Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Petaluma Post-acute Rehabilitation during CMS and state inspections, most recent first.
Failure to provide access to vision and hearing services: two residents reported sensory device problems on admission, but one resident’s broken glasses remained unaddressed and another resident’s missing hearing aids were not acted on. Records showed both residents had documented sensory needs, yet Social Services assessments did not identify a need for referral or follow-up, and the residents stated they continued to have difficulty seeing or hearing clearly.
An unlabeled Lantus Solostar insulin pen was found in the med refrigerator with no resident name, directions, or open date, and staff could not identify who it belonged to. In addition, loose meds intended for wasting were kept in an unlabeled urine specimen cup inside a med cart, and staff stated this was not standard practice; the DON also stated it was not best practice and the facility could not provide a specific wasting policy.
An LPN used the same blood pressure cuff on two residents without disinfecting it between uses. The LPN stated the cuff should have been cleaned between residents, and the IP and DON stated reusable vitals equipment should be disinfected between residents per facility infection control expectations and policy.
A resident was transferred to the hospital for SOB, and the facility notified the physician and the resident’s husband, but did not notify the Ombudsman. The DON, SS, and ADM all confirmed the Ombudsman notification was not completed, despite the facility’s stated process that a Notice of Transfer should be entered in the EMR and automatically emailed to the Ombudsman.
A resident was discharged without proper training for G-tube feeding and without a feeding pump delivered to his home, resulting in over 30 hours without nutrition and subsequent readmission. The facility failed to ensure the delivery of necessary equipment and did not provide adequate training to the resident's family.
A resident was allowed to keep Biofreeze at their bedside without an assessment of their ability to self-administer medication, as required by facility policy. The resident, admitted with a femur fracture and intact cognition, stated they had permission, but the RN and DON were unaware of any completed assessment or team discussion.
Staff failed to wear gowns during high-contact care for two residents under enhanced barrier precautions, despite facility policy requiring PPE to prevent MDRO transmission. One resident with urine retention and an indwelling catheter was repositioned without staff wearing gowns, and another with chronic kidney disease received incontinence care without a gown. The Infection Preventionist confirmed the need for PPE in such cases.
Failure to Provide Access to Vision and Hearing Services
Penalty
Summary
The facility failed to ensure access to vision services for one resident who reported on admission that her glasses were broken. Her record showed she was admitted with a left patella fracture and a large contusion over her left eye after a fall. Although her inventory of personal effects documented broken glasses, the initial Social Services assessment indicated no vision referral was needed, and the care plan later identified a vision deficit and need for glasses. During observation, her glasses were present but the right lens was completely shattered, and she stated she needed them for distance, watching TV, driving, physical therapy, and walking. She also stated she had told staff about the problem, but could not remember who. The facility also failed to ensure access to hearing services for another resident who reported losing his hearing aids during transfer from the hospital. His record showed he was admitted for surgical aftercare and had minimal cognitive impairment with moderate difficulty hearing. Nursing documented that he reported the missing hearing aids and that Social Services would be notified, but the initial Social Services assessment later indicated no hearing amplifier or hearing referral was needed. When interviewed, the resident stated he did not have his hearing aids, needed them, and had difficulty communicating because he had to ask people to repeat themselves frequently. The SSD stated there may have been confusion, that nothing had been done about the missing hearing aids, and that concerns reported verbally could be missed or delayed.
Unlabeled insulin pen and loose medications stored improperly
Penalty
Summary
Safe medication labeling and storage practices were not followed when a loose Lantus Solostar insulin pen was found in the medication refrigerator with no label, no resident name, no instructions, and no open date. During the observation, the Nurse Manager stated he did not know why the pen was not labeled or which resident it belonged to, and stated that if a medication was not labeled it could be used for the wrong resident. The Director of Nursing later stated that all medications should be labeled with the resident name, date of birth, directions, expiration date, and open date, and that the unlabeled insulin pen did not meet expectations because staff did not know who it belonged to. The facility policy reviewed stated prescription labels should include the resident name, directions for use, medication name and strength, prescriber name, date dispensed, quantity, expiration date, pharmacy information, and prescription number. Medication tablets and pills intended for wasting were also found stored in an unlabeled urine specimen cup inside a medication cart. During observation, a nurse spilled a med cup with two medications and placed the medications into the urine cup filled with loose meds in the cart drawer. The nurse stated the cup was for non-controlled medications intended for destruction and acknowledged it was full, but was unsure when or by whom it had been emptied. Other nurses stated loose medications should not be kept in the cart and that medications for destruction should be taken to the medication room and disposed of there. The Nurse Manager stated non-controlled medications should be destroyed by the end of the shift and that a urine cup holding loose medications in the cart should not be full. The DON stated she did not feel it was best practice to keep a urine specimen cup full of loose medications in the cart, and the facility could not provide a more specific policy during the survey. The policy reviewed stated non-controlled medications shall be disposed in the proper waste container in the medication room.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
Infection control procedures were not followed for two residents when LN 1 used the same blood pressure cuff on Resident 64 and then on Resident 62 without disinfecting the cuff between uses. During observation in Hall A, LN 1 checked Resident 64’s blood pressure and did not disinfect the cuff afterward, then checked Resident 62’s blood pressure shortly afterward and did not disinfect the cuff before using it again. LN 1 stated she should have cleaned the cuff between residents to stop the spread of germs from resident to resident. The IP stated all vitals equipment should be cleaned at the start of the shift and between residents, and the DON stated it was her expectation that all reusable equipment be cleaned between residents and that staff follow the infection control program. The facility policy stated non-critical reusable items are disinfected between residents and as needed.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure the Ombudsman was notified when Resident #83 was transferred to the hospital for shortness of breath on 10/20/2025. During interviews and record review, the DON stated the resident was admitted to the hospital and that the physician and the resident’s husband were notified, but she could not find documentation that the Ombudsman was notified and stated the Ombudsman was not notified. The Administrator later stated that anytime a resident left the facility, the Ombudsman SHALL be notified, and confirmed that this was not completed for Resident #83. Social Services stated a Notice of Transfer document was completed in the electronic medical record and was supposed to be automatically emailed to the Ombudsman, but after searching the medical record and a binder of notifications, she found that the notification was not done and said, “We missed it.” She stated they did not complete the notice to the Ombudsman for this discharge and transfer and that they did not follow the facility Policy & Procedure. The Policy and Procedure for Transfer Notification to the Ombudsman was requested and not received by the end of survey.
