Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
10’22
21’23
1’24
25’25
10’26
67 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 29, 2026 | D · potential | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Complaint |
| Jul 29, 2026 | D · potential | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Complaint |
| Jun 10, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jun 10, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| May 1, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Apr 16, 2026 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 2, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Apr 2, 2026 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
| Jan 7, 2026 | E · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jan 7, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Dec 22, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 11, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 11, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Nov 25, 2025 | E · potential | Keep residents' personal and medical records private and confidential. | Routine |
| Nov 25, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Routine |
| Nov 25, 2025 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Nov 25, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Nov 25, 2025 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Nov 25, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Nov 25, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Nov 25, 2025 | E · potential | 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. | Routine |
| Nov 25, 2025 | E · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Nov 25, 2025 | E · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Nov 25, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Nov 25, 2025 | D · potential | Dispose of garbage and refuse properly. | Routine |
| Nov 25, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Nov 25, 2025 | D · potential | 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. | Routine |
| Nov 25, 2025 | E · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Sep 8, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 22, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Jul 22, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jul 22, 2025 | D · potential | 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. | Complaint |
| May 8, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Apr 16, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Jan 7, 2025 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Mar 29, 2024 | D · potential | Assist a resident in gaining access to vision and hearing services. | Complaint |
| Nov 17, 2023 | E · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Routine |
| Nov 17, 2023 | E · potential | The resident has the right to receive notices in a format and a language he or she understands. | Routine |
| Nov 17, 2023 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Nov 17, 2023 | E · potential | 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. | Routine |
| Nov 17, 2023 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Nov 17, 2023 | E · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Nov 17, 2023 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Nov 17, 2023 | E · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Nov 17, 2023 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Nov 17, 2023 | E · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Nov 17, 2023 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Nov 17, 2023 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Routine |
| Nov 17, 2023 | D · potential | 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. | Routine |
| Nov 17, 2023 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Nov 17, 2023 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Nov 17, 2023 | E · potential | Hire a qualified full-time social worker in a facility with more than 120 beds. | Routine |
| Nov 17, 2023 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Nov 17, 2023 | D · potential | 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. | Routine |
| Nov 17, 2023 | D · potential | Keep all essential equipment working safely. | Routine |
| Nov 17, 2023 | E · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| Nov 17, 2023 | E · potential | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Complaint |
| Feb 7, 2022 | E · potential | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Routine |
| Feb 7, 2022 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Routine |
| Feb 7, 2022 | E · potential | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | Routine |
| Feb 7, 2022 | E · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Feb 7, 2022 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Feb 7, 2022 | E · potential | Observe each nurse aide's job performance and give regular training. | Routine |
| Feb 7, 2022 | E · potential | 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. | Routine |
| Feb 7, 2022 | C · minimal | 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. | Routine |
| Feb 7, 2022 | E · potential | Have a plan that describes the process for conducting QAPI and QAA activities. | Routine |
| Feb 7, 2022 | E · potential | Provide and implement an infection prevention and control program. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Blue Oak Post-Acute
850 Sonoma Ave, Santa Rosa, CA 95404 · (707) 544-7750
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 056090
- Certified beds
- 181
- Legal owner
- Macao Holdings LLC
- Part of
- Spyglass Healthcare
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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