Santa Rosa Post Acute
4650 Hoen Avenue · Santa Rosa, CA · 95405 · 7075460471
99 certified beds For profit - Limited Liability company Chain: Pacs Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results have improved across recent cycles.
The composite number cleared 70 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 3 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 4.02 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.67 | 0.55–0.75 |
| Weekend hours / resident-day | 3.47 | ≈ weekday level |
| Nursing turnover / year | 30% | median 45% |
| Fines (3-yr window) | 1 · $10,166 |
Inspection citations (54 in the current record)
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Potential for harm · D March 11, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 9, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E March 11, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 5, 2026 · Quality of Life and Care
-
Potential for harm · D February 6, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 13, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 26, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has no plan of correction · Resident Rights
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Potential for harm · D December 26, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has no plan of correction · Pharmacy Service
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Potential for harm · D September 12, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected October 6, 2025 · Resident Assessment and Care Planning
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Potential for harm · D September 12, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 6, 2025 · Quality of Life and Care
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Potential for harm · D September 12, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Corrected October 6, 2025 · Quality of Life and Care
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Potential for harm · E September 12, 2025
Observe each nurse aide's job performance and give regular training.
Corrected October 6, 2025 · Nursing and Physician Services
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Potential for harm · E September 12, 2025
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected October 6, 2025 · Quality of Life and Care
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Potential for harm · E September 12, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 6, 2025 · Nutrition and Dietary
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Potential for harm · D September 12, 2025
Provide and implement an infection prevention and control program.
Corrected October 6, 2025 · Infection Control
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Potential for harm · D September 12, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected October 6, 2025 · Environmental
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Potential for harm · D September 12, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected October 6, 2025 · Environmental
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Potential for harm · E September 12, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected October 6, 2025 · Environmental
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Potential for harm · E September 2, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected October 5, 2025 · Resident Assessment and Care Planning
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Potential for harm · F May 2, 2025 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected May 12, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · F May 2, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected May 12, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 25, 2025 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected May 16, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 25, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected May 16, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E April 9, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected May 2, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E March 24, 2025 · found via complaint
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 April 7, 2025 · Resident Rights
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Potential for harm · E February 24, 2025 · found via complaint
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected March 11, 2025 · Resident Rights
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Actual harm · G January 28, 2025 · found via complaint
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected February 13, 2025 · Quality of Life and Care
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Potential for harm · F December 5, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected January 3, 2025 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 28, 2025 | Fine | $10,166 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055854 · certified since November 3, 1967. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.