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
2 of 5 overall
Blue Oak Post-Acute (Santa Rosa, CA) has an overall rating of 2 out of 5 stars. Its health inspection rating is very low at 1 out of 5, staffing is rated 5 out of 5 but reported nurse staffing is 3.70 hours per resident per day, below the federal benchmark of 4.1, and it has had $36,384 in fines in the last 24 months plus a recent abuse citation.
Facility ratings
Health inspections
Staffing
3.6962 hrs/resident/day
Quality measures
Last inspection: January 7, 2026Penalties, last 24 months: $36,384recent abuse citation
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.6962.
Staffing detail
- Registered nurses
- 0.57
- Licensed practical nurses
- 1.10
- Nurse aides
- 2.02
- Weekend nursing
- 3.19
Hours per resident per day.
Total staff turnover: 19%
Registered nurse turnover: 26%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
26.7%Improving
Residents with a fall causing major injury
0.7%Steady
Residents with pressure ulcers (bedsores)
1.2%Worsening
Residents with a urinary tract infection
0.4%Worsening
Residents who lost too much weight
3.5%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
7.7%Improving
Residents whose ability to walk got worse
7.7%Worsening
Show all measures
Long-stay residents on antianxiety or sleep medication
27.7%Improving
Short-stay residents newly given an antipsychotic
0%Steady
Residents with a long-term catheter
1.6%Steady
Residents with new or worsening incontinence
11.3%Worsening
Residents with depressive symptoms
3.4%Improving
Long-stay residents given the seasonal flu vaccine
99.3%Steady
Long-stay residents given the pneumonia vaccine
96.7%Improving
Short-stay residents given the seasonal flu vaccine
85.9%Steady
Short-stay residents given the pneumonia vaccine
79.6%Worsening
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 home failed to properly label and securely store medications and biologicals. Cited November 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 761 — 42 CFR §483.45(g) — 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 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
- Ownership
- For profit - Corporation
- Occupancy
- 147.4 residents on an average day (81% 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.