BLUE OAK POST-ACUTE

CMS abuse icon · CCN 056090 · HILBORN CARE, INC. · For profit - Corporation · 181 certified beds · Sonoma · CA


BLUE OAK POST-ACUTE is a 181-bed nursing home in SANTA ROSA, California. CMS has certified it for Medicare and Medicaid since 1974-02-01. It averages 163.3 residents a day.

What harm was found in the violations cited at BLUE OAK POST-ACUTE?

CMS lists 65 health-inspection deficiencies for BLUE OAK POST-ACUTE since 2022-02-07, 55 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is G; the most recent health inspection was 2026-06-10.

Survey dateTagDeficiencySeverity
2026-06-10F0656, F0658Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Ensure services provided by the nursing facility meet professional standards of quality.D
2026-05-01F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.D
2026-04-16F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.E
2026-04-02F0656, F0919Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Make sure that a working call system is available in each resident's bathroom and bathing area.D
2026-01-07F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.E
2026-01-07F0658Ensure services provided by the nursing facility meet professional standards of quality.D
2025-12-22F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D
2025-12-11F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.G
2025-12-11F0610Respond appropriately to all alleged violations.D
2025-11-25F0583, F0761, F0805, F0806, F0812, F0880, F0919Keep residents' personal and medical records private and confidential. / 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. / Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. / Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program. / Make sure that a working call system is available in each resident's bathroom and bathing area.E
2025-11-25F0600, F0641, F0658, F0692, F0695, F0755, F0814, F0887Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Ensure each resident receives an accurate assessment. / Ensure services provided by the nursing facility meet professional standards of quality. / Provide enough food/fluids to maintain a resident's health. / Provide safe and appropriate respiratory care for a resident when needed. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Dispose of garbage and refuse properly. / 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.D
2025-09-08F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D
2025-07-22F0550, F0609, F0761Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / 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.D
2025-05-08F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D
2025-04-16F0610Respond appropriately to all alleged violations.D
2025-01-07F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G
2024-03-29F0685Assist a resident in gaining access to vision and hearing services.D
2023-11-17F0557, F0574, F0584, F0609, F0656, F0677, F0697, F0725, F0804, F0850, F0921, F0943Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. / The resident has the right to receive notices in a format and a language he or she understands. / 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. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide safe, appropriate pain management for a resident who requires such services. / Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. / Hire a qualified full-time social worker in a facility with more than 120 beds. / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. / Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.E
2023-11-17F0580, F0600, F0692, F0698, F0803, F0812, F0880, F0887, F0908Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Provide enough food/fluids to maintain a resident's health. / Provide safe, appropriate dialysis care/services for a resident who requires such services. / 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. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program. / 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. / Keep all essential equipment working safely.D
2022-02-07F0561, F0640, F0657, F0730, F0761, F0865, F0880Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. / Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Observe each nurse aide's job performance and give regular training. / 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. / Have a plan that describes the process for conducting QAPI and QAA activities. / Provide and implement an infection prevention and control program.E
2022-02-07F0607, F0658Develop and implement policies and procedures to prevent abuse, neglect, and theft. / Ensure services provided by the nursing facility meet professional standards of quality.D
2022-02-07F0838Conduct 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.C

Why was BLUE OAK POST-ACUTE fined 2 times?

DateTypeAmount
2025-12-11Fine$28,614
2025-01-07Fine$8,278

How is BLUE OAK POST-ACUTE staffed relative to the CA average?

MeasureThis facilityCA average
Total nurse staffing hours per resident per day3.443354.51570
Total nursing staff turnover (%)18.536.7
Average number of residents per day163.387.9

Who owns BLUE OAK POST-ACUTE?

BLUE OAK POST-ACUTE is registered with CMS as For profit - Corporation, operates under the legal business name HILBORN CARE, INC.

RoleOwnerAssociation date
DIRECT OWNERSHIP INTERESTJOSE, JOSEKUTTYsince 03/01/2023
CORPORATE DIRECTORJOSE, JOSEKUTTYsince 12/05/2022
CORPORATE OFFICERJOSE, JOSEKUTTYsince 12/05/2022
OPERATIONAL/MANAGERIAL CONTROLMATALON, ERAN, ROSE, MEGAN, SURATOS, RAUL, TRASK, APRILsince 01/01/2002
ADP OF THE SNFJOSE, JOSEKUTTY, MATALON, ERAN, ROSE, MEGAN, SURATOS, RAUL, TRASK, APRILsince 01/01/2002

Were you or a family member harmed at BLUE OAK POST-ACUTE?