Petaluma Post-Acute Rehabilitation
1115 B Street, Petaluma, CA 94952 · For profit - Limited Liability company · 90 certified beds · (707) 765-3030 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.5% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.5% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.5% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.5% | 1.6% | 3.3% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 9.0% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.5% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.3% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 15.1% | 10.2% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.5% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.2% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.2% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.7% | 11.2% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.03 | 2.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.25 | 1.57 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
69.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 355 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 65.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 133 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.52 therapist hours per resident per day in 2026Q1 — more than 83% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 54% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 69.6%CMS range 64.2–74.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.0%CMS range 6.5–12.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 65.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 58.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 4.2–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 90 beds and averages 78.2 residents a day — about 87% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.22 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.11 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.63 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.04 hrs/resident/day on weekends vs 4.30 on weekdays — 6% thinner on weekends. RN hours go from 1.14 to 1.04 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · E2025-12-19 · tag F0685 — patternAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of two residents (Resident 36 and Resident 92) had access to devices needed for sensory impairment when,1. Resident 36 reported broken glasses, needed for distance, on admission, and the glasses remained unaddressed a month later. And,2. Resident 92 reported needing hearing aids to hear people clearly, on admission, and Social Services did not respond to his request.This failure affected both residents' ability to actively engage in their care, their overall functionality, and their sense of well-being. Findings:1. A review of Resident 36's clinical record indicated she was admitted in 11/2025, with a diagnosis of a fracture of her left patella and a large contusion over her left eye after a fall. A review of Resident 36's inventory of personal effects, dated 11/18/25, indicated she reported that glasses were broken. A review of Resident 36's MDS (MDS-A resident assessment tool), dated 11/22/25, indicated no cognitive impairment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-19 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure safe medication labeling and storage practices were followed when,1. A loose Lantus Solostar Insulin Pen (A disposable prefilled injection device for long-acting insulin administration for diabetic residents) was found in the medication refrigerator with no label, no resident name, no instructions, no open date. And,2. Medication tablets and pills intended for wasting, were collected and filled in an unlabeled urine specimen cup that was stored inside a medication cart.These failures had the potential to contribute to unsafe medication use and administration and medication diversion.Findings: 1. During a concurrent observation and interview on 12/17/25 at 1:05 p.m., in the main medication room with the Nurse Manager (NM), a loose unlabeled Lantus Solostar Insulin Pen was found in the medication refrigerator. The NM stated he did not know why it was not labeled or which resident it was for. The NM further stated, if the medication was not labeled it could be used for the wrong resident. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-19 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure infection control procedures were followed for two of two Residents (Resident 62 and Resident 64), when Licensed Nurse 1(LN 1) did not disinfect the blood pressure cuff between use on these residents.This failure had the potential to spread infection between residents.Findings:During an observation on 12/17/25 at 8:09 a.m., in Hall A, LN1 checked the blood pressure of Resident 64 and did not disinfect the blood pressure cuff afterwards.During an observation on 12/17/25 at 8:26 a.m., in Hall A, LN1 proceeded to check the blood pressure of Resident 62 and did not disinfect the blood pressure cuff prior to using.During an interview on 12/17/25 at 8:43 a.m., with LN 1, LN1 stated she should have cleaned the blood pressure cuff between residents to stop the spread of germs from resident to resident.During an interview on 12/17/25 at 1:36 p.m., with the Infection Preventionist (IP), the