16 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Santa Rosa, CA
5-star overall rating with 3-star inspections with $44,730 in total fines with 16 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
5555 Montgomery Drive, Santa Rosa, CA
(707) 538-8400
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
70
Certified beds
Average residents
45
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Front Porch
Operator or chain grouping
Approved since
1986-12-04
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
9 facilities
Chain averages 5 overall / 4 health / 4 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
1.12
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.80
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.22
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.42
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.58
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.86
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
1.24
CMS adjusted RN staffing hours
Adjusted total hours
5.77
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
780
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.85
Composite VBP score used to determine payment impact.
Payment multiplier
1.0185
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.08
Baseline 17.72% · Performance 20.47% · Measure score 2.08 · Achievement 2.08 · Improvement 0
Healthcare-associated infections
5.36
Baseline 5.57% · Performance 6.23% · Measure score 5.36 · Achievement 5.36 · Improvement 0
Total nurse turnover
10
Baseline 47.27% · Performance 16.67% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
8.10
Baseline 5.09 hours · Performance 5.38 hours · Measure score 8.10 · Achievement 8.10 · Improvement 3.76
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.36% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 165 · Observed rate 4.85% · Lower 95% interval 5.86% |
| Discharge to community | 64.16% |
50.57%
13.6 pts better
|
Better than the National Rate · Eligible stays 177 · Observed rate 68.36% · Lower 95% interval 57.71% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.41% |
95.27%
3.1 pts better
|
Numerator 124 · Denominator 126 |
| Falls with major injury | 1.59% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 126 |
| Discharge self-care score | 74.11% |
53.69%
20.4 pts better
|
Numerator 83 · Denominator 112 |
| Discharge mobility score | 83.93% |
50.94%
33 pts better
|
Numerator 94 · Denominator 112 |
| Pressure ulcers or injuries, new or worsened | 2.38% |
2.29%
0.1 pts worse
|
Numerator 3 · Denominator 126 · Adjusted rate 2.38% |
| Healthcare-associated infections requiring hospitalization | 6.23% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 2.86% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | 15.12% |
8.2%
6.9 pts better
|
Numerator 13 · Denominator 86 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 81.25% |
56.45%
24.8 pts better
|
Numerator 91 · Denominator 112 |
| Transfer of health information to provider | 97.78% |
95.95%
1.8 pts better
|
Numerator 88 · Denominator 90 |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 22 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 41.89% |
25.2%
16.7 pts better
|
Numerator 31 · Denominator 74 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
2.3
1.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.6
1.2 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
98.5%
0.1 pts worse
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.8% · Q3 96.7% · Q4 100.0% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
98.2%
6.5 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
1.6%
About the same
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 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 who lose too much weight | 1.0% |
4.1%
3.1 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.7% |
13.7%
8 pts better
|
19.6%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 3.8% · Q3 3.8% · Q4 4.0% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
14.2%
3 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.7% · Q3 17.4% · Q4 9.5% · 4Q avg 11.2% · 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 | 20.6% |
11.0%
9.6 pts worse
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
10.7%
3.7 pts worse
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 11.5% · Q3 11.5% · Q4 24.0% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.0%
0.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · 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 | 24.5% |
10.9%
13.6 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 19.4% · Q3 27.9% · Q4 27.4% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.7%
1.2 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 0.0% · Q3 3.4% · Q4 2.6% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
94.0%
5.4 pts worse
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.5% · Q2 87.9% · Q3 94.6% · Q4 85.4% · 4Q avg 88.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
11.2%
4.5 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 5.6% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.9% · Q3 1.6% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.2% |
93.2%
9 pts worse
|
79.7%
4.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
23.2%
4.7 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 13.6% · Expected 17.5% · Used in QM five-star |
Survey summary
Top issue: Nutrition and Dietary (4 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-08
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-08
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-03-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-08
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2025-03-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-08
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-03-08
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-08
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-08
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-05-15
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-05-15
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-15
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-05-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-15
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-15
Fire Safety
Use approved construction type or materials.
Corrected 2023-05-15
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-05-15
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-15
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-05-15
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-15
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-15
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-15
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-15
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-05-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-15
Fire Safety
Provide emergency officials' contact information.
Corrected 2020-04-08
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2020-04-08
Fire Safety
Use approved construction type or materials.
Corrected 2020-04-08
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-04-08
Inspection history
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-15
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-03-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-14
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-14
Health
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 2025-03-14
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-14
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-14
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-14
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-14
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 2025-03-14
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-03-14
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-03-14
Health
Dispose of garbage and refuse properly.
Corrected 2025-03-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-30
Health
Dispose of garbage and refuse properly.
Corrected 2023-06-30
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-30
Health
Provide activities to meet all resident's needs.
Corrected 2023-06-30
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-30
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-30
Health
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.
Corrected 2020-04-02
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2020-04-02
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2020-04-02
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-04-02
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-04-02
Health
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 2020-04-02
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 2020-04-02
Penalties and ownership
Fine · fine $44,730
Fine
Payment Denial · denial start 2023-06-10 · 35 days
35 day denial
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Nearby options
Santa Rosa, CA
5-star overall rating with 5-star inspections with $3,145 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Santa Rosa, CA
3-star overall rating with 2-star inspections with abuse icon flag with 19 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Santa Rosa, CA
2-star overall rating with 1-star inspections with $107,746 in total fines with 18 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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