Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Summerfield Health Care Center during CMS and state inspections, most recent first.
A resident who had undergone cervical spine surgery and needed ongoing skilled care was being planned for discharge home, but the discharge was later canceled due to medical reasons and he was transferred to a GACH after a change in condition. After hospitalization, the facility declined readmission, citing an expired bed hold and no available bed, even though later census records showed male beds became available and the DON confirmed the resident, family, and receiving SNF were not notified. The resident wanted to return, the family wanted him back, and the record did not show a completed discharge plan before hospitalization; DHCS OAH granted the appeal and found the facility had not met legal requirements for involuntary discharge.
Improper PPE Use During Care of Residents With COVID-19: An unlicensed staff member was observed in a room with two residents with confirmed COVID-19 while wearing a gown, gloves, face shield, and a surgical mask that covered only the mouth and not the nose. An LPN noted the mask was loose and said the staff member should have changed to the facility’s N95 mask, and the IP stated an N95 type of face mask should have been worn while caring for residents with an active respiratory infection.
A resident with a high fall risk and cognitive impairment fell and sustained injuries within 24 hours of admission due to inadequate supervision. Despite being aware of the resident's impulsive behaviors and previous need for a 1:1 sitter during hospitalization, the facility did not provide the necessary supervision, relying instead on a tab alarm and positioning near the nursing station. The resident's family had to hire a private sitter after the fall occurred.
A resident with a fractured wrist was not wearing a required wrist brace for two days due to a lack of communication among staff and private sitters. The physician had ordered the brace to be worn 24/7 to ensure proper healing, but staff were unaware of this requirement. The facility admitted responsibility for the oversight during a care conference with the family.
Two residents were transferred from a facility to other skilled nursing facilities without proper consent or documentation. One resident was moved to a lower-rated facility without being informed, causing emotional distress. The other resident was transferred while in poor health, and the family was not informed. The facility failed to provide valid reasons or documentation for these transfers.
The facility failed to ensure that the nursing care plans for managing pain for two residents were comprehensive and resident-centered. Despite pain management reviews indicating specific pharmacological and non-pharmacological interventions, these were not incorporated into the care plans, resulting in generalized and ineffective pain management strategies.
The pharmacy consultant failed to identify instances where Polycarbophil was administered alongside other medications, contrary to the manufacturer's guidelines. This error was observed in three residents, with nurses administering Polycarbophil concurrently with other medications. The Pharmacy Consultant reports for January and February 2024 did not document these irregularities, and the consultant admitted to being unaware of the required two-hour interval between Polycarbophil and other medications.
The facility failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 21%. Errors included improper administration of Polycarbophil, Potassium Chloride, and Metformin, as well as the substitution of over-the-counter fish oil for the prescribed Lovaza. Staff admitted to being unaware of proper administration guidelines.
The facility failed to maintain proper temperature controls for medication storage from December 2023 through February 2024. Despite multiple temperature deviations in the medication refrigerator, no corrective actions were taken, compromising the safety and effectiveness of the stored medications.
The facility failed to ensure safe food storage and staff knowledge of sanitizing practices. A dietary aid could not describe the three-compartment dishwashing method or find relevant policies. Additionally, temperatures in storage areas were not regularly checked or recorded, risking food safety.
The facility failed to provide necessary respiratory care consistent with a resident's care plan and physician's orders. A resident with COPD and Chronic Respiratory Failure was observed receiving oxygen at 3.5 LPM, contrary to the physician's order of up to 2 LPM as needed. This discrepancy was confirmed by an LVN and the Director of Nursing, highlighting a failure to verify and adhere to prescribed oxygen therapy.
The facility failed to provide appropriate pain management for a resident with chronic pain, administering medication intended for moderate pain even when the resident reported severe pain. Nurses did not consult the physician for a stronger pain medication, leading to inadequate pain relief.
A resident with Iron Deficiency Anemia was not served the alternate meal he ordered, causing frustration and repeated issues with meal preferences. The facility's policy to provide suitable alternate meals was not followed, as confirmed by multiple staff interviews.
The facility failed to ensure that two of four trash cans in the kitchen were completely covered when not in use. These trash cans had large circular holes in their lids, allowing trash to be exposed to air. One trash can was found overflowing with garbage, with soiled gloves sitting on top. A kitchen staff member confirmed these trash cans had been in use for a year and found them convenient for discarding trash without opening the lid each time.
A facility failed to ensure complete and accurate clinical documentation for a resident with Diabetes Mellitus. A physician's order to recheck the resident's blood glucose level was not documented as completed, and the recheck was done at an incorrect time, questioning the credibility of the documentation.
