Skilled Nursing

BLUE OAK POST-ACUTE

850 SONOMA AVE, SANTA ROSA, CA 95404

181beds
Skilled Nursingcare types
2/5CMS rating
Updated2026

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Inspection & Compliance

Data from CMS (Centers for Medicare & Medicaid Services), updated weekly. Medicare.gov Care Compare

CMS Abuse/Neglect Flag

This facility has been flagged by CMS for substantiated abuse or neglect of residents.

View full report

3.2h

Hrs/resident · weekday

Expected: 4.6h

4.0h

Hrs/resident · weekend

vs 3.2h on weekdays

Not reported

30-day hospital readmission rate

Annual Staff Turnover Rates

High turnover is one of the strongest predictors of care quality. National average CNA turnover is ~75%.

RNs
26%
LPNs
CNAs
19%

Administrator turnover: 0 in the past year

Health Inspection Deficiencies · Last 3 Years

55 standard deficiencies in the last 3 years

View all
0600Severity EApr 16, 2026

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0919Severity DApr 2, 2026

Make sure that a working call system is available in each resident's bathroom and bathing area.

0656Severity DApr 2, 2026

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0658Severity DJan 7, 2026

Ensure services provided by the nursing facility meet professional standards of quality.

0609Severity EJan 7, 2026

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0600Severity DDec 22, 2025

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0610Severity DDec 11, 2025

Respond appropriately to all alleged violations.

0600Severity GDec 11, 2025

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0919Severity ENov 25, 2025

Make sure that a working call system is available in each resident's bathroom and bathing area.

0887Severity DNov 25, 2025

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.

0880Severity ENov 25, 2025

Provide and implement an infection prevention and control program.

0814Severity DNov 25, 2025

Dispose of garbage and refuse properly.

0812Severity ENov 25, 2025

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0806Severity ENov 25, 2025

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

0805Severity ENov 25, 2025

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

0761Severity ENov 25, 2025

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.

0755Severity DNov 25, 2025

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0695Severity DNov 25, 2025

Provide safe and appropriate respiratory care for a resident when needed.

0692Severity DNov 25, 2025

Provide enough food/fluids to maintain a resident's health.

0658Severity DNov 25, 2025

Ensure services provided by the nursing facility meet professional standards of quality.

0641Severity DNov 25, 2025

Ensure each resident receives an accurate assessment.

0600Severity DNov 25, 2025

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0583Severity ENov 25, 2025

Keep residents' personal and medical records private and confidential.

0600Severity DSep 8, 2025

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0761Severity DJul 22, 2025

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.

0609Severity DJul 22, 2025

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0550Severity DJul 22, 2025

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0550Severity DMay 8, 2025

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0610Severity DApr 16, 2025

Respond appropriately to all alleged violations.

0689Severity GJan 7, 2025

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0685Severity DMar 29, 2024

Assist a resident in gaining access to vision and hearing services.

0943Severity ENov 17, 2023

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

0921Severity ENov 17, 2023

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

0908Severity DNov 17, 2023

Keep all essential equipment working safely.

0887Severity DNov 17, 2023

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.

0880Severity DNov 17, 2023

Provide and implement an infection prevention and control program.

0850Severity ENov 17, 2023

Hire a qualified full-time social worker in a facility with more than 120 beds.

0812Severity DNov 17, 2023

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0804Severity ENov 17, 2023

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0803Severity DNov 17, 2023

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.

0725Severity ENov 17, 2023

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0698Severity DNov 17, 2023

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0697Severity ENov 17, 2023

Provide safe, appropriate pain management for a resident who requires such services.

0692Severity DNov 17, 2023

Provide enough food/fluids to maintain a resident's health.

0677Severity ENov 17, 2023

Provide care and assistance to perform activities of daily living for any resident who is unable.

0656Severity ENov 17, 2023

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0609Severity ENov 17, 2023

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0600Severity DNov 17, 2023

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0584Severity ENov 17, 2023

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.

0580Severity DNov 17, 2023

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0574Severity ENov 17, 2023

The resident has the right to receive notices in a format and a language he or she understands.

0557Severity ENov 17, 2023

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

0842Severity DJul 14, 2023

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0690Severity DJul 14, 2023

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0636Severity DJul 14, 2023

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

View full inspection history on Medicare.gov

Civil Monetary Penalties

No civil monetary penalties on record.

Nearby Hospitals

No hospitals found within 10 miles.

Proximity to emergency care is especially important for medically complex residents.

Ownership

HILBORN CARE, INC.· For profit - Corporation

Data updated weekly from CMS. Last sync: Jun 26, 2026. Medicare.gov Care Compare →

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Data sourced from the Centers for Medicare & Medicaid Services and state licensing agencies. ← Back to search

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