Failure in Discharge Planning for Enteral Nutrition
Penalty
Summary
The facility failed to implement an effective discharge planning process for Resident 1, who was discharged without proper training for the administration of enteral nutrition via a gastrostomy tube (G-tube) and without the necessary feeding pump being delivered to his home. Resident 1, who had a history of pneumonitis, severe protein-calorie malnutrition, dysphagia, and dyskinesia of the esophagus, was discharged with instructions that did not include special training for tube feeding administration. The licensed nurse assigned to Resident 1 assumed that the social services department had arranged for the feeding pump delivery, which did not occur. Upon discharge, Resident 1's family member was under the impression that the facility would order the necessary tube feeding formula and feeding pump for home use. However, the family member was not trained on how to start the tube feeding using the feeding pump. As a result, Resident 1 did not receive any nutrition for over 30 hours, leading to his transfer to the Emergency Department for evaluation and subsequent readmission to the facility. The home health nurse, who visited Resident 1's home the day after discharge, found that the necessary equipment had not been delivered and advised the family member to take Resident 1 to the hospital. The facility's management staff failed to verify the delivery of the enteral feeding formula and feeding pump to Resident 1's home prior to discharge. Management Staff C only provided the family with the name and contact information of the medical supply company and home health company, without ensuring the delivery of the necessary equipment. Management Staff D, who was responsible for ordering durable medical equipment, discovered post-discharge that the medical supply company did not deliver to resident homes. This oversight resulted in Resident 1's readmission due to a delay in nutrition supply.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to complete an assessment to determine if a resident was able to self-administer their medication. The facility's policy on self-administration of medications requires staff to assess each resident's mental and physical abilities to determine if self-administration is clinically appropriate. This includes evaluating the resident's ability to read and understand medication labels, comprehend the purpose and proper dosage, and recognize risks and adverse consequences. However, for one resident, this assessment was not completed. The resident in question was admitted with a diagnosis of intracapsular fracture of the right femur and had a BIMS score indicating intact cognition. Despite this, the resident was allowed to keep Biofreeze, a pain relief gel, at their bedside without the necessary assessment. The resident stated they had spoken with someone who agreed to this arrangement, but the RN and DON were unaware of any completed assessment or interdisciplinary team discussion regarding the resident's ability to self-administer the medication.
Failure to Use PPE During High-Contact Care
Penalty
Summary
The facility failed to ensure that staff wore appropriate personal protective equipment (PPE) when providing care to residents under enhanced barrier precautions. Specifically, staff did not wear gowns while providing incontinence care to two residents, despite the facility's policy requiring the use of gowns and gloves during high-contact activities. The policy, effective August 6, 2024, mandates the use of PPE to prevent the transmission of multidrug-resistant organisms (MDROs) during activities such as device care, wound care, bathing, and changing soiled linens. Resident #66, admitted on November 7, 2024, with a history of urine retention and an indwelling catheter, was observed being repositioned by two CNAs who wore gloves but no gowns. Both CNAs stated they believed gowns were only necessary when emptying the catheter bag. Similarly, Resident #34, who had chronic kidney disease and an indwelling catheter, was provided incontinence care by a CNA who did not wear a gown. The Infection Preventionist confirmed that PPE should be used for high-contact activities for residents on enhanced barrier precautions.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Petaluma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Post Acute | 0 mi | ★★★★★ | 29 | 0 |
| Ridgeway Post Acute | 0.1 mi | ★★★★★ | 2 | 0 |
| North Bay Post Acute | 0.7 mi | ★★★★★ | 24 | 0 |
| Vineyard Post Acute | 2.5 mi | ★★★★★ | 28 | 0 |
| Novato Healthcare Center | 9.5 mi | ★★★★★ | 44 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.