Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Valley Of The Moon Post Acute during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction with hemiplegia/hemiparesis, diabetes, and heart failure, and intact cognition (BIMS 15/15), was struck by another cognitively impaired resident (BIMS 0/15, with amnesia and dementia) using a wheelchair footrest, causing bleeding injuries to the face and arm. Staff witnessed the assault, and the injured resident was later found in the ED to have a nose laceration, forearm contusions, and multiple abrasions, along with elevated BP. The injured resident subsequently displayed anxiety, expressed distress about other residents, and was noted to have PTSD related to the event. Facility policies stated residents must be free from abuse, including abuse by other residents, and defined abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish.
The facility failed to provide residents and their families with access to contact information for the Ombudsman and CDPH, as well as survey results. Bulletin boards with this information were blocked by medication carts, and the notices were in small font. Interviews revealed that staff, residents, and family members were unaware of how to contact these entities or access survey results, indicating a deficiency in implementing the facility's policy on resident rights.
The facility failed to ensure residents and families had access to contact information for the Ombudsman, CDPH, and survey results. Observations showed bulletin boards were blocked by medication carts, and interviews revealed staff, residents, and families were unaware of how to access this information. The facility's policy mandates these rights, but the information was not easily visible or accessible.
The facility failed to maintain an adequate inventory of portable oxygen tanks, impacting residents dependent on oxygen therapy. Observations revealed missing oxygen tanks from the crash cart, and staff interviews highlighted a lack of awareness and policy for maintaining respiratory equipment. The facility relied on a vendor for weekly deliveries but faced issues with timely supply, leaving residents at risk during emergencies.
The facility failed to ensure RNs had verified competencies for PICC line care, with RN B and RN C lacking complete documentation and assessment of skills. Additionally, LVN L was incorrectly documented as competent in PICC line care, which is outside LVN's legal scope. The DON acknowledged the lack of itemized skills lists and reliance on discussion rather than observation for competency assessment, posing potential risks to residents with PICC lines.
A medication administration error occurred when a nurse in an LTC facility administered Gabapentin, Omeprazole DR, and Metformin to a resident without following the physician's orders. Omeprazole DR was supposed to be given on an empty stomach, while the other medications required food. The error was acknowledged by the nurse and highlighted by the Director of Staff Development and Interim DON, emphasizing the importance of proper medication timing for absorption and efficacy.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from physical abuse when another resident struck him during an altercation. One resident, with a history of cerebral infarction resulting in hemiplegia/hemiparesis, diabetes, and heart failure, and with intact cognition as evidenced by a BIMS score of 15/15, was in his room when another resident struck his left arm with a wheelchair footrest, causing bleeding injuries to his nasal bridge and left arm. Staff witnessed the incident at approximately 7 a.m. and observed bleeding from the resident’s face and arm. The injured resident was later found in the emergency room to have a nose laceration, left forearm contusions, and abrasions at various sites, along with elevated blood pressure readings at the time of examination. The resident who committed the assault had been admitted with diagnoses of amnesia and dementia and had a BIMS score of 0/15, indicating significant problems with memory, orientation, and decision-making. Following the incident, the assaulted resident reported being hit on the left side of his face near his nose/eye and on his arms, and physical observations showed redness and swelling near the nasal bridge and red, raised marks on the left wrist. Subsequent documentation indicated the assaulted resident expressed anxiety about other residents, requested that a new roommate not communicate with him, and was noted to be anxious and experiencing PTSD related to the event. Facility policies in place stated that each resident has the right to be free from abuse, including abuse by other residents, and defined abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish, noting that cognitive impairment does not automatically preclude deliberate or non-accidental actions.
Failure to Provide Access to Ombudsman and Survey Information
Penalty
Summary
The facility failed to ensure that residents and their family members had access to contact information for the Ombudsman and the California Department of Public Health (CDPH), as well as the results of facility surveys and plans of correction. Observations revealed that bulletin boards containing this information were obstructed by medication carts, and the notices were printed in small font, making them difficult to see. Additionally, key areas such as the activity/dining room and staff break room lacked posters with this essential information. Interviews with staff, residents, and family members consistently showed a lack of awareness regarding how to contact the Ombudsman or CDPH, or where to find survey results. Even the Interim Director of Nursing (DON) was initially unaware of the location of this information, which was eventually found in a binder on top of the resident chart rack. The facility's policy on resident rights, which includes the right to access this information, was not effectively implemented, leading to a deficiency in ensuring residents' rights to a dignified existence and self-determination.
Failure to Provide Access to Advocacy Information and Survey Results
Penalty
Summary
The facility failed to ensure that residents and their families were informed about and had access to contact information for the Ombudsman, the California Department of Public Health (CDPH), and the results of facility surveys. Observations revealed that bulletin boards, which were supposed to display this information, were obstructed by medication carts, making the information inaccessible. Additionally, the font size of the notices was too small, further hindering visibility. Interviews with staff, residents, and family members consistently showed a lack of awareness regarding how to contact these advocacy agencies or where to find survey results. The deficiency was further highlighted by the facility's own policy, which mandates that residents have the right to contact advocacy groups and examine survey results. Despite this policy, numerous interviews with staff, residents, and family members revealed that they were unaware of how to access this information. The Interim Director of Nursing (DON) acknowledged the issue, noting that the information was not easily visible and that the survey results were not readily accessible, as they were stored in a binder on top of a resident chart rack. This lack of accessibility and awareness potentially prevented residents and their families from exercising their rights to address concerns about care received at the facility.
