The nursing home failed to protect residents from abuse and neglect by others. Cited December 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 600 — 42 CFR §483.12 — S/S: G
Nursing home report
BLUE OAK POST-ACUTE
SANTA ROSA, CA · Medicare-certified · 181 beds
Needs attention
Abuse citationFor-profit
Data as of July 1, 2026
2 of 5 overall
BLUE OAK POST-ACUTE (SANTA ROSA, CA) has a 2-star overall rating, with a 1-star health inspection rating, a recent abuse citation, and $36,384 in fines over the last 24 months. Staffing is rated 5 stars, but reported nurse staffing is 3.44 hours per resident per day, below the federal benchmark of 4.1.
Facility ratings
Health inspections
Staffing
3.4434 hrs/resident/day
Quality measures
Last inspection: May 1, 2026Penalties, last 24 months: $36,384recent abuse citation
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.4434.
Staffing detail
- Registered nurses
- 0.56
- Licensed practical nurses
- 0.76
- Nurse aides
- 2.13
- Weekend nursing
- 3.05
Hours per resident per day.
Total staff turnover: 19%
Registered nurse turnover: 19%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
29.5%24.6%Improving
Residents with a fall causing major injury
0.7%0.8%No change
Residents with pressure ulcers (bedsores)
0%1.2%Worsening
Residents with a urinary tract infection
0.8%0%Improving
Residents who lost too much weight
2.3%3.8%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
7.1%0%Improving
Residents whose ability to walk got worse
10.1%0%Improving
Long-stay residents on antianxiety or sleep medication
29.9%28%Improving
Short-stay residents newly given an antipsychotic
0%0%No change
Residents with a long-term catheter
2.5%0%Improving
Residents with new or worsening incontinence
12.9%9.2%Improving
Residents with depressive symptoms
5.2%4.2%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—99.3%—
Long-stay residents given the pneumonia vaccine
96.3%98.5%Improving
Short-stay residents given the seasonal flu vaccine
—85.9%—
Short-stay residents given the pneumonia vaccine
84.3%88.4%Improving
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited January 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
The home failed to promptly report suspected abuse, neglect, or theft and share the investigation results with the proper authorities. Cited January 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 609 — 42 CFR §483.12 — S/S: E
The nursing home failed to ensure a working call system was available in each resident’s bathroom and bathing area. Cited November 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 919 — 42 CFR §483.90 — S/S: E
The home failed to keep residents’ personal and medical records private and confidential. Cited November 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 583 — 42 CFR §483.10 — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $28,106 was recorded.
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- PENALTY
A federal fine of $8,278 was recorded.
Penalties & enforcement
On record with Medicare: 2 fines · $36,384 in total fines.
- $28,106
Federal fine
Dec 11, 2025
- $8,278
Federal fine
Jan 7, 2025
Operator & ownership
Recent ownership change · Mar 1, 2023
Now operated by Creekside Rehabilitation & Behavioral Health, previously Creekside Rehabilitation and Behavioral Health.
- Ownership
- For profit - Corporation
- Occupancy
- 163.3 residents on an average day (90% of 181 beds)
- Resident voice
- Resident & family councils
- Medicare history
- Certified for 52 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.