Facility WatchInspection records for every certified US nursing home
Blue OAK Post-acute
850 Sonoma AVE Santa Rosa, CA 95404 (707) 544-7750
Abuse icon
CCN
056090
Certified beds
181
Ownership
For profit - Corporation
Nurse staffing
4.62
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.72 hours per resident per day
Nursing staff turnover: 19% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected April 16, 2026
1 citation · from a complaint investigation · Health
E
F0600No actual harm with potential for more than minimal harm · Pattern
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected April 17, 2026
Inspected April 2, 2026
2 citations · from a complaint investigation · Health
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected April 3, 2026
D
F0919No actual harm with potential for more than minimal harm · Isolated
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected April 3, 2026
Inspected January 7, 2026
2 citations · from a complaint investigation · Health
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected January 8, 2026
E
F0609No actual harm with potential for more than minimal harm · Pattern
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected January 8, 2026
Inspected December 22, 2025
1 citation · from a complaint investigation · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected January 6, 2026
Inspected December 11, 2025
2 citations · from a complaint investigation · Health
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected January 5, 2026
G
F0600Actual harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected January 5, 2026
Inspected November 25, 2025
15 citations · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected December 3, 2025
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected December 3, 2025
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected December 3, 2025
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected December 3, 2025
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected December 3, 2025
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected December 3, 2025
D
F0814No actual harm with potential for more than minimal harm · Isolated
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected December 3, 2025
D
F0887No actual harm with potential for more than minimal harm · Isolated
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Deficient, Provider has date of correction · corrected December 3, 2025
E
F0583No actual harm with potential for more than minimal harm · Pattern
Keep residents' personal and medical records private and confidential.
Deficient, Provider has date of correction · corrected December 3, 2025
E
F0761No actual harm with potential for more than minimal harm · Pattern
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Deficient, Provider has date of correction · corrected December 3, 2025
E
F0805No actual harm with potential for more than minimal harm · Pattern
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Deficient, Provider has date of correction · corrected December 3, 2025
E
F0806No actual harm with potential for more than minimal harm · Pattern
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected December 3, 2025
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected December 3, 2025
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected December 3, 2025
E
F0919No actual harm with potential for more than minimal harm · Pattern
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected December 3, 2025
Inspected September 8, 2025
1 citation · from a complaint investigation · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected September 22, 2025
Inspected July 22, 2025
3 citations · from a complaint investigation · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected August 26, 2025
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected August 26, 2025
D
F0761No actual harm with potential for more than minimal harm · Isolated
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Deficient, Provider has date of correction · corrected August 26, 2025
Inspected May 8, 2025
1 citation · from a complaint investigation · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected June 5, 2025
Inspected April 16, 2025
1 citation · from a complaint investigation · Health
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected April 28, 2025
Inspected January 7, 2025
1 citation · from a complaint investigation · Health
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected January 23, 2025
Inspected March 29, 2024
1 citation · from a complaint investigation · Health
D
F0685No actual harm with potential for more than minimal harm · Isolated
Assist a resident in gaining access to vision and hearing services.
Deficient, Provider has date of correction · corrected April 24, 2024
Inspected November 17, 2023
21 citations · from a complaint investigation · Health
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected January 5, 2024
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected January 5, 2024
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected January 5, 2024
D
F0698No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected January 5, 2024
D
F0803No actual harm with potential for more than minimal harm · Isolated
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Deficient, Provider has date of correction · corrected January 5, 2024
D
F0812No actual harm with potential for more than minimal harm · Isolated
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected January 5, 2024
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected January 5, 2024
D
F0887No actual harm with potential for more than minimal harm · Isolated
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Deficient, Provider has date of correction · corrected January 5, 2024
D
F0908No actual harm with potential for more than minimal harm · Isolated
Keep all essential equipment working safely.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0557No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0574No actual harm with potential for more than minimal harm · Pattern
The resident has the right to receive notices in a format and a language he or she understands.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0584No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0609No actual harm with potential for more than minimal harm · Pattern
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0656No actual harm with potential for more than minimal harm · Pattern
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0677No actual harm with potential for more than minimal harm · Pattern
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0697No actual harm with potential for more than minimal harm · Pattern
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0725No actual harm with potential for more than minimal harm · Pattern
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0804No actual harm with potential for more than minimal harm · Pattern
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0850No actual harm with potential for more than minimal harm · Pattern
Hire a qualified full-time social worker in a facility with more than 120 beds.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0921No actual harm with potential for more than minimal harm · Pattern
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected January 5, 2024
E
F0943No actual harm with potential for more than minimal harm · Pattern
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Deficient, Provider has date of correction · corrected January 5, 2024
Inspected July 14, 2023
3 citations · from a complaint investigation · Health
D
F0636No actual harm with potential for more than minimal harm · Isolated
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Deficient, Provider has date of correction · corrected July 27, 2023
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected July 27, 2023
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected July 27, 2023
Inspected February 7, 2022
10 citations · Health
C
F0838No actual harm with potential for minimal harm · Widespread
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Deficient, Provider has date of correction · corrected April 5, 2022
D
F0607No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected April 5, 2022
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected April 5, 2022
E
F0561No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Deficient, Provider has date of correction · corrected April 5, 2022
E
F0640No actual harm with potential for more than minimal harm · Pattern
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Deficient, Provider has date of correction · corrected April 5, 2022
E
F0657No actual harm with potential for more than minimal harm · Pattern
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected April 5, 2022
E
F0730No actual harm with potential for more than minimal harm · Pattern
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected April 5, 2022
E
F0761No actual harm with potential for more than minimal harm · Pattern
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Deficient, Provider has date of correction · corrected April 5, 2022
E
F0865No actual harm with potential for more than minimal harm · Pattern
Have a plan that describes the process for conducting QAPI and QAA activities.
Deficient, Provider has date of correction · corrected April 5, 2022
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected April 5, 2022
Penalties
Date
Type
Amount
December 11, 2025
Fine
$28,106
January 7, 2025
Fine
$8,278
Ownership transfers
Effective
Seller
Buyer
03/01/2023
Nadhan Inc.
Hilborn Care, Inc.
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.