Healdsburg Hospital D/P SNF

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

How full it usually is: this home is certified for 17 beds and averages 15.3 residents a day — about 90% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 10.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 4.43 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.67 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 9.55 hrs/resident/day on weekends vs 10.99 on weekdays — 13% thinner on weekends. RN hours go from 4.61 to 3.96 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

• Potential for harm · E2024-08-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview and facility policy review, the facility failed to ensure food items were stored in a manner that complied with food handling practices to prevent food-borne illness (illness caused by the ingestion of contaminated food or beverages), when two bowls of prepared food were in the walk-in refrigerator without any labeling and several food items were opened and without labels in the dry storage area. This failure had the potential to result in the rapid growth of pathogenic (capable of causing disease) microorganisms (e. g. bacteria, virus etc.) that could cause food-borne illnesses and could affect the residents of the facility. Findings: During an observation on 8/12/24 at 9:15 a.m., food items in the freezers were labeled with the arrival date. Food items in the refrigerators had the arrival date. Food items in dry storage were labeled with the arrival date. On 8/14/24 at 9:30 a.m., during an observation in the dry storage area, several open food packages were found without a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-16 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interviews and records review, the facility failed to develop a person-centered individualized care plan for 1 of 8 sampled residents (Resident 7.) This failure had the potential for facility staff to not provide adequate care to Resident 7's eyes which could cause further damage to his eyes and/or blindness. Findings: During on observation on 8/13/24 at 10:25 a.m., in Resident 7's room, Resident 7 had his right eye covered with a gauze dressing. Resident 7's left eye was open and seemed to be looking at the HFEN. During an interview on 8/13/24 at 2:57 p.m., Licensed Nurse C stated Resident 7 has his eye covered because his medical condition causes the eye to be swollen preventing the eye lids from closing. He got eye drops and the dressing to prevent his eye from drying out. During an interview and concurrent record review on 8/14/24 at 3:35 p.m., Licensed Nurse C reviewed the electronic care plan for Resident 7, and it was determined that an individualized care plan concerning Resident 7's vision had not been written. The facilities policy Person-Centered…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-16 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure professional standards of practice when two of three residents (Resident 16 and Resident 5) did not have their enteral tube (a soft, flexible tube which enters a surgically created opening in the abdominal wall and is used to administer food, fluids, and medications to a person that cannot receive food, fluid, or medications through their mouth) flushed (the process of gently pushing water through the tube to clean it) before and after medication administration. This failure had the potential to cause a blockage in the enteral tube and delay the administration of critical medications (priority medications that should not be omitted or delayed). Findings: Record review of a document titled, Face Sheet (resident demographics) for Resident 16, indicated Resident 16 was admitted to the facility on [DATE]. Record review of a document titled, Problem List for Resident 16, indicated Resident 16 had the following diagnoses: traumatic brain…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2018-12-14 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to follow medication administration policy for 1 of 8 residents (Resident 9), when the nurse did not hold the feeding tube before administering Phenytoin (medication used to treat and control seizure/epilepsy.). This failure had the potential to result in Phenytoin subtherapeutic blood levels (a dosage less than the amount required for a therapeutic effect), which could put Resident 9 at risk for seizures. Findings: During a medication administration observation and concurrent interview on 12/12/18, at 10:30 a.m. for Resident 9, Licensed Staff C was preparing to administer medications that would go into the J-tube (Jejunostomy tube - a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine). Resident 9's nutritional supplement, via the feeding tube (medical device used to provide nutrition to people who cannot obtain nutrition by mouth, unable to swallow safely, or need nutritional supplementation), was running at 45 milliliter per hour (ml/hr). At 10:45 a.m.,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2018-12-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to provide respiratory care for 1 of 8 residents (Resident 7), when Resident 7's corrugated aerosol tubing was disconnected from the oxygen source. This failure had the potential to result in respiratory distress for Resident 7. Findings: During an observation on 12/10/18, at 9:05 a.m. Resident 7 had a tracheostomy (an opening in the neck used to deliver oxygen to the lungs). Resident 7's corrugated aerosol tubing was disconnected from the oxygen source and humidifier (medical devices used to humidify supplemental oxygen to provide long-lasting moisture for patients' comfort during oxygen therapy, especially in drier climates). During an observation and concurrent interview on 12/10/18, at 9:12 a.m., Licensed Staff B noticed Resident 7's corrugated aerosol tubing was disconnected from the oxygen source. Licensed Staff B stated the aerosol tubing came off. Licensed Staff B stated if the Respiratory Therapists from Night and Day shift did a walking round (giving reports at resident bedside); the disconnected…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2018-12-14 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to follow infection control practices when: 1. The staff did not dispose of the suction catheter right away after suctioning Resident 1's airway; and 2. Condensation collected from Resident 7's corrugated aerosol tubing was touching the floor. These failures had the potential to spread infection among residents and staff. Findings: 1. During an observation and concurrent interview on 12/10/18, at 10:19 a.m., Resident 1 was sitting in his wheelchair by the nurse station with a suction catheter laying on top of his pillow. When the suction catheter was pointed out, Licensed Staff D stated, I think it's suction. Licensed Staff D disposed of the suction catheter. Review of the Resident 1's Minimum Data Set (an assessment tool) dated 9/9/18, indicated the facility was providing oxygen therapy, suctioning and tracheostomy care (an opening in the neck in order to place a tube into a person's windpipe, requiring care to keep the tube clean to prevent a clogged and decreased risk of infection.). During an interview on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction

Fines & penalties

$45,872 in federal fines across 6 penalties.

• $4,587 — penalty dated 2023-11-13
• $4,587 — penalty dated 2023-11-06
• $13,762 — penalty dated 2023-10-17
• $4,587 — penalty dated 2023-10-02
• $4,587 — penalty dated 2023-09-25
• $13,762 — penalty dated 2023-09-05

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to PROVIDENCE HEALTH & SERVICES — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in CA