Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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 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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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 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 | — | 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 August 2026) and official state health department websites.