Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Sonoma Post Acute during CMS and state inspections, most recent first.
Two residents with dementia, Parkinson’s disease, oropharyngeal dysphagia, and documented severe swallowing impairments had active physician and SLP orders, care plans, and dietary instructions requiring 1:1 feeding assistance or supervision, small bites and sips, and specific swallowing strategies during meals. One resident, care planned for continuous 1:1 assistance at meals, was left alone with a breakfast tray; an RN later found the resident unresponsive in bed with scrambled eggs in the mouth, and a coroner report identified asphyxia from airway obstruction by a food bolus as the cause of death. Another resident, recently started on pureed oral intake while still on tube feeding and ordered 1:1 supervision during all eating, was observed eating a pureed lunch alone in bed without staff present until an RN entered and acknowledged the resident should not have been left unattended. These events occurred despite a facility policy stating staff will assist residents who require help with eating and will feed residents who cannot feed themselves with attention to safety.
A certified nurse assistant was allowed to begin direct resident care before a criminal background check was completed, with the check being conducted approximately nine months after hire. This action was in direct violation of facility policy, which requires background checks to be completed before employment.
The facility did not ensure that its services met professional standards of quality, as observed during the survey. The report identifies a lack of adherence to established professional guidelines in the care provided.
A resident with multiple chronic conditions was given a blood pressure medication on three occasions when their systolic blood pressure was below the prescriber's ordered parameters. Both the LPN and DON confirmed that the medication should have been held according to the physician's order and facility policy, but it was administered regardless.
A resident with diabetes was found unresponsive with severe hypoglycemia, and a nurse administered glucose gel orally despite the resident's inability to respond or follow commands. Facility policy and staff interviews confirmed that glucagon injection should have been used in this situation, as oral glucose gel poses a risk of aspiration or choking in unresponsive individuals.
A resident with multiple complex medical conditions was discharged after being unable to return from an approved leave, without being provided essential medications or necessary mobility equipment. Facility staff confirmed that standard discharge procedures, including medication provision and DME coordination, were not followed, resulting in the resident experiencing emotional distress and withdrawal symptoms.
The facility failed to provide residents with access to private phone calls, as only one working wireless phone was available and often missing. Two residents reported being unable to make or receive private calls, with staff confirming the phones were frequently lost and uncharged. Residents had to use non-private landline phones at the nursing station, violating their right to privacy.
A resident with a history of stroke and quadriplegia did not receive prescribed Lidocaine cream for pain relief due to the facility's failure to reorder the medication in a timely manner. Despite the availability of the medication in the cart, it was not administered on several occasions, as confirmed by staff and records. The lack of documentation and timely reordering led to missed doses, causing potential pain and suffering for the resident.
Failure to Provide Ordered 1:1 Supervision During Meals Resulting in Choking Death and Aspiration Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents who had physician-ordered 1:1 assistance or supervision during meals were continuously attended while they had access to meal trays. One resident with dementia, severe cognitive impairment (BIMS score 00), and oropharyngeal dysphagia was admitted with documented swallowing concerns, poor safety awareness, impulsive intake behaviors, and impaired cognition that limited the ability to follow swallowing strategies. The resident’s care plan and physician orders, in place from admission through the date of death, specified 1:1 feeding assistance with meals and continuous assistance at meals, including whole pills to be given in applesauce one at a time. The Speech Therapy evaluation documented ongoing aspiration risk and the need for supervision during oral intake. On the morning of the incident, the nurse assigned to this resident documented that at 7:47 a.m. a CNA was notified to assist the resident with breakfast. When the nurse entered the resident’s room at approximately 8:10 a.m., no nursing staff were present with the resident despite the active 1:1 feeding assistance order. The nurse found the resident upright in bed, unresponsive, without respirations or carotid pulse, and observed scrambled eggs in the oral cavity, which were removed during airway assessment. CPR was initiated, EMS was called, and resuscitative efforts continued until the resident was pronounced deceased. The Sonoma County Sheriff’s Office Death Investigation Report listed the cause of death as asphyxia due to obstruction of the airway by a food bolus, with scene observations noting scrambled eggs on the sheets, pillow, suction device container, and floor near the resident’s head. The medical director, nursing staff, and the director of staff development all confirmed that the resident had an active 1:1 feeding assistance order at the time and that such an order required staff to remain with the resident during meals. A second resident with Parkinson’s disease, oropharyngeal dysphagia, and a feeding tube was also identified as not receiving the ordered 1:1 supervision during oral intake. This resident had recently begun oral intake to transition off tube feedings and had dietary orders for a pureed diet with mildly thick liquids, small bites and sips, chin-down posture when swallowing, and 1:1 supervision during all eating to prevent choking. The SLP evaluation for this resident documented severe swallowing problems, a history of silent aspiration, and the need for 1:1 supervision any time food or liquid was given. During an observation, the resident was seen sitting upright in bed eating a pureed lunch alone, with no nursing staff present to provide the ordered 1:1 supervision. When a nurse entered the room during the observation, the nurse acknowledged that the resident should not have been left alone with the meal tray and remained to provide continuous supervision while the resident finished eating. The facility’s Assistance with Meals Policy stated that staff will help residents who require assistance with eating and that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, which was not followed for these two residents. The facility is disputing this citation.
