SANTA ROSA POST ACUTE

4650 HOEN AVENUE, SANTA ROSA, CA 95405

C
Facility Assessment 1 federal violation at this facility remains unresolved. Inspectors recorded 2 citations at the actual-harm level or worse in the last three survey cycles.

At or above the 2024 benchmark — average inspection record.

Quality Breakdown

RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
0.67 — At or above the repealed 0.55 hr benchmark

The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why

Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
Total 54
Outstanding 1
Actual harm or worse (G–L) 2
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
Quality: ★★★★★ (5/5)
Staffing: ★★★★☆ (4/5)
NursingHomeGrade Score
52/100

Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

2 actual harm issues found among 54 total deficiencies. 53 corrected. — 1 still outstanding

Most recent inspection (September 12, 2025)

D Potential harm — isolated F0600 Status: Outstanding — No Plan

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has no plan of correction

D Potential harm — isolated F0919 Status: Corrected

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2025

D Potential harm — isolated F0921 Status: Corrected

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2025

E Potential harm — pattern F0925 Status: Corrected

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2025

F Potential harm — widespread F0607 Status: Corrected

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 12, 2025

F Potential harm — widespread F0610 Status: Corrected

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 12, 2025

D Potential harm — isolated F0607 Status: Corrected

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2025

D Potential harm — isolated F0609 Status: Corrected

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2025

E Potential harm — pattern F0609 Status: Corrected

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected May 2, 2025

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2025

E Potential harm — pattern F0730 Status: Corrected

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2025

E Potential harm — pattern F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2025

G Actual harm — isolated F0760 Status: Corrected

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 14, 2026

D Potential harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2025

D Potential harm — isolated F0697 Status: Corrected

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2025

E Potential harm — pattern F0741 Status: Corrected

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2025

E Potential harm — pattern F0658 Status: Corrected

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 5, 2025

D Potential harm — isolated F0655 Status: Corrected

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 6, 2025

Inspection cycle 2 (December 5, 2024)

F Potential harm — widespread F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected January 3, 2025

D Potential harm — isolated F0800 Status: Corrected

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 12, 2024

D Potential harm — isolated F0801 Status: Corrected

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.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 12, 2024

E Potential harm — pattern F0804 Status: Corrected

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected July 12, 2024

D Potential harm — isolated F0755 Status: Corrected

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2024

G Actual harm — isolated F0678 Status: Corrected

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 13, 2025

D Potential harm — isolated F0692 Status: Corrected

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected September 15, 2024

E Potential harm — pattern F0655 Status: Corrected

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected July 12, 2024

E Potential harm — pattern F0584 Status: Corrected

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 7, 2025

E Potential harm — pattern F0573 Status: Corrected

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected March 11, 2025

D Potential harm — isolated F0576 Status: Corrected

Ensure residents have reasonable access to and privacy in their use of communication methods.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 23, 2024

E Potential harm — pattern F0576 Status: Corrected

Ensure residents have reasonable access to and privacy in their use of communication methods.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected November 6, 2024

Inspection cycle 3 (January 3, 2024)

D Potential harm — isolated F0839 Status: Corrected

Employ staff that are licensed, certified, or registered in accordance with state laws.

Administration Deficiencies — Deficient, Provider has date of correction, corrected January 13, 2024

E Potential harm — pattern F0908 Status: Corrected

Keep all essential equipment working safely.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2023

E Potential harm — pattern F0600 Status: Corrected

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 16, 2024

D Potential harm — isolated F0607 Status: Corrected

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 28, 2023

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 31, 2023

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 25, 2021

D Potential harm — isolated F0755 Status: Corrected

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 8, 2024

D Potential harm — isolated F0755 Status: Corrected

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 25, 2021

D Potential harm — isolated F0761 Status: Corrected

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 25, 2021

E Potential harm — pattern F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 8, 2024

E Potential harm — pattern F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 13, 2023

E Potential harm — pattern F0689 Status: Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 5, 2023

D Potential harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 11, 2023

D Potential harm — isolated F0679 Status: Corrected

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 25, 2021

E Potential harm — pattern F0656 Status: Corrected

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 16, 2024

E Potential harm — pattern F0658 Status: Corrected

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 14, 2023

E Potential harm — pattern F0657 Status: Corrected

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 5, 2023

E Potential harm — pattern F0655 Status: Corrected

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 11, 2023

D Potential harm — isolated F0656 Status: Corrected

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 25, 2021

D Potential harm — isolated F0842 Status: Corrected

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 25, 2021

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 25, 2021

D Potential harm — isolated F0575 Status: Corrected

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 25, 2021

E Potential harm — pattern F0623 Status: Corrected

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 25, 2021

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C

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