Facility Fails to Maintain Adequate Oxygen Supply for Residents
Penalty
Summary
The facility failed to maintain an adequate inventory of portable oxygen tanks and did not properly anticipate the respiratory care equipment needs for residents requiring oxygen therapy. This deficiency was observed during a survey where several residents, including those with chronic obstructive pulmonary disease (COPD) and heart failure, were dependent on oxygen therapy. The facility's crash cart was found to be missing a portable oxygen tank, which was supposed to be part of its standard equipment. Interviews with staff revealed a lack of awareness regarding the number of residents dependent on oxygen and the absence of a policy for maintaining respiratory equipment inventory. The Director of Nursing (DON) admitted to not knowing the number of oxygen-dependent residents and was unable to provide an inventory of available portable oxygen tanks. The facility relied on a contracted vendor for weekly oxygen deliveries but lacked a clear understanding of how many tanks were needed, especially in emergencies. The Administrator mistakenly believed that a shared services agreement with a nearby hospital would provide additional oxygen tanks, but hospital staff were unaware of such an agreement, indicating a communication breakdown. Observations and interviews highlighted that residents were at risk due to the facility's inability to ensure their oxygen needs were met, particularly during emergencies requiring evacuation. The facility's crash cart was used to replace low oxygen tanks for residents, further depleting the emergency supply. Staff reported issues with timely oxygen deliveries, and the facility's storage only accommodated a limited number of tanks, exacerbating the problem. The lack of a formal policy and procedure for respiratory care and equipment maintenance contributed to the deficiency, leaving residents vulnerable to respiratory distress.
Inadequate Competency Verification for PICC Line Care
Penalty
Summary
The facility failed to ensure that Registered Nurses (RNs) had accurate and verified competencies in their employee files, specifically regarding the care of peripherally inserted central catheters (PICC lines). Two sampled RNs, RN B and RN C, did not have documented, complete PICC line competencies as per facility policy. RN B's skills checklist indicated competencies in PICC line flushing and dressing changes, but the method of evaluation was not documented, and her competency regarding PICC IV tubing or monitoring the insertion site was not assessed. Similarly, RN C was assessed for PICC flushing and catheter changes, but not for IV tubing or monitoring the insertion site, and the evaluation method was not documented. Additionally, the facility failed to ensure that a Licensed Vocational Nurse (LVN L) had accurate competencies in his employee file. LVN L's file indicated he had PICC line competencies, but LVNs are not legally or professionally qualified to care for PICC lines. The Director of Nursing (DON) stated that all nurses undergo annual competency checks, but the skills list for PICC lines was not itemized, and the method of assessing skills was often through discussion rather than observation. The DON also mentioned providing impromptu in-services when residents with PICC lines were admitted, but this did not reflect specific items required in the policy. The facility's policy on nurse staff competency requires sufficient nursing staff with appropriate competencies to assure resident safety. However, the facility's practices did not align with this policy, as evidenced by the lack of proper documentation and assessment of competencies for RNs and the inappropriate assignment of PICC line care to an LVN. This deficiency posed a potential risk for unsafe nursing practice and placed residents with PICC lines at risk of harm.
Medication Administration Error Due to Non-Compliance with Physician's Orders
Penalty
Summary
The facility failed to ensure the safe administration of medications for a resident, leading to a significant medication error. On the morning of October 8, 2024, a Licensed Vocational Nurse administered Gabapentin, Omeprazole DR, and Metformin to a resident without adhering to the specific instructions for each medication. Omeprazole DR was ordered to be given on an empty stomach, while Gabapentin and Metformin were to be administered with food. The nurse administered all three medications simultaneously, shortly after breakfast, which was against the physician's orders. During interviews, the Licensed Vocational Nurse admitted uncertainty about the administration instructions and acknowledged not following the physician's orders. The Director of Staff Development confirmed that the nurse had been educated on proper medication administration, emphasizing the importance of administering medications like Omeprazole DR on an empty stomach to ensure proper absorption. The Interim Director of Nursing also highlighted that the administration of Omeprazole DR with food constituted a medication error, as it could affect the medication's absorption and efficacy. The Pharmacist, during a phone interview, expressed a lack of awareness of the facility's policy and procedures for medication errors and did not attend the Quality Assurance Committee meetings. The Pharmacist noted that while the manufacturer's recommendations for administering GERD medication on an empty stomach were important, the physician's orders should be followed. The resident involved had a medical history that included conditions such as GERD, benign neoplasm of the transverse colon, and gastrointestinal hemorrhage, which necessitated careful medication management.
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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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Nursing homes near Sonoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sonoma Post Acute | 0.5 mi | ★★★★★ | 23 | 0 |
| Broadway Villa Post Acute | 0.9 mi | ★★★★★ | 11 | 0 |
| Vineyard Post Acute | 9 mi | ★★★★★ | 28 | 0 |
| The Meadows Of Napa Valley | 9.3 mi | ★★★★★ | 0 | 0 |
| Piners Nursing Home | 9.4 mi | ★★★★★ | 40 | 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.