Compiled from official CMS federal data
BLUE OAK POST-ACUTE, SANTA ROSA, CA — Violations & Inspection Reports
Does BLUE OAK POST-ACUTE have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), BLUE OAK POST-ACUTE (CCN 056090), in SANTA ROSA, CA, has federal inspection findings. CMS currently displays its federal abuse icon for this facility — a flag CMS assigns under its own published methodology for abuse-related citations (deficiency tag F600 and related).
In its current inspection cycle, CMS cited the facility for 27 deficiencies; the most severe is rated G, a level CMS classifies as actual harm. The latest standard health inspection on file is dated 2025-11-25. Earlier-cycle citations appear in the dated timeline below as historical, not current. CMS has $36,384 in civil money penalties on file against the facility. The record also includes 12 abuse- or neglect-related citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series; most recent Apr 2026). This page restates the federal record and draws no conclusion of its own.
Abuse-, fall-, and care-related findings on the federal record
- 12 citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series) — most recent Apr 2026.
- 1 citation for accident hazards or inadequate supervision (F689) — the deficiency family behind fall-related findings; most recent Jan 2025.
- 2 nutrition and hydration citations (F692) — the consumer terms are "malnutrition" and "dehydration"; most recent Nov 2025.
- 22 findings on file from complaint-triggered inspections.
Every figure above restates CMS’s own dated record; this page draws no conclusion of its own. Strict state filing deadlines can apply to nursing-home injury claims — a licensed attorney in your state can review this record.
FOR FAMILIES
What brings you to this record?
The Federal Record
CMS displays its federal abuse icon on this facility's official record.
Below is this facility's federal inspection record as on file with CMS.
Federal abuse icon on file
CMS displays this icon for facilities it has cited for resident abuse under its own published methodology — the government's own flag, restated here.
Scope & Severity — current cycle
CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.
Civil money penalties on file
$36,384
Have a lawyer review this record →
About this record: Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
Deficiency timeline
Citations are listed by scope/severity (most severe first), not chronologically; each entry is labeled current-cycle or historical.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
57 more citations on file — Abuse & neglect 9 · Nutrition & hydration 2 · Medication & pharmacy 4 · Resident rights 8 · Other citations 31 (expand)
Make sure that a working call system is available in each resident's bathroom and bathing area.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure services provided by the nursing facility meet professional standards of quality.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Respond appropriately to all alleged violations.
Keep residents' personal and medical records private and confidential.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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.
Dispose of garbage and refuse properly.
Ensure each resident receives an accurate assessment.
Provide safe and appropriate respiratory care for a resident when needed.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Respond appropriately to all alleged violations.
Assist a resident in gaining access to vision and hearing services.
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Honor 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.
Provide enough food/fluids to maintain a resident's health.
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.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Observe each nurse aide's job performance and give regular training.
Provide and implement an infection prevention and control program.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Overall CMS star rating
This facility: 2 · CMS state average: 3.2
Both figures as published by CMS.
You may be reading this record for the first time.
If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.
Your federal record — tap to preview
Federal record
BLUE OAK POST-ACUTE — Federal Record
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SECTION 7 — CASE CONTEXT
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No call centers, no auctions. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. The federal record is a point-in-time inspection record and may understate what actually occurred. CareSentinel is operated by Nodal Logics LLC.
Strict time limits can apply to taking legal action — consider consulting a qualified attorney promptly.
If you believe a resident is in immediate danger, call 911. Care concerns can also be reported at no cost to your state survey agency or the Long-Term Care Ombudsman program (ltcombudsman.org) — independent of any legal inquiry.
How to read this record
Making sense of a CMS inspection record
CMS scores every citation on a grid from A to L, combining how widespread a finding was with how serious it was. A–C is a deficiency CMS classifies as no harm; D–F as the potential for harm; G–I as actual harm that reached a resident; and J–L as immediate jeopardy, CMS’s most serious level. Later letters mark more serious findings.
Three questions to ask on a tour
- How is the home staffed on nights, weekends, and holidays?
- What happens when a resident’s condition changes suddenly?
- How, and how quickly, are families told about an incident?