2018-04-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-10 | 2018-04-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-04-10 | 2018-04-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-10 | 2018-04-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-04-10 | 2018-04-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-04-10 | 2018-04-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-10 | 2018-04-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-16 | 2018-04-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-03-16 | 2018-04-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-16 | 2018-04-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-03-16 | 2018-04-20 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-03-16 | 2018-04-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-03-16 | 2018-04-20 | 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 | 2018-03-16 | 2018-04-20 | N |