Failure to Complete Discharge Process and Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure an appropriate transfer and discharge process for one resident who had been admitted after cervical spine surgery and required ongoing skilled nursing, rehabilitation, respiratory, medication management, catheter, and wound care services. Social services notes showed the facility was actively planning for discharge home, with home health services, durable medical equipment, caregiver support, and community services being arranged, but the planned discharge was later canceled by the physician due to medical reasons. The resident then experienced a significant change in condition and was transferred to a GACH. After the hospitalization, the GACH case manager contacted the facility about readmission, but the facility declined to accept the resident back on several occasions. The resident and a family member repeatedly requested contact with the facility because they wanted him to return there. The resident stated he wanted to return because he liked the facility, believed it could meet his needs, and was familiar with the staff and services. The family member stated the facility was chosen because it was closest to home and that she wanted him to return. The Administrator and DON stated the resident was not denied readmission because of behavior, care needs, equipment needs, or inability to provide care, but because the seven-day bed hold had expired and there were no available beds when the hospital requested readmission. However, census records showed available male beds existed after the transfer, and the DON confirmed the facility did not notify the resident, his family member, or the other SNF when beds later became available. The resident’s record also did not show a completed discharge plan before hospitalization or documentation that the discharge process had been completed. A DHCS Office of Administrative Hearings and Appeals document stated the appeal was granted and that the facility had not met the legal requirements to involuntarily discharge the resident.
Improper PPE Use During Care of Residents With COVID-19
Penalty
Summary
The facility failed to ensure that one of three staff members, Unlicensed Staff A, used proper PPE while caring for two residents with confirmed COVID-19. During an observation on 9/04/25 at 9:40 a.m., Unlicensed Staff A was in the room with the two residents and was seen starting to clean and reposition one of them while wearing a gown, gloves, face shield, and a surgical mask that covered only her mouth and not her nose. After prompting, she adjusted the mask to cover her nose, but it slid back down so that the nose remained uncovered. During an interview on 9/04/25 at 9:45 a.m., Licensed Staff B stated that the mask Unlicensed Staff A was wearing was loose and that she would have her change to the facility’s N95 mask. During an interview on 9/05/25 at 1:35 p.m., the Infection Preventionist stated that Unlicensed Staff A should have worn an N95 type of face mask while caring for residents with an active respiratory infection. The facility’s policy titled Infection Control, Personal Protective Equipment, dated 2/2023, stated that PPE may include gowns, gloves, masks, and eye protection during patient care and routine facility tasks, and that source control refers to use of respirators or well fitting facemasks to prevent spread of respiratory secretions.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident who was assessed as a high fall risk due to a history of falls, decreased mobility, generalized weakness, restlessness, and cognitive impairment. Despite being aware of the resident's impulsive and unsafe behaviors, the facility did not provide the necessary 1:1 supervision that was required during the resident's recent hospitalization. Instead, the facility relied on interventions such as a tab alarm and positioning the resident near the nursing station, which proved inadequate as the resident fell within the first 24 hours of admission, resulting in a head injury, seizures, skin tears, and a fractured right wrist. Interviews with facility staff revealed that the resident was placed in a wheelchair with a tab alarm at the nursing station, and staff were able to prevent falls during the resident's first two attempts to stand. However, during the third attempt, staff were not positioned close enough to prevent the fall. The Director of Admissions acknowledged that the resident required significant care and informed the family that a private sitter might be necessary. Despite this, the facility did not provide a 1:1 sitter upon admission, and the resident's family had to hire a private caregiver after the fall occurred. The facility's Director of Nursing and other staff members indicated that various interventions were attempted before considering a 1:1 sitter, citing staffing expenses as a concern. The facility's policies and procedures emphasized the importance of identifying interventions to prevent falls, yet the care plan for the resident only included basic safety measures. The facility's failure to provide adequate supervision and the necessary 1:1 sitter, despite the resident's known high fall risk and impulsive behavior, directly contributed to the resident's fall and subsequent injuries.
