Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
SANTA ROSA POST ACUTE
SANTA ROSA, CA · 99 certified beds · Last Life Safety survey September 12, 2025
CMS Certification Number 055854 · first certified November 1967
Ownership
Operated by PACS GROUP · For profit - Limited Liability company
- Ownership changed December 16, 2016 (change of ownership)from BEVERLY HEALTH AND REHABILITIATION SERVICES, INC
Position within CA
22 citations — more than 60% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to March 2027. This facility’s last Life Safety survey was September 2025. Facilities in CA are typically surveyed 12–18 months after the last one (median 14), measured over 1,766 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 22 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
10 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 22 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0584 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.
- F-0908 Keep all essential equipment working safely.
How that compares
Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 22 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 23, 2021 | 10 |
| March 7, 2024 | 6 |
| September 12, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2025-09-12 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2025-09-12 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-09-12 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2021-04-23 |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | 1 | 2021-04-23 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2025-09-12 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2021-04-23 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2024-03-07 |
What the citations cover
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Miscellaneous Deficiencies 3
- Emergency Preparedness Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Miscellaneous Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 12, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 23, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 23, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (October 23, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (November 30, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 23, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 23, 2025) |
March 7, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (March 30, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 30, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 30, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 30, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 30, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 30, 2024) |
April 23, 2021 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (July 1, 2021) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (July 1, 2021) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (July 1, 2021) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (July 1, 2021) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (July 1, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 1, 2021) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 1, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 1, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 1, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 1, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.