IP stated all vitals equipment should be cleaned at the start of the shift and between residents always, all multi-use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-19 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility failed to ensure the Ombudsman (A government official who advocates for residents directly with the facility to resolve concerns and complaints) was notified, when one Resident (Sampled Resident #83) was transferred to the hospital.This failure had the potential to deny protection to Resident #83 from being inappropriately transferred or discharged and to have access to an advocate who could inform them of their options and rights. Findings:During a concurrent interview with the Nurse Manager (NM) on 12/17/2025 at 11:47 AM, the NM stated, when a resident was going to be transferred the expectation for nurses was to call the physician, notify family, get paperwork ready and to complete a hand-off report to the accepting facility. The NM did not state the expectation was to also notify the facility Ombudsman.During an interview and concurrent record review with the Director of Nursing (DON) at 11:47 AM, she stated Resident #83 was sent to the hospital for shortness of breath on 10/20/2025. She stated Resident #83 was admitted to the hospital, and the physician and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-12 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement an effective discharge planning process for one resident (Resident 1) of three sampled residents when Resident 1 and his family member were not trained on how to administer Resident 1's enteral nutrition formula (liquid nutrition) using Resident 1's gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and Resident 1's feeding pump (used to deliver the enteral nutrition) had not been delivered to Resident 1's residence upon his discharge. These failures resulted in Resident 1 not having received any nutrition for over 30 hours after his discharge from the facility, his transfer to the Emergency Department (ED) to be evaluated because of the potentially negative effect to his health and well-being, and his readmission to the facility one day after discharge. Findings: A review of Resident 1's admission record indicated he was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-19 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, facility policy review, the facility failed to complete an assessment to determine if a resident was able to self-administer their medication(s) for 1 (Resident #52) of 18 sampled residents. Findings included: A facility policy titled, Self-Administration of Medications, revised 12/2022, indicated, 1. As part of their overall evaluation, the staff will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff will perform a more specific skill assessment, including (but not limited to) the residents a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. An admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-19 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore a gown and gloves when they provided incontinence care to 2 (Resident #34 and Resident #66) of 18 sampled residents. Findings included: A facility policy titled Enhanced Barrier Precautions, effective 08/06/2024, revealed, Enhanced Barrier Precautions (EBP) - used in conjunction with the standard precautions and expand the use of PPE [personal protective equipment] to donning of gown and gloves during high-contact resident care activities and in situations of expected exposure to blood, body fluids, skin breakdown, or mucous membranes that provide opportunities for transfer of MDROs [multidrug-resistant organisms] to staff hands and clothing to reduce transmission. The policy specified, 4. Facility staff shall perform hand hygiene and in cases when standard precautions may not be sufficient, will don gown and gloves before performing high-contact resident care activities. The list below is not all-inclusive, and activities requiring EBP are on a case by case basis as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-11 · tag F0563 — failed to protect the right to visitors — patternHonor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents could receive visitors outside of regular working hours for one (Resident 64) of 17 sampled residents. This failure did not ensure Resident 64's rights, and had the potential to negatively affect residents' psychosocial outcomes due to restricted visitation of families and friends who may want to visit and cheer-up residents in the morning or evening, outside of business hours. Findings: A review of Resident 64's admission Record indicated she was admitted to the facility on [DATE], with a history of bleeding between the brain and tissue covering the brain, high blood pressure, insulin dependent diabetes and generalized muscle weakness. During an observation on 3/7/22 at 12:38 p.m., in Resident 64's room, she was observed sleeping in her bed not opening her eyes or responding to name by voice. Resident 64 could not be interviewed as she would not wake up, become alert and respond to requests for interview. During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-11 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview and record review the facility failed to provide individualized activities for three of 