Failure to Ensure Resident Wore Wrist Brace as Ordered
Penalty
Summary
Facility staff failed to follow physician orders for a resident to wear a wrist brace on her right wrist at all times, from February 10 to February 11. This oversight was discovered when a family member visited the resident and noticed the absence of the brace. The family member inquired with both licensed and unlicensed staff, none of whom were aware of the brace's location or the requirement for the resident to wear it continuously. The physician had ordered the brace to be worn 24/7 to ensure proper healing of the resident's fractured wrist. Interviews with various staff members revealed a lack of communication regarding the resident's need for the wrist brace. A private sitter and unlicensed staff were unaware of the requirement, and licensed staff not assigned to the resident were also uninformed about the wrist fracture and the necessity of the brace. The Director of Rehabilitation Services confirmed that the resident was supposed to wear a cervical collar and a right-hand splint, as per the physician's orders, and acknowledged the risk of further injury if the orders were not followed. The Assistant Director of Nursing and the Director of Nursing both acknowledged the physician's orders and the need for staff to communicate about the brace. However, the private sitter's manager stated that no communication had been made to ensure the placement of the wrist brace. The facility admitted responsibility for the oversight during a care conference with the family, acknowledging that the resident's wrist brace was not on during the specified dates. Medical records indicated that the resident had a history of trying to remove the splint, and staff were supposed to monitor the wrist for circulation and swelling every shift.
Improper Resident Transfers Without Consent or Documentation
Penalty
Summary
The facility failed to permit two residents to remain in the facility when they were transferred to other skilled nursing facilities without adequate reason or proper documentation. Resident 1 was transferred to a lower-rated facility without being informed or consenting to the move, causing her emotional distress. The Social Services Director (SSD) had informed Resident 1's family member that the resident would stay for at least three weeks, but the transfer occurred on the sixth day without Resident 1's knowledge or consent. The SSD documented verbal consent from a family member, but Resident 1 was the only authorized decision-maker. Resident 2 was also transferred without proper documentation or consent. The resident was in poor health at the time of transfer, suffering from malnutrition, dehydration, and a urinary tract infection. The family member of Resident 2 was surprised by the transfer and had not requested it. The SSD documented verbal consent from the family member, but there was no evidence that Resident 2 initiated the transfer. The SSD admitted that the reasons for transfer listed on the documents were not valid for either resident. The facility's policy required documentation for transfers, but the SSD failed to provide any rationale or documentation for the transfers. The SSD stated that the initial care conference triggered discussions about transfers, but there was no documentation of these conversations. The facility's policy did not include an option for SNF-to-SNF transfers, leading the SSD to incorrectly mark the reason for transfer as the residents' health improvement, which was not the case.
Failure to Develop Comprehensive Pain Management Care Plans
Penalty
Summary
The facility failed to ensure that the nursing care plans for managing pain for two residents were comprehensive, resident-centered, and included specific pharmacological and non-pharmacological interventions based on the residents' pain assessments. Resident 11, who was admitted with diagnoses including Diabetes Mellitus with Diabetic Neuropathy, reported severe pain due to neuropathy. Despite a pain management review indicating the use of Acetaminophen and Oxycodone, and non-pharmacological interventions like cold packs, hot packs, rest, and repositioning, these specifics were not incorporated into Resident 11's care plan. The care plan only contained standard interventions without addressing the individualized needs identified in the pain assessment. Similarly, Resident 109, who had a left artificial shoulder joint and experienced constant pain, also had a care plan that lacked specific interventions. Despite a pain management review indicating the use of Tylenol and Oxycodone, and non-pharmacological interventions like warm packs, breathing and relaxation, and repositioning, these were not included in the care plan. Both the Licensed Vocational Nurse and the Registered Nurse acknowledged that the care plans were too generalized and not comprehensive. The facility's policy required the interdisciplinary team to develop a comprehensive care plan for each resident, which was not adhered to in these cases.
Pharmacy Consultant Fails to Identify Polycarbophil Administration Errors
Penalty
Summary
The pharmacy consultant failed to identify instances where patients received Polycarbophil in conjunction with other oral medications, contrary to the manufacturer's guidelines. These guidelines stipulate that Polycarbophil should be taken at least two hours before or after other medications. This error was observed in three patients who received Polycarbophil alongside other medications. During observations, it was noted that Licensed Vocational Nurse (LVN) A, Registered Nurse (RN) B, and LVN C administered Polycarbophil along with other medications to Residents 28, 153, and 106, respectively. The Medication Administration Records (MAR) for these residents indicated that Polycarbophil was scheduled to be administered at the same time as other medications, which is against the manufacturer's guidelines. A review of the Pharmacy Consultant reports for January and February 2024 revealed no documented irregularities related to the administration of Polycarbophil and the required spacing between it and other medications. During an interview, the Pharmacy Consultant E admitted to being unaware of the guideline requiring a two-hour interval between the administration of Polycarbophil and other medications. This oversight led to the concurrent administration of Polycarbophil with other medications, potentially diminishing their effectiveness.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 21%. During a medication pass, six medication errors were observed out of twenty-eight opportunities for three residents. Licensed Vocational Nurse (LVN) A administered Polycarbophil to Resident 28 with only 30 milliliters of water instead of the required 8 ounces and did not separate the administration of Polycarbophil from other medications by at least two hours. Additionally, LVN A administered Potassium Chloride to Resident 28 without food, contrary to the recommended guidelines. LVN A admitted to being unaware of these administration guidelines. Registered Nurse (RN) B administered Polycarbophil to Resident 153 with only 50-60 milliliters of water and did not separate it from other medications. RN B also administered Metformin to Resident 153 without food, despite the requirement for the medication to be taken with food. RN B acknowledged her lack of awareness regarding the proper administration guidelines for these medications. LVN C administered Polycarbophil to Resident 106 with only 100 milliliters of water and did not separate it from other medications. Additionally, LVN C administered over-the-counter fish oil instead of the prescribed Lovaza to Resident 106, mistakenly believing the two were interchangeable. LVN C admitted her confusion was due to a lack of knowledge about the differences between the two medications.
