Nursing HomeInspections

Blue Oak Post-Acute

Nursing home in Santa Rosa, CA

Medicare & Medicaid certified1★ overall (CMS)CMS abuse icon

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Public-record details

Address
850 Sonoma Ave, Santa Rosa, CA 95404
Phone
(707) 544-7750
Listed under
For-profit
Medicare CCN
056090
Overall star rating
1 of 5 ★☆☆☆☆
Health inspection rating
1 of 5
Staffing rating
3 of 5
Quality measures rating
3 of 5
Certified beds
181
Average residents per day
172
Ownership
For-profit, corporation
Legal business name
Macao Holdings LLC
Chain
Spyglass Healthcare (14 facilities)
Certified for
Medicare and Medicaid
First approved by Medicare/Medicaid
Feb 1, 1974
Changed ownership in last 12 months
No
Continuing care retirement community
No
Located inside a hospital
No
Resident or family council
Resident and family councils
Sprinklers in all required areas
Yes

CMS certification number 056090. Source: CMS Nursing Home Provider Information, Health Deficiencies and Penalties (record). Data as of 2026-11-07.

Inspection record

Most recent standard health inspection: Nov 25, 2025. CMS lists 67 health citations for this facility across its last three standard inspection cycles and complaint inspections (Feb 7, 2022 to Jul 29, 2026): 24 from complaint inspections, 2 at the “actual harm” level or higher. CMS shows its abuse icon for this facility, which it uses for nursing homes cited for abuse at the harm level recently or at the potential-harm level in each of the last two years.

InspectionCitationSeverity
Jul 29, 2026Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Resident Rights · complaint inspection
D
Potential for more than minimal harm, isolated
Jul 29, 2026Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights · complaint inspection
D
Potential for more than minimal harm, isolated
Jun 10, 2026Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning · complaint inspection
D
Potential for more than minimal harm, isolated
Jun 10, 2026Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning · complaint inspection
D
Potential for more than minimal harm, isolated
May 1, 2026Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care · complaint inspection
D
Potential for more than minimal harm, isolated
Apr 16, 2026Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation · complaint inspection
E
Potential for more than minimal harm, pattern
Apr 2, 2026Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning · complaint inspection
D
Potential for more than minimal harm, isolated
Apr 2, 2026Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental · complaint inspection
D
Potential for more than minimal harm, isolated
Jan 7, 2026Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning · complaint inspection
D
Potential for more than minimal harm, isolated
Jan 7, 2026Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation · complaint inspection
E
Potential for more than minimal harm, pattern
Dec 22, 2025Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation · complaint inspection
D
Potential for more than minimal harm, isolated
Dec 11, 2025Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation · complaint inspection
D
Potential for more than minimal harm, isolated

Showing the 12 most recent of 67. Full inspection reports are on Medicare Care Compare.

Severity letters follow CMS's scope-and-severity grid: A–C potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, J–L immediate jeopardy. Most citations are corrected; a citation is what inspectors found on that date. Source: CMS Health Deficiencies file, processed Oct 1, 2026.

Fines and payment denials

CMS records 2 fines totalling $36,892 in the last three years.

Dec 11, 2025Fine: $28,614
Jan 7, 2025Fine: $8,278

Source: CMS Penalties file, processed Oct 1, 2026. Amounts are as CMS reports them and may reflect later reductions or appeals.

Staffing

Total nurse staffing per resident per day
3.34 hours
Registered nurse (RN) time per resident per day
0.46 hours
Nurse aide time per resident per day
2.07 hours
Total nurse staffing on weekends
3.00 hours
Nursing staff turnover (yearly)
32%
RN turnover (yearly)
42%
Administrators who left in the past year
1

From payroll-based staffing data the facility submits to CMS. Hours are per resident per day.

A citation is what inspectors found on one date; most are corrected within weeks. Look for patterns — the same problem cited in several inspections — and for anything at the G–L level (actual harm or immediate jeopardy). The full inspection narrative (Form CMS-2567) is linked from Medicare Care Compare, and your state long-term care ombudsman can tell you about complaints.

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