JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Kaiser Foundation Hospital-Santa Rosa

3 / 5

At a glance

Kaiser Foundation Hospital-Santa Rosa carries a 3-star CMS overall rating — in line with the national norm. On healthcare-associated infection measures, it performs better than the national average on 12 and worse on 0.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit0.242Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit1.836Same as national
Central Line Associated Bloodstream Infection: Number of Device Days6017Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases5.255Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases4Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.761Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.009Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.932Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days5445Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases5.293Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.189Better than national
SSI - Colon Surgery: Lower Confidence Limit0.118Same as national
SSI - Colon Surgery: Upper Confidence Limit2.327Same as national
SSI - Colon Surgery: Number of Procedures121Same as national
SSI - Colon Surgery: Predicted Cases2.839Same as national
SSI - Colon Surgery: Observed Cases2Same as national
SSI - Colon Surgery0.704Same as national
SSI - Abdominal Hysterectomy: Lower Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Upper Confidence Limit—Not available
SSI - Abdominal Hysterectomy: Number of Procedures6Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.076Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal Hysterectomy—Not available
MRSA Bacteremia: Lower Confidence Limit0.143Same as national
MRSA Bacteremia: Upper Confidence Limit2.823Same as national
MRSA Bacteremia: Patient Days47204Same as national
MRSA Bacteremia: Predicted Cases2.341Same as national
MRSA Bacteremia: Observed Cases2Same as national
MRSA Bacteremia0.854Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.284Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.892Better than national
Clostridium Difficile (C.Diff): Patient Days43438Better than national
Clostridium Difficile (C.Diff): Predicted Cases22.862Better than national
Clostridium Difficile (C.Diff): Observed Cases12Better than national
Clostridium Difficile (C.Diff)0.525Better than national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patients—Not available—
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.1Same as national86
Death rate for heart attack patients—Not available—
Death rate for CABG surgery patients—Not available—
Death rate for COPD patients—Not available—
Death rate for heart failure patients—Not available—
Death rate for pneumonia patients—Not available—
Death rate for stroke patients—Not available—
Pressure ulcer rate0.50Same as national344
Death rate among surgical inpatients with serious treatable complications—Not available—
Iatrogenic pneumothorax rate0.20Same as national467
In-hospital fall-associated fracture rate0.31Same as national474
Postoperative hemorrhage or hematoma rate2.29Same as national68
Postoperative acute kidney injury requiring dialysis rate—Not available—
Postoperative respiratory failure rate—Not available—
Perioperative pulmonary embolism or deep vein thrombosis rate3.37Same as national72
Postoperative sepsis rate—Not available—
Postoperative wound dehiscence rate2.09Same as national26
Abdominopelvic accidental puncture or laceration rate1.03Same as national102
CMS Medicare PSI 90: Patient safety and adverse events composite0.95Same as national—

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patients—Not available—
Hospital return days for heart failure patients—Not available—
Hospital return days for pneumonia patients—Not available—
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.1Same as national127
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)—Not available—
Rate of inpatient admissions for patients receiving outpatient chemotherapy—Not available—
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy—Not available—
Ratio of unplanned hospital visits after hospital outpatient surgery—Not available—
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate—Not available—
Rate of readmission for CABG—Not available—
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients—Not available—
Heart failure (HF) 30-Day Readmission Rate—Not available—
Rate of readmission after hip/knee replacement—Not available—
Pneumonia (PN) 30-Day Readmission Rate—Not available—

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating31865
Doctor communication - star rating31865
Communication about medicines - star rating21865
Discharge information - star rating31865
Cleanliness - star rating31865
Quietness - star rating11865
Overall hospital rating - star rating31865
Recommend hospital - star rating41865
Summary star rating31865

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volume——
Global Malnutrition Composite Score——
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented——
Global Malnutrition Composite Score: Malnutrition Risk Screening——
Global Malnutrition Composite Score: Nutrition Assessment——
Global Malnutrition Composite Score: Nutritional Care Plan——
Hospital Harm - Severe Hyperglycemia89136
Hospital Harm - Severe Hypoglycemia12127
Hospital Harm - Opioid Related Adverse Events——
Healthcare workers given influenza vaccination604147
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better——
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better——
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better——
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better——
Left before being seen——
Head CT results——
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients——
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery——
ST-Segment Elevation Myocardial Infarction (STEMI)——
Safe Use of Opioids - Concurrent Prescribing132923
Appropriate care for severe sepsis and septic shock61142
Septic Shock 3-Hour Bundle6042
Septic Shock 6-Hour Bundle9020
Severe Sepsis 3-Hour Bundle78142
Severe Sepsis 6-Hour Bundle9259
Discharged on Antithrombotic Therapy97144
Anticoagulation Therapy for Atrial Fibrillation/Flutter——
Antithrombotic Therapy by End of Hospital Day 2——
Venous Thromboembolism Prophylaxis——
Intensive Care Unit Venous Thromboembolism Prophylaxis——

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth——
Risk Adjusted Severe Obstetric Complications (All)——
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)——
Maternal Morbidity Structural MeasureYes—

Frequently asked questions

How is Kaiser Foundation Hospital-Santa Rosa rated?
Kaiser Foundation Hospital-Santa Rosa has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Kaiser Foundation Hospital-Santa Rosa have emergency services?
Yes. Kaiser Foundation Hospital-Santa Rosa operates a 24/7 emergency department.
Where is Kaiser Foundation Hospital-Santa Rosa located?
Kaiser Foundation Hospital-Santa Rosa is located at 401 Bicentennial Way, Santa Rosa, CA 95403.
What type of hospital is Kaiser Foundation Hospital-Santa Rosa?
Kaiser Foundation Hospital-Santa Rosa is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

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