Improper Temperature Control for Medication Storage
Penalty
Summary
The facility did not maintain proper temperature controls for medication storage from December 2023 through February 2024. The medication refrigerator temperatures were found to be outside the acceptable range of 36 F to 46 F on multiple occasions, with temperatures recorded as low as 30 F. Despite the facility's policy requiring immediate notification of the Director of Nursing (DON) when temperatures fall outside the acceptable range, no direct actions were taken to address these deviations. The DON acknowledged the temperature excursions but could not provide documentation of any corrective actions taken during this period. Interviews with the Pharmacy Consultant and Infection Preventionist revealed that staff were educated on the importance of maintaining proper temperature controls, yet failed to document or act on the temperature deviations. The Infection Preventionist admitted to not reviewing the temperature logs and confirmed that no adjustments were made to the medication refrigerator during the three months in question. This inaction compromised the safety and effectiveness of the stored medications, as freezing and thawing cycles can diminish their efficacy.
Deficiencies in Food Storage and Sanitizing Practices
Penalty
Summary
The facility failed to ensure resident food was stored safely and that staff were knowledgeable of sanitizing practices. A dietary aid was unable to describe the three-compartment method for washing and sanitizing dishes during emergencies and could not find the facility policy or procedure that explained the process. The dietary aid also had difficulty understanding the English-written policies. Additionally, the temperature in the dry storage room and emergency food storage room, where food and drinks for residents were stored, was not checked regularly, and there were no records to verify that food was being stored at safe temperatures. This was confirmed through observations and interviews with the dietary manager and administrative assistant, who were unable to provide evidence of regular temperature checks or a policy requiring such documentation. During an observation, it was noted that there was no thermometer or recording log in the dry storage area to check and record the temperature. The emergency food and water storage room had a thermometer, but no log was available to check if the temperature was being recorded. The dietary manager admitted to checking the temperature occasionally but not daily and could not provide evidence of these checks. The facility's policy required food to be stored within a specific temperature range but did not mandate documentation of these temperatures. The maintenance director also confirmed that while he checked the temperature in residents' rooms, he did not check the temperature of the kitchen storage areas.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility did not provide the necessary respiratory care consistent with the resident's care plan and current physician's orders for oxygen therapy. Resident 41, who had medical diagnoses including COPD and Chronic Respiratory Failure with Hypoxia, was observed receiving oxygen therapy via nasal cannula at 3.5 LPM. However, the physician's order specified that oxygen should be titrated up to 2 LPM as needed for O2 saturation less than 90% or shortness of breath. During an observation and interview, LVN J confirmed that Resident 41 was on 3.5 LPM of oxygen, which was inconsistent with the physician's order and the resident's care plan. The Director of Nursing stated that licensed nurses are expected to verify the physician's order for oxygen therapy. A review of the resident's MAR and care plan confirmed the discrepancy between the observed oxygen administration and the physician's order. The facility's policy and procedure for oxygen administration also emphasized the need to verify the physician's order and review the resident's care plan. This failure to adhere to the prescribed oxygen therapy had the potential to result in respiratory acidosis and affect the health and well-being of Resident 41.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 151, who had a history of chronic low back pain, compression fractures, kidney stones, and a possible urinary tract infection. Despite having a physician's order for Hydrocodone-Acetaminophen to be administered for moderate pain (pain level 4-6), the medication was repeatedly given to Resident 151 when he reported severe pain (pain level 7-9). This discrepancy was observed on multiple occasions, with the medication being administered 32 times for severe pain out of 44 total administrations from 3/3/24 to 3/14/24. During interviews, both Licensed Vocational Nurse K and Registered Nurse L acknowledged that it was inappropriate to administer the medication for severe pain and admitted that they should have contacted the physician for a stronger pain medication. However, they failed to do so. Resident 151 consistently reported that the medication did not relieve his severe pain, indicating that his pain management needs were not being adequately addressed. The Director of Nursing confirmed that there should have been communication between the nurses and the physician regarding the inadequacy of the current pain management plan. The facility's policies and procedures for pain management and medication administration were not followed, as they clearly state that the physician should be consulted if the current pain management orders are ineffective. This failure to adhere to professional standards of practice and the resident's comprehensive care plan resulted in inadequate pain management for Resident 151.
