Blue Oak Post-Acute
850 Sonoma Ave · Santa Rosa, CA · 95404 · 7075447750
181 certified beds For profit - Corporation
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 1 of 5 Staffing: 5 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.70 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.57 | 0.55–0.75 |
| Weekend hours / resident-day | 3.19 | ≈ weekday level |
| Nursing turnover / year | 19% | median 45% |
| Fines (3-yr window) | 2 · $36,384 |
Inspection citations (65 in the current record)
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Potential for harm · E April 16, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 17, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 2, 2026 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 3, 2026 · Resident Assessment and Care Planning
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Potential for harm · D April 2, 2026 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected April 3, 2026 · Environmental
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Potential for harm · E January 7, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected January 8, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 7, 2026 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected January 8, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 22, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 6, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G December 11, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 5, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 11, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected January 5, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E November 25, 2025
Keep residents' personal and medical records private and confidential.
Corrected December 3, 2025 · Resident Rights
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Potential for harm · D November 25, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 3, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 25, 2025
Ensure each resident receives an accurate assessment.
Corrected December 3, 2025 · Resident Assessment and Care Planning
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Potential for harm · D November 25, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected December 3, 2025 · Resident Assessment and Care Planning
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Potential for harm · D November 25, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected December 3, 2025 · Quality of Life and Care
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Potential for harm · D November 25, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected December 3, 2025 · Quality of Life and Care
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Potential for harm · D November 25, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 3, 2025 · Pharmacy Service
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Potential for harm · E November 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.
Corrected December 3, 2025 · Pharmacy Service
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Potential for harm · E November 25, 2025
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected December 3, 2025 · Nutrition and Dietary
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Potential for harm · E November 25, 2025
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected December 3, 2025 · Nutrition and Dietary
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Potential for harm · E November 25, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected December 3, 2025 · Nutrition and Dietary
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Potential for harm · D November 25, 2025
Dispose of garbage and refuse properly.
Corrected December 3, 2025 · Nutrition and Dietary
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Potential for harm · E November 25, 2025
Provide and implement an infection prevention and control program.
Corrected December 3, 2025 · Infection Control
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Potential for harm · D November 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.
Corrected December 3, 2025 · Infection Control
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Potential for harm · E November 25, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected December 3, 2025 · Environmental
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Potential for harm · D September 8, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 22, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 22, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected August 26, 2025 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 11, 2025 | Fine | $28,106 |
| January 7, 2025 | Fine | $8,278 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056090 · certified since February 1, 1974. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.