Map showing the location of SANTA ROSA POST ACUTE in SANTA ROSA, California
4650 HOEN AVENUE, SANTA ROSA, CA, 95405

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • CaliforniaAbove only 37% of peers1,154 rated homes · average 3.2★
  • Sonoma CountyAbove only 18% of peers18 rated homes · average 3.6★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs CA avg
  • StaffingCan add or remove a star4★+0.9 vs CA avg
  • Quality measuresCan add or remove a star5★+0.9 vs CA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersCA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 60% of peersCA avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 57% of peersCA avg4.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.97hrsAbove only 21% of peersCA avg4.51Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.67hrsAbove 72% of peersCA avg0.65Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better36%Above 54% of peersCA avg38%RN turnover27%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$10,166Above only 35% of peersCA avg$26,970Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
59citations
30inspection dates
3actual harm (G–I)
0immediate jeopardy (J–L)
Dec 26, 2025most recent

Citations by monthApr 2021 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 26, 20251 citationCycle 1worst G · actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceG · isolatedCorrected Jan 14, 2026
Sep 12, 202510 citationsCycle 1worst E · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Oct 6, 2025
  2. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalE · patternCorrected Oct 6, 2025
  3. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalD · isolatedCorrected Oct 6, 2025
  4. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Oct 6, 2025
  5. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Oct 6, 2025
  6. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Oct 6, 2025
  7. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Oct 6, 2025
  8. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected Oct 6, 2025
  9. F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Quality of Life and CareE · patternCorrected Oct 6, 2025
  10. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Oct 6, 2025
Sep 2, 20251 citationCycle 1worst E · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Oct 5, 2025
May 2, 20252 citationsCycle 1worst F · no actual harm
  1. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected May 12, 2025
  2. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected May 12, 2025
Apr 25, 20252 citationsCycle 1worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 16, 2025
  2. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 16, 2025
Apr 9, 20251 citationCycle 1worst E · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected May 2, 2025
Mar 24, 20251 citationCycle 1worst E · no actual harm
  1. F584Honor 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.Resident RightsE · patternCorrected Apr 7, 2025
Feb 24, 20251 citationCycle 1worst E · no actual harm
  1. F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Resident RightsE · patternCorrected Mar 11, 2025
Jan 28, 20251 citationCycle 2worst G · actual harm$10,166
  1. Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and CareG · isolatedCorrected Feb 13, 2025
Dec 5, 20241 citationCycle 2worst F · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jan 3, 2025
Oct 4, 20242 citationsCycle 2worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Oct 23, 2024
  2. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsD · isolatedCorrected Oct 23, 2024
Aug 28, 20241 citationCycle 2worst E · no actual harm
  1. F576Ensure residents have reasonable access to and privacy in their use of communication methods.Resident RightsE · patternCorrected Nov 6, 2024
Aug 6, 20241 citationCycle 2worst D · no actual harm
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Sep 15, 2024
Apr 10, 20244 citationsCycle 2worst E · no actual harm
  1. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected Jul 12, 2024
  2. F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Nutrition and DietaryD · isolatedCorrected Jul 12, 2024
  3. F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryD · isolatedCorrected Jul 12, 2024
  4. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jul 12, 2024
Jan 24, 20242 citationsCycle 3worst E · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Feb 16, 2024
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Feb 16, 2024
Jan 3, 20241 citationCycle 3worst D · no actual harm
  1. F839Employ staff that are licensed, certified, or registered in accordance with state laws.AdministrationD · isolatedCorrected Jan 13, 2024
Dec 22, 20232 citationsCycle 3worst E · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jan 8, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Jan 8, 2024
Dec 15, 20231 citationCycle 3worst E · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 31, 2023
Dec 14, 20231 citationCycle 3worst E · no actual harm
  1. F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Dec 30, 2023
Nov 2, 20231 citationCycle 3worst E · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Nov 14, 2023
Sep 28, 20231 citationCycle 3worst E · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Oct 13, 2023
Jun 22, 20231 citationCycle 3worst D · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jul 28, 2023
Jun 20, 20232 citationsCycle 3worst E · no actual harm
  1. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected Aug 5, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Aug 5, 2023
Apr 24, 20232 citationsCycle 3worst E · no actual harm
  1. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected May 11, 2023
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 11, 2023
Apr 12, 20231 citationCycle 3worst D · no actual harm
  1. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 28, 2023
Mar 14, 20232 citationsCycle 3worst E · no actual harm
  1. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsE · patternCorrected Mar 29, 2023
  2. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Mar 29, 2023
Mar 1, 20232 citationsCycle 3worst G · actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Apr 3, 2023
  2. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 3, 2023
Feb 28, 20231 citationCycle 3worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 7, 2023
Feb 14, 20231 citationCycle 3worst D · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Feb 28, 2023
Apr 23, 20219 citationsCycle 3worst E · no actual harm
  1. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected May 25, 2021
  2. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected May 25, 2021
  3. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected May 25, 2021
  4. F575Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.Resident RightsD · isolatedCorrected May 25, 2021
  5. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected May 25, 2021
  6. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected May 25, 2021
  7. F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected May 25, 2021
  8. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected May 25, 2021
  9. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected May 25, 2021

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.97hrsAbove only 21% of peers−0.54 vs CA avg
  • Registered nursesRN hours only0.67hrsAbove 72% of peers+0.02 vs CA avg
  • Licensed practical nursesLPN hours0.89hrs
  • Nurse aidesCNA hours2.41hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.43hrs
  • California average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better36%Above 54% of peersCA avg 38%
  • RN turnoverRegistered nurses only27%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy99 certified beds · ~95 residents a day96%Above 87% of peersCA avg 88%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $10,166In fines
  • 1Fine
  • 0Payment denials
  • $26,970CA avg in fines
Above only 35% of peersFewer fines than 35% of rated homes in California

Actions on record

  1. Jan 28, 2025Civil money penalty$10,166

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Pacs Group254 facilities in the chain2.9★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Providence Group Wine Country LLC
Indirect owners (5%+)
  • Pacs Group, INC.
  • Pacs Holdings, LLC
  • Providence Group Nh, LLC
  • Mark Hancock
  • Jason Murray
Operational or managerial control
  • Kevan Bills
Corporate officers
  • Frederick Apt
  • Mark Hancock
  • Joshua Jergensen
  • John Mitchell
Contracted managers
  • Dominic Picetti
Managing employees
  • Kevan Bills

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 055854 · 4650 HOEN AVENUE, SANTA ROSA, CA, 95405.
  • Percentiles compare this facility with every rated nursing home in California and Sonoma County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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