Cycle 1
Health 2025-09-05 · Fire 2025-09-05
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Santa Rosa, CA
Summerfield Health Care Center
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
1280 Summerfield Rd, Santa Rosa, CA
(707) 539-1515
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1972-06-21
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
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.09
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.69
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.60
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.91
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.39
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
3.60
CMS adjusted total nurse staffing hours
Case-mix index
1.75
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,082
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9995
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.30
Baseline 14.60% · Performance 18.05% · Measure score 7.30 · Achievement 7.30 · Improvement 0
Healthcare-associated infections
3.91
Baseline 5.21% · Performance 6.67% · Measure score 3.91 · Achievement 3.91 · Improvement 0
Total nurse turnover
5.15
Baseline 42.86% · Performance 42.65% · Measure score 5.15 · Achievement 5.15 · Improvement 0
Adjusted total nurse staffing
2.09
Baseline 3.53 hours · Performance 3.67 hours · Measure score 2.09 · Achievement 2.09 · Improvement 0.15
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.3% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 622 · Observed rate 10.29% · Lower 95% interval 9.35% |
| Discharge to community | 67.66% |
50.57%
17.1 pts better
|
Better than the National Rate · Eligible stays 633 · Observed rate 63.98% · Lower 95% interval 62.84% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.17% |
95.27%
2.1 pts worse
|
Numerator 450 · Denominator 483 |
| Falls with major injury | 0.21% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 483 |
| Discharge self-care score | 65.15% |
53.69%
11.5 pts better
|
Numerator 258 · Denominator 396 |
| Discharge mobility score | 71.21% |
50.94%
20.3 pts better
|
Numerator 282 · Denominator 396 |
| Pressure ulcers or injuries, new or worsened | 0.21% |
2.29%
2.1 pts better
|
Numerator 1 · Denominator 483 · Adjusted rate 0.27% |
| Healthcare-associated infections requiring hospitalization | 6.67% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 433 · Observed rate 5.77% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 15.25% |
8.2%
7.1 pts better
|
Numerator 18 · Denominator 118 |
| Staff flu vaccination coverage | 75.19% |
42%
33.2 pts better
|
Numerator 100 · Denominator 133 |
| Discharge function score | 67.17% |
56.45%
10.7 pts better
|
Numerator 266 · Denominator 396 |
| Transfer of health information to provider | 80.3% |
95.95%
15.7 pts worse
|
Numerator 53 · Denominator 66 |
| Transfer of health information to patient | 91.2% |
96.28%
5.1 pts worse
|
Numerator 373 · Denominator 409 |
| Resident COVID-19 vaccinations up to date | 5.66% |
25.2%
19.5 pts worse
|
Numerator 15 · Denominator 265 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
98.5%
0.5 pts worse
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
1.6%
2.3 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.3% |
6.8%
1.5 pts worse
|
11.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
4.1%
2.1 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.0% |
13.7%
13.7 pts better
|
19.6%
19.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.7% |
14.2%
8.5 pts worse
|
16.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.7% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
10.7%
0.1 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.6% · 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 · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.0% |
10.9%
6.1 pts worse
|
19.8%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
94.0%
2.7 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 96.6% · Q3 96.1% · Q4 96.4% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
11.2%
2 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 12.4% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.8% · Q3 0.9% · Q4 0.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
93.2%
2.2 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
23.2%
2.4 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 18.7% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
11 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-01-14 · Fire 2022-01-14
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-09-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-11
F · Potential for more than minimal harm
2024-03-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-03-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-08
D · Potential for more than minimal harm
2022-01-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-02-11
D · Potential for more than minimal harm
2022-01-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-11
D · Potential for more than minimal harm
2022-01-14
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-02-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-03-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-20
D · Potential for more than minimal harm
2024-09-05
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-03-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-06
E · Potential for more than minimal harm
2024-03-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-04-06
E · Potential for more than minimal harm
2024-03-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-06
E · Potential for more than minimal harm
2024-03-15
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 2024-04-06
E · Potential for more than minimal harm
2024-03-15
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 2024-04-06
D · Potential for more than minimal harm
2024-03-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-06
D · Potential for more than minimal harm
2024-03-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-06
D · Potential for more than minimal harm
2024-03-15
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-04-06
D · Potential for more than minimal harm
2024-03-15
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-04-06
D · Potential for more than minimal harm
2024-03-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-06
F · Potential for more than minimal harm
2023-05-11
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 2023-05-11
D · Potential for more than minimal harm
2023-05-11
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 2023-05-11
F · Potential for more than minimal harm
2022-01-14
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 2022-03-10
E · Potential for more than minimal harm
2022-01-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-03-10
E · Potential for more than minimal harm
2022-01-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-03-10
D · Potential for more than minimal harm
2022-01-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-10
Penalties and ownership
What sits behind the stars
$3,145
2023-08-07
Fine
Fine · fine $3,145
Fine
Ownership
Flagstone Healthcare North LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Bush, Cason
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Sae, Aynna
Operational/Managerial Control · Individual
Willits, Adam
Corporate Officer · Individual
Nearby options
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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
#2
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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
#3
Spring Lake Village
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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
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