Facility Watch Inspection 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
F0600 No 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
F0656 No 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
F0919 No 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
F0658 No 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
F0609 No 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
F0600 No 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
F0610 No 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
F0600 Actual 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
F0600 No 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
F0641 No 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
F0658 No 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
F0692 No 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
F0695 No 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
F0755 No 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
F0814 No 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
F0887 No 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
F0583 No 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
F0761 No 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
F0805 No 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
F0806 No 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
F0812 No 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
F0880 No 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
F0919 No 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
F0600 No 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
F0550 No 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
F0609 No 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
F0761 No 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
F0550 No 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
F0610 No 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
F0689 Actual 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
F0685 No 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
F0580 No 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
F0600 No 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
F0692 No 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
F0698 No 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
F0803 No 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
F0812 No 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
F0880 No 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
F0887 No 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
F0908 No 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
F0557 No 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
F0574 No 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
F0584 No 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
F0609 No 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
F0656 No 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
F0677 No 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
F0697 No 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
F0725 No 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
F0804 No 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
F0850 No 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
F0921 No 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
F0943 No 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
F0636 No 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
F0690 No 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
F0842 No 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
F0838 No 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
F0607 No 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
F0658 No 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
F0561 No 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
F0640 No 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
F0657 No 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
F0730 No 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
F0761 No 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
F0865 No 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
F0880 No 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

DateTypeAmount
December 11, 2025Fine$28,106
January 7, 2025Fine$8,278

Ownership transfers

EffectiveSellerBuyer
03/01/2023Nadhan 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.