17 sampled residents (Resident 43, 58, and 64). This deficient practice had the potential to affect the quality of life of residents by placing them at risk of sensory deprivation and decreased cognitive functioning. Findings: 1. During a review of Resident 43's, admission Record, dated 2/10/22, indicated she had been admitted to the facility on [DATE] following a hip replacement surgery (surgery to implant an artificial hip joint), muscle weakness and low blood pressure when standing or sitting. A review of Resident 43's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 1/31/22, indicated the resident exhibited no cognitive deficits. During a concurrent observation an interview on 3/7/22, at 3:28 p.m., Resident 43 stated that no one had come to her bedside to offer books or or provide other activities to complete at the bedside. Resident 43 was asked if she attended…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-03-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the Infection Control Policy for 2 of 17 residents (Residents 14 and 33) when: 1. The Infection Preventionist (IP) did not perform hand hygiene between concluding a wound care and treatment for one resident (Resident 14) and touching doorknobs inside the resident's room. In 7/2021, Resident 14's wound became colonized with an infection caused Methicillin-resistant Staphylococcus aureus (MRSA, a strain of bacteria resistant to certain antibiotics and spread by contact with infected people, surfaces, or things that carry the bacteria); 2. Resident 33 exhibited potential symptoms of C. Diff. (a healthcare-associated infection causing loose stools) but the facility delayed implementation of its infection surveillance policy. These failures delayed monitoring and treatment for Resident 33's infection, and had the potential to spread MRSA and C. Diff infections among residents in the facility. Findings: 1) During an observation on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · D2022-03-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to care plan (care plans provide communication among nurses, their residents and other healthcare providers to achieve health care outcomes) its continued use of a position change alarm (an audible alarm that alerts staff the resident is getting up, and that should be used only when medically necessary and with intermittent reevaluation for continued use) for for 1 of 17 sampled residents (Resident 28). Resident 28 was known to remove the clip connected to the alarm. The failure to care plan resulted in the position change alarm constantly in use, and had the potential to diminish Resident 28's psychosocial well-being. Findings: During an observation on 3/7/22 at 11:10 a.m., Resident 28 was sleeping in her bed. A position change alarm device was visible at the head of her bed. During an observation and concurrent interview on 3/8/22 at 10:25 a.m., Resident 28 was resting in bed. Staff L stated Resident 28 prefers to get up after lunch. We get her up into a wheelchair and she moves herself around the facility.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-11 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise a care plan with updated interventions for one (Resident 64) of 17 sampled residents, when facility staff reviewed the nutritional care plan but did not document new interventions to manage resident 64's continued weight loss. This failure resulted in Resident 64 suffering significant weight loss within one month. Findings: During a review of Resident 64's, admission Record she had been admitted to the facility on [DATE], with a history of bleeding between the brain and tissue covering the brain, high blood pressure, insulin dependent diabetes and generalized muscle weakness. During a review of Resident 64's, Dietary Progress Notes, dated 2/15/22, the Dietary Progress Note indicated Resident 64 was admitted to the facility with a weight of 44.8 kilograms or 98.56 pounds. Resident 64 has been prescribed a tube feeding (nutrients are supplied through a tube for people who cannot get enough nutrients through eating) formula to be infuse 55…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-11 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to adopt a discharge care plan that identified nutritional needs for one (Resident 64) of 17 sampled residents, when the facility's discharge plan for Resident 64 did not address weight loss and how to stabilize or gain weight. This failure had the potential to cause Resident 64 further weight loss and fatigue. Findings: During a review of Resident 64's, Nursing Progress Notes, dated 11/11/21, indicated Resident 64 had been admitted to the facility with a diagnosis of acute renal failure (a condition which the kidneys suddenly cannot filter waste from the blood), requiring dialysis (a process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions) and surgery. During a review of Resident 64's, Nursing Progress Notes, dated 11/16/21, indicated Resident 64 had discontinued dialysis. During a review of Resident 64's, Dietary Progress Notes, dated 11/19/21, indicated Resident 64 had lost 5.2 pounds, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed maintain acceptable nutrition for one (Resident 64) of 17 sampled residents. This resulted in Resident 64 suffering a significant weight