Vineyard Post Acute
101 Monroe Street · Petaluma, CA · 94954 · 7077634109
99 certified beds For profit - Limited Liability company Chain: Pacs Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $55,692 in fines in the last 24 months.
- 3 citations involved actual harm to residents.
Red flags
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
$55,692 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.94 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.48 | 0.55–0.75 |
| Weekend hours / resident-day | 3.47 | ≈ weekday level |
| Nursing turnover / year | 40% | median 45% |
| Fines (3-yr window) | 3 · $63,135 |
Inspection citations (47 in the current record)
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Potential for harm · D March 30, 2026 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected April 22, 2026 · Resident Rights
-
Potential for harm · D March 30, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 22, 2026 · Quality of Life and Care
-
Potential for harm · D March 10, 2026 · found via complaint
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 March 29, 2026 · Pharmacy Service
-
Potential for harm · D January 22, 2026 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected February 23, 2026 · Resident Assessment and Care Planning
-
Potential for harm · D December 18, 2025
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected January 15, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 18, 2025
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected January 15, 2026 · Quality of Life and Care
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Potential for harm · E December 18, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected January 15, 2026 · Pharmacy Service
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Potential for harm · E December 18, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected January 15, 2026 · Pharmacy Service
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Potential for harm · E December 18, 2025
Ensure that residents are free from significant medication errors.
Corrected January 15, 2026 · Pharmacy Service
-
Potential for harm · E December 18, 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 January 15, 2026 · Pharmacy Service
-
Potential for harm · D December 18, 2025
Provide or get specialized rehabilitative services as required for a resident.
Corrected January 15, 2026 · Quality of Life and Care
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Potential for harm · D December 18, 2025
Provide and implement an infection prevention and control program.
Corrected January 15, 2026 · Infection Control
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Potential for harm · E December 18, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected January 15, 2026 · Environmental
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Potential for harm · E December 18, 2025 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 15, 2026 · Nutrition and Dietary
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Potential for harm · F December 18, 2025 · found via complaint
Dispose of garbage and refuse properly.
Corrected January 15, 2026 · Nutrition and Dietary
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Potential for harm · D September 16, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected November 28, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 22, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected May 16, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 11, 2025 · found via complaint
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.
Corrected March 25, 2025 · Resident Rights
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Potential for harm · E February 25, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 29, 2025 · Infection Control
-
Actual harm · G February 13, 2025 · found via complaint
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected March 5, 2025 · Quality of Life and Care
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Potential for harm · D February 12, 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 February 25, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E November 23, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected December 20, 2024 · Resident Rights
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Potential for harm · D November 23, 2024
Ensure each resident receives an accurate assessment.
Corrected December 20, 2024 · Resident Assessment and Care Planning
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Potential for harm · D November 23, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected December 20, 2024 · Quality of Life and Care
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Potential for harm · E November 23, 2024
Ensure that residents are free from significant medication errors.
Corrected December 20, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 12, 2025 | Fine | $34,034 |
| November 22, 2024 | Fine | $21,658 |
| September 5, 2023 | Fine | $7,443 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 555120 · certified since November 7, 1980. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.