Cycle 1
Health 2025-12-19 · Fire 2025-12-19
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cloverdale, CA
Cloverdale Healthcare Center
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
300 Cherry Creek Rd, Cloverdale, CA
(707) 894-5201
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1974-07-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
4.52
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,497
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.43
Composite VBP score used to determine payment impact.
Payment multiplier
1.0034
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 21.31% · Performance 16.54% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
4.66
Baseline 7.07% · Performance 6.44% · Measure score 4.66 · Achievement 4.66 · Improvement 2.55
Total nurse turnover
1.79
Baseline 50.88% · Performance 56.36% · Measure score 1.79 · Achievement 1.79 · Improvement 0
Adjusted total nurse staffing
3.32
Baseline 4.38 hours · Performance 4.02 hours · Measure score 3.32 · Achievement 3.32 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.12% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 180 · Observed rate 6.67% · Lower 95% interval 6.45% |
| Discharge to community | 68.36% |
50.57%
17.8 pts better
|
Better than the National Rate · Eligible stays 174 · Observed rate 67.24% · Lower 95% interval 58.8% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.81% |
95.27%
3.5 pts better
|
Numerator 83 · Denominator 84 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 84 |
| Discharge self-care score | 64.52% |
53.69%
10.8 pts better
|
Numerator 40 · Denominator 62 |
| Discharge mobility score | 61.29% |
50.94%
10.4 pts better
|
Numerator 38 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 84 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.44% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 5.36% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | 9.41% |
8.2%
1.2 pts better
|
Numerator 8 · Denominator 85 |
| Staff flu vaccination coverage | 69.61% |
42%
27.6 pts better
|
Numerator 71 · Denominator 102 |
| Discharge function score | 67.74% |
56.45%
11.3 pts better
|
Numerator 42 · Denominator 62 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 69 · Denominator 69 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 46 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.1 |
2.3
2.2 pts better
|
1.9
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.1 · Observed 0.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
98.2%
0.8 pts worse
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
1.6%
0.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 2.8% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.9% |
6.8%
5.1 pts worse
|
11.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 9.7% · Q3 11.4% · Q4 8.1% · 4Q avg 11.9% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
4.1%
3.2 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.7% |
13.7%
6 pts worse
|
19.6%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 21.4% · Q3 13.8% · Q4 15.2% · 4Q avg 19.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
14.2%
3.3 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 12.0% · Q3 11.5% · Q4 7.4% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.8% |
11.0%
2.2 pts better
|
16.3%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.7% |
10.7%
9 pts better
|
14.9%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.9% |
10.9%
2 pts worse
|
19.8%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 13.8% · Q3 11.4% · Q4 13.7% · 4Q avg 12.9% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.7%
4.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
11.2%
0.7 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 10.5% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.9% |
93.2%
5.7 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.4% |
23.2%
10.8 pts better
|
23.9%
11.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 10.5% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-01-09 · Fire 2025-01-09
1 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-10-21 · Fire 2022-10-21
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-12-31
F · Potential for more than minimal harm
2025-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-28
D · Potential for more than minimal harm
2025-01-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-21
D · Potential for more than minimal harm
2025-01-09
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-01-16
D · Potential for more than minimal harm
2022-10-21
K525 · Services Deficiencies
Fire Safety
Enure that solid fuel-burning fireplaces are not in patient sleeping areas.
Corrected 2022-12-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-29
E · Potential for more than minimal harm
2025-12-19
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-12-19
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-12-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-03-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-17
B · Minimal harm
2025-01-09
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-02-02
E · Potential for more than minimal harm
2022-10-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-01-30
E · Potential for more than minimal harm
2022-10-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-01-30
E · Potential for more than minimal harm
2022-10-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-30
D · Potential for more than minimal harm
2022-10-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-01-30
D · Potential for more than minimal harm
2022-10-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-30
D · Potential for more than minimal harm
2022-10-21
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-01-30
D · Potential for more than minimal harm
2022-10-21
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-01-30
Penalties and ownership
What sits behind the stars
Ownership
Burnam, Soon
Corporate Officer · Individual
Flagstone Healthcare North LLC
5% Or Greater Direct Ownership Interest · Organization
Gamble, Shawndee
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Serrano, Noel
Operational/Managerial Control · Individual
The Ensign Group Inc
5% Or Greater Direct Ownership Interest · Organization
Twomagnets LLC
Operational/Managerial Control · Organization
Willits, Adam
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Healdsburg Hospital D/P SNF
Healdsburg, CA
5-star overall rating with 5-star inspections with $59,634 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Lakeport Post Acute
Lakeport, CA
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Rocky Point Care Center
Lakeport, CA
3-star overall rating with 2-star inspections with abuse icon flag with 16 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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