loss within one month of admission, which effected her overall health and well-being. Findings: During a review of Resident 64's, admission Record she had been admitted to the facility on [DATE], with a history of bleeding between the brain and tissue covering the brain, high blood pressure, insulin dependent diabetes and generalized muscle weakness. During a review of Resident 64's, Dietary Progress Notes, dated [DATE], the Dietary Progress Note indicated Resident 64 was admitted to the facility with a weight of 44.8 kilograms or 98.56 pounds. Resident 64 has been prescribed a tube feeding (nutrients are supplied through a tube for people who cannot get enough nutrients through eating) formula to be infuse 55 milliliters (ml) an hour (hr.) for 20 hours and to stop the feeding from 10:00 a.m. until 2:00 p.m.,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-11 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide necessary behavioral health care and services for 1 out of 17 residents (Resident 50), when facility staff failed to facilitate the resident's referral for psychological services and evaluation. This failure resulted on Resident 50 showing increased anxious behavior and receiving a new medication to address her anxiety, and did not ensure services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, Findings: During an observation, interview and record review with Resident 50 on 3/7/22 at 3:00 p.m., Resident 50 was crying. Resident 50 stated she's sad and anxious but refused to discuss the matters further. Review of admission Minimum Data Set (an assessment tool) dated, 2/09/22, the facility admitted Resident 50 on 2/07/22 with a diagnosis of Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and a Brief Interview for Mental Status (BIMS, a brief test is used to learn how well a person functions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-11 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the drug regimen for one of 17 residents (Resident 33) was free from unnecessary drugs, when facility staff administered laxitive medication to Resident 33 when the resident had loose bowel movements, contrary to physician order. This failure resulted in Resident 33 receiving medication that was not clinically indicated, which had the potential to cause unnecessary discomfort and stress to the gastrointestinal (GI) tract, and delay diagnosis for the cause of the GI resident's distress. Findings: During a review of Resident 33's Discharge summary, dated [DATE], this document indicated Resident 33 was in the hospital 11/16/21 to 11/21/21 for epididymitis/orchitis (inflammation and infection of the scrotum and testicles). The summary indicated Resident 33 was started on antibiotics in the hospital and continued taking them at the facility, until the end date of 12/1/21. During a review of Resident 33's Bowel Elimination task report…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ASPEN SKILLED HEALTHCARE — 35 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.7 | +1.3 vs chain |
| Health inspection | 5 of 5 | 3.1 | +1.9 vs chain |
| Staffing | 5 of 5 | 3.9 | +1.1 vs chain |
| Quality measures | 5 of 5 | 4.5 | +0.5 vs chain |
The other 34 homes this chain runs (chain average 3.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| APTB, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 06/25/2019 |
| BRADSHAW, PETER | Individual | INDIRECT OWNERSHIP INTEREST | — | since 07/07/2023 |
| ELSNER, ERIC | Individual | INDIRECT OWNERSHIP INTEREST | — | since 06/25/2019 |
| KIRKWOOD, JARED | Individual | INDIRECT OWNERSHIP INTEREST | — | since 06/25/2019 |
| ORGILL, CRAIG | Individual | INDIRECT OWNERSHIP INTEREST | — | since 06/25/2019 |
| PARTI, RAJESH | Individual | INDIRECT OWNERSHIP INTEREST | — | since 06/25/2019 |
| PARTI, SHRUTY | Individual | INDIRECT OWNERSHIP INTEREST | — | since 06/25/2019 |
| PAXMAN, MARCUS | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 01/01/2023 |
| RAWE, COLTON | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| KRAFT, SHIRLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2018 |
| MCLAUGHLIN, HALEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/20/2020 |
| RANADIVE, RAJINA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2018 |
| BRADSHAW, JEFFREY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 01/01/2023 |
| ASPEN HEALTHCARE SERVICES LLC | Organization | ADP OF THE SNF | — | since 01/01/2023 |
| EAST WEST BANK | Organization | ADP OF THE SNF | — | since 06/25/2019 |
| MOSS ADAMS LLP | Organization | ADP OF THE SNF | — | since 06/25/2019 |
| SEQUOIA HEALTHCARE GROUP LLC | Organization | ADP OF THE SNF | — | since 01/01/2023 |
| WELLS FARGO BANK, NATIONAL ASSOCIATION | Organization | ADP OF THE SNF | — | since 06/25/2019 |
| YANKE PETALUMA PROPERTY, LLC | Organization | ADP OF THE SNF | — | since 05/12/2025 |
| BRADY, VERN | Individual | ADP OF THE SNF | — | since 01/01/2023 |
| CASE, RYAN | Individual | ADP OF THE SNF | — | since 01/01/2023 |
| JURADO, FRANK | Individual | ADP OF THE SNF | — | since 01/01/2023 |
CMS files one row per role, so the 31 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.
7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $956K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 056072. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.