Inspection Results » Santa Rosa Post Acute

Health Inspection on March 28, 2019 ^[1]

1. Isolated: Actual harm that is not immediate jeopardy

   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected N/A)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected N/A)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected N/A)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected N/A)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected N/A)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected N/A)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected N/A)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected N/A)
   • Provide and implement an infection prevention and control program. (Corrected N/A)
   • PASARR screening for Mental disorders or Intellectual Disabilities (Corrected N/A)
   • 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. (Corrected N/A)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Reasonably accommodate the needs and preferences of each resident. (Corrected N/A)
   • 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. (Corrected N/A)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Corrected N/A)
   • Ensure medication error rates are not 5 percent or greater. (Corrected N/A)
   • 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. (Corrected N/A)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected N/A)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected N/A)
   • Ensure each resident receives an accurate assessment. (Corrected N/A)