Failure to Honor Resident's Meal Preferences
Penalty
Summary
The facility failed to honor the food preferences of Resident 107, who had ordered an alternate meal but was served the regular meal of the day. Resident 107, who has a medical diagnosis of Iron Deficiency Anemia, expressed frustration and stated that this was not the first time such an incident had occurred. The Dietary Manager and Assistant Administrator confirmed that Resident 107 had ordered the alternate meal earlier that day, but the request was missed during trayline service. The Meal Change Request Form, which indicated the resident's preference for soup and a tuna wrap, was not provided to the surveyor in printed form, and the Dietary Manager could not recall when the form was received by the kitchen. Interviews with various staff members, including Cook H and Occupational Therapist I, revealed that the Meal Change Request Form was submitted at least one hour before trayline service began. However, the form was not processed in time, resulting in Resident 107 receiving the incorrect meal. The facility's policy states that residents will be provided a suitable nourishing alternate meal if the planned meal is refused, but this policy was not followed in the case of Resident 107. Multiple interviews confirmed that this was not an isolated incident, as Resident 107 had previously reported receiving incorrect meals on several occasions.
Improper Disposal of Garbage in Kitchen
Penalty
Summary
The facility failed to ensure that two of four trash cans in the kitchen were completely covered when not in use. These trash cans had large circular holes measuring approximately 12 inches in diameter cut out in their lids, which allowed staff to discard garbage without removing the lid. This resulted in the trash being exposed to air at all times. During an observation, one of the trash cans was found overflowing with garbage, with soiled gloves sitting on top of the trash due to the overflow. The trash cans were not in continuous use, with lapses of five to ten minutes when nobody disposed of garbage. A kitchen staff member confirmed that these trash cans had been in use since he was hired a year ago and found them convenient for discarding trash without opening the lid each time. The facility's policy required all food waste to be placed in sealed, leak-proof, non-absorbent, tightly closed containers, and for garbage and trash cans to be inspected daily to ensure no debris was on the ground or surrounding area, and that the lids were closed. The FDA Food Code 2022 also indicated that receptacles for refuse should be durable, cleanable, insect- and rodent-resistant, leakproof, and nonabsorbent, and should be kept covered. The facility's failure to comply with these standards had the potential to result in the development and growth of pests, foul odors, and the spread of pathogenic microorganisms.
Failure to Document Blood Glucose Recheck
Penalty
Summary
The facility failed to ensure clinical documentation for one resident was complete and accurate. Specifically, a physician's order to recheck a resident's blood glucose (BG) level was not documented in the medical record as completed. The resident, who had a medical history including Diabetes Mellitus with Diabetic Neuropathy, had a BG level recorded as 384 mg/dl, but there was no documentation of a recheck in three hours as required by the physician's order. The Director of Nursing (DON) claimed the recheck was done based on information from the glucometer and an interview with the Licensed Vocational Nurse (LVN) responsible, but the glucometer did not indicate the identity of the resident, and the recheck was done at an incorrect time, further questioning the credibility of the documentation. Interviews with the DON and the Director of Staff Development (DSD) revealed that while it was considered best practice to document BG rechecks, it was not confirmed as a requirement. The facility's policy on charting and documentation indicated that all services provided to the resident should be documented to facilitate communication among the interdisciplinary team. However, the failure to document the BG recheck as per the physician's order resulted in incomplete and inaccurate clinical documentation, which could have serious implications for the resident's care.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Rosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Santa Rosa Post Acute | 0.6 mi | ★★★★★ | 29 | 0 |
| Park View Post Acute | 0.8 mi | ★★★★★ | 13 | 0 |
| Spring Lake Village | 1.4 mi | ★★★★★ | 10 | 0 |
| Blue Oak Post-acute | 2.7 mi | ★★★★★ | 33 | 0 |
| Northvine Postacute Care | 3.6 mi | ★★★★★ | 1 | 0 |
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