Summerfield Health Care Center: Illegal Discharge - CA
Resident 1 had been living at Summerfield Health Care Center when he was hospitalized. The facility held his bed for seven days, which is standard. When the hospital was ready to discharge him and asked Summerfield to take him back, the facility said the bed hold had expired and there were no available beds. He was sent to a different skilled nursing facility.
His family member told inspectors she had specifically chosen Summerfield because of how close it was to home. She wanted him back. The facility's administrator and director of nursing told inspectors the refusal had nothing to do with his behavior, his care needs, his equipment, or any inability to provide care. Their position was simply that the bed hold had run out and there was no room.
The census records told a different story. After Resident 1 was transferred to the other facility, available male beds existed at Summerfield on not one but eight separate dates. Nobody called.
The director of nursing confirmed this during an interview with inspectors. She said that once a resident had been admitted to another skilled nursing facility, there was no reason to keep communicating about future bed availability. That was the policy, in practice if not on paper. Resident 1, his family, and the facility where he had been sent were never told a bed had opened up. Not once, across eight dates.
There was no completed discharge plan in his medical record before he was hospitalized. No documentation that the discharge process had been finished. A planned discharge home had been canceled by his physician for medical reasons, which meant the facility knew he still needed their services, and still needed somewhere to go.
Resident 1 filed an appeal with the California Department of Health Care Services Office of Administrative Hearings and Appeals. The ruling came back unambiguous: the appeal was granted. The document reviewed by inspectors stated directly that Summerfield had not met the legal requirements to involuntarily discharge him.
The administrative record from that hearing established three things in sequence. The facility refused to readmit Resident 1 on a specific date, citing no available bed. The facility never provided him with a written transfer and discharge notice. And on that same date, an available bed existed at the facility, and neither Resident 1 nor his authorized representative was told about it.
Summerfield's own bed hold policy, last revised in November 2016, stated that residents hospitalized beyond the seven-day period retained the right to return to the facility upon first availability of a semi-private room, provided they continued to require facility services and remained eligible for Medicare or Medi-Cal. The director of nursing's explanation, that there was simply no reason to call once someone had landed somewhere else, does not square with that policy or with the eight dates on the census records.
The facility is contesting the citation.
What is not in dispute is that a man who needed nursing home care, whose family had picked this particular facility to keep him close, was turned away and sent somewhere else. That beds were available afterward and no one said so. That a state appeals body reviewed the evidence and concluded Summerfield had not followed the law. And that his family member, who had wanted him back from the start, was never given the chance to bring him home.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Summerfield Health Care Center from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
SUMMERFIELD HEALTH CARE CENTER in SANTA ROSA, CA was cited for violations during a health inspection on May 29, 2026.
Resident 1 had been living at Summerfield Health Care Center when he was hospitalized.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.