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
14’21
13’24
7’25
9’26
43 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Mar 5, 2026 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Mar 5, 2026 | D · potential | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Routine |
| Mar 5, 2026 | D · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Routine |
| Mar 5, 2026 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Mar 5, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Mar 5, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Mar 5, 2026 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Mar 5, 2026 | F · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Jan 30, 2026 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Sep 3, 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 |
| Jul 17, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Jun 2, 2025 | 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 2, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Apr 29, 2025 | E · potential | Ensure that residents are free from significant medication errors. | Complaint |
| Jan 14, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jan 14, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| May 17, 2024 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| May 17, 2024 | E · potential | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Routine |
| May 17, 2024 | 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 |
| May 17, 2024 | E · potential | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Routine |
| May 17, 2024 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Complaint |
| May 17, 2024 | 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 |
| May 17, 2024 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| May 17, 2024 | E · potential | Provide activities to meet all resident's needs. | Routine |
| May 17, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| May 17, 2024 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| May 17, 2024 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| May 17, 2024 | E · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| May 17, 2024 | E · potential | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Routine |
| Nov 5, 2021 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Nov 5, 2021 | 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 5, 2021 | E · potential | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Routine |
| Nov 5, 2021 | 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 5, 2021 | E · potential | Honor each resident's preferences, choices, values and beliefs. | Routine |
| Nov 5, 2021 | E · potential | Provide activities to meet all resident's needs. | Routine |
| Nov 5, 2021 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Nov 5, 2021 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Nov 5, 2021 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Nov 5, 2021 | E · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| Nov 5, 2021 | 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. | Routine |
| Nov 5, 2021 | D · potential | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Routine |
| Nov 5, 2021 | E · potential | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Routine |
| Nov 5, 2021 | 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
Park View Post Acute
3751 Montgomery Dr, Santa Rosa, CA 95405 · (707) 525-1250
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 056411
- Certified beds
- 116
- Legal owner
- Ensign Montgomery LLC
- Part of
- The Ensign Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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