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Nursing HomeMedicaid Investigative

Santa Rosa Post Acute

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

4650 Hoen Avenue, Santa Rosa, CA 9540599 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.4/5

based on 78 Google reviews

5
4
3
2
1
Santa Rosa Post Acute Nursing Home in Santa Rosa, CA — Street View
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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Above-median deficiencies (18 vs median 13.0)

Below average in CA · Below recommended RN staffing · Below chain average · $107,746 in fines

Source: Medicare data

What this means for your family

This facility offers exceptional physical and occupational therapy that can significantly aid in post-surgical recovery. However, you must be extremely vigilant regarding medical monitoring, as multiple family members have reported alarming instances of staff failing to recognize serious medical declines.

Google Reviews

Google Reviews

78 reviews on Google
Families seeking rehabilitation will find highly praised physical and occupational therapy services and a compassionate nursing staff. However, there are serious, critical reports regarding medical neglect, dehydration, and failure to recognize declining health, which should be investigated thoroughly.

Quality Themes

Tap a score for details
Food7.0Staff8.0Clean9.0ActivitiesN/AMedsN/AMemoryN/AComms6.0ValueN/A

Strengths

  • Excellent physical and occupational therapy
  • Compassionate and caring nursing staff
  • Clean and well-maintained environment
  • Positive and supportive atmosphere

Concerns

  • Critical medical neglect and failure to monitor patient decline (mentioned by 2 reviewers)
  • Inconsistent responsiveness to call lights (mentioned by 2 reviewers)
  • Issues with patient clothing/belongings management

Rating Trends

Tap a year to see what changed

234'16(1)'20(21)'22(2)'24(6)'26(12)

Distribution · 82 analyzed

5
63
4
10
3
0
2
1
1
8
13 reviews posted between Nov 8, 2020Nov 13, 2020 · 12 were 5-star

How They Respond to Reviews

23%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1We've heard wonderful things about the physical and occupational therapy programs here; could you tell us more about how those sessions are tailored to each resident's needs?
  • 2How does the nursing team monitor changes in a resident's health to ensure that any decline in condition is caught and addressed immediately?
  • 3What is the protocol for responding to call lights, and how do you ensure that residents receive timely assistance throughout the night?
  • 4Could you describe the process for managing and tracking residents' personal belongings and clothing to prevent anything from getting lost?
  • 5What kind of daily activities or social events are organized to help residents stay engaged and part of the community?
  • 6In the event of a medical emergency, what are the specific steps the staff takes to coordinate care and communicate with the family?

Personalized based on this facility's data


Key Review Excerpts

The staff is AMAZING, respectful, helpful, patient, kind, and CARING. If I was ever in need of physical rehab again I would definitely go to Summerfield.

Rehab patient · 2025★★★★★

My grandfather was transferred from our local hospital to this facility after undergoing surgery. This facility almost cost him his life.

Family member · 2025☆☆☆☆

The facility may be look run down, but it is very well-run, the staff is excellent across the board, the CNAs are very kind and competent, as are the RNs, PTs, OTs, SLP, doctor and administrators.

Long-term resident's family · 2026★★★★★
Source: 78 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.67hrs
89%
Registered nurses for medical care
Total Nursing
4.02hrs
98%
All nurses + aides combined
Staff Turnover
30%
Lower is better (< 30% = good)
RN Turnover
15%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
5/ 5
Better Than Avg

12

measures

Worse Than Avg

1

measures

Mixed Results

4

measures

Long-Stay Residents
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility3.1%
Better than Avg
Here
3.1%
US
14.4%
CA
10.4%
Sonoma
8.6%
😔

Residents with depression symptoms

↓ Lower is better
This Facility1.2%
Better than Avg
Here
1.2%
US
12.1%
CA
7.0%
Sonoma
4.4%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility19.4%
Worse than Avg
Here
19.4%
US
19.4%
CA
10.7%
Sonoma
14.1%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
CA
98.6%
Sonoma
98.2%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility8.9%
Better than Avg
Here
8.9%
US
15.3%
CA
10.5%
Sonoma
11.5%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility19.4%
Mixed vs Avgs
Here
19.4%
US
19.5%
CA
13.7%
Sonoma
14.3%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility97.7%
Better than Avg
Here
97.7%
US
81.8%
CA
94.2%
Sonoma
95.9%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility95.5%
Better than Avg
Here
95.5%
US
79.7%
CA
93.2%
Sonoma
93.9%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
CA
1.5%
Sonoma
1.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

19deficiencies
2penalties
Above state avg (15.4)
36 complaint-triggered
$107,746 in fines

Santa Rosa Post Acute has significant care concerns, with 38 of 79 deficiencies triggered by family complaints. The facility shows persistent problems with preventing abuse and neglect, medication management, and infection control. While all issues have correction dates, the recurring nature across multiple surveys—especially regarding resident safety and treatment quality—suggests ongoing challenges that families should carefully evaluate before placement.

Mar 11, 2026Complaint
2
0689Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0600Potential for harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Feb 6, 2026Complaint
1
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Dec 26, 2025Complaint
3
0760Actual harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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

Sep 12, 2025Routine
16
0324Potential for harm · WidespreadCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0914Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0730Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

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

0741Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0925Potential for harm · PatternCorrected

Environmental Deficiencies

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

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0655Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0919Potential for harm · IsolatedCorrected

Environmental Deficiencies

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

0921Potential for harm · IsolatedCorrected

Environmental Deficiencies

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

0711Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Sep 2, 2025Complaint
1
0658Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

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

May 2, 2025Complaint
2
0607Potential for harm · WidespreadCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0610Potential for harm · WidespreadCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Federal Penalties

Payment Denial

Dec 26, 2025

4-day denial

Fine

Jan 28, 2025

$10,166

Ownership & Operations

Who Operates This Facility

Owner / Operator

Santa Rosa Post Acute

Organization Type

for profit

Chain Affiliation

Chain Name

Pacs Group

Chain Size

279 facilities nationwide

Chain avg rating: 2.9/5 · Rank 176 of 260

Ownership & Management

Owners

Providence Group Wine Country LLC

Owner · Organization

100%

Providence Group Nh, LLC

Owner (parent company) · Organization

100%

Key personnel

Picetti, DominicContracted Managing EmployeeBills, KevanW-2 Managing EmployeeApt, FrederickOfficer / DirectorHancock, MarkOfficer / DirectorJergensen, JoshuaOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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