Failure to Complete Background Check Prior to Direct Care Employment
Penalty
Summary
The facility failed to complete a criminal background check prior to allowing a certified nurse assistant (CNA) to begin direct resident care. According to facility records, the CNA was hired and started working with residents on 1/17/23, but the required background check was not conducted until 10/16/23, approximately nine months after employment began. During an interview, the Director of Staff Development confirmed that the CNA's background check was ordered after the employee had already started working with residents, contrary to facility policy, which requires background checks to be completed before employment. Facility policy also states that background and criminal checks are to be initiated within two days of an offer and completed prior to employment.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Follow Prescriber Parameters for Blood Pressure Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including lung cancer, chronic lung disease, heart failure, and hypertension was administered doxazosin mesylate, a blood pressure medication, despite prescriber orders to hold the medication if the resident's systolic blood pressure (SBP) was less than 100 or pulse was less than 60. Medication Administration Records (MARs) showed that the medication was given on three occasions when the resident's SBP was below the ordered parameter: 99, 93, and 96, respectively. Interviews with a licensed nurse and the Director of Nursing confirmed that the medication should have been held on those dates, as per the physician's order and facility policy. Both staff members acknowledged the importance of following medication parameters to prevent adverse effects. The facility's policy required medications to be administered in accordance with prescriber orders, and the failure to do so resulted in the identified deficiency.
Improper Administration of Glucose Gel to Unresponsive Resident During Hypoglycemic Emergency
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of diabetes mellitus was found unresponsive with a critically low blood glucose level. The lead nurse administered glucose gel into the resident's mouth while the resident was unconscious and unable to follow commands. This action was observed by a paramedic who responded to the emergency and noted the presence of glucose gel in and around the resident's mouth. The nurse confirmed during interview that the resident was unresponsive at the time of administration. Facility policy for management of hypoglycemia, as well as staff interviews, indicated that in cases of unresponsiveness due to hypoglycemia, the appropriate intervention is to administer a glucagon injection, not oral glucose gel, due to the risk of aspiration or choking. The Director of Nursing and another licensed nurse both confirmed that the facility's policy requires glucagon administration in such situations, and that glucose gel should not be given to an unconscious resident.
Failure to Ensure Safe and Proper Discharge for a Resident
Penalty
Summary
A deficiency occurred when a resident was discharged from the facility without adequate reason and without proper discharge planning, after being unable to return from an approved leave due to her ride's emergency. The resident contacted the facility to explain her situation, but was informed the following day that she had been discharged. Despite her requests to return, the facility did not allow her back and did not provide her with her essential medications or necessary durable medical equipment (DME) for safe ambulation. The resident had multiple significant medical diagnoses, including type 2 diabetes, acute and chronic respiratory failure, acute kidney failure, bipolar disorder, anxiety disorder, muscle weakness, and a history of strokes. She required assistance with personal care and had orders for several essential medications, such as insulin, antidepressants, and medications for blood pressure and cholesterol. At the time of discharge, she did not have access to her medications or a walker, only a single cane, which was not considered safe for her ambulation needs. The facility also failed to provide her with a planned ankle foot orthosis (AFO) for her left foot drop. Interviews with facility staff confirmed that the resident did not leave against medical advice and that the facility's standard discharge process was not followed. Staff acknowledged that essential medications and appropriate DME were not provided at discharge, and that the resident was left without access to care, experiencing withdrawal symptoms and emotional distress. The facility's own policy required assessment and coordination of discharge needs, including medications and equipment, but these steps were not completed for this resident.
Lack of Access to Private Phone Calls for Residents
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically telephones. During an onsite visit, it was observed that the facility only had one working wireless telephone for resident use, which could not be located. This issue affected two residents, who were unable to make or receive private phone calls. Resident 1, who had medical diagnoses including a fracture of the right femur and chronic obstructive pulmonary disease, was unreachable by phone despite multiple attempts by a family member and the surveyor. The Director of Nursing confirmed that two of the three phones intended for resident use were not working, and the remaining phone was missing. Interviews with staff and residents revealed that the wireless phone was frequently lost and not charged, making it unavailable for resident use. Unlicensed staff members reported that residents had complained about the lack of phone access, and they often had to search for the phones throughout the facility. Residents were forced to use landline phones at the nursing station, which did not provide privacy. Resident 1 confirmed that he was not notified of incoming calls and had to borrow another resident's cell phone or use the nursing station's phone, while Resident 2 also reported a lack of privacy when using the nursing station phone. The facility's policy on resident rights, which guarantees the right to use a telephone in privacy, was not upheld in this situation.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required Lidocaine cream for pain relief. The resident, who had a medical history of stroke, quadriplegia, and high blood pressure, reported that the Lidocaine ointment was supposed to be administered twice daily but had not been applied for several days. The resident mentioned that the facility provided excuses such as the medication being refused or back-ordered. A review of the Medication Administration Record and Physician orders for June 2024 showed that the medication was not administered on multiple occasions, with codes indicating non-administration or missing documentation. During an observation and interview, it was found that a tube of Lidocaine cream was available in the medication cart, but the medication had not been reordered in a timely manner, leading to missed doses. Licensed Staff A confirmed that the medication was not administered on specific dates due to it being reordered but not yet delivered. The Director of Nursing indicated that the medication was ordered and reordered, but there was no documentation to explain why it was not reordered before running out. The lack of documentation and timely reordering resulted in the resident not receiving the necessary pain 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) |
|---|---|---|---|---|
| Valley Of The Moon Post Acute | 0.5 mi | — | 1 | 0 |
| Broadway Villa Post Acute | 0.7 mi | — | 5 | 0 |
| The Meadows Of Napa Valley | 8.7 mi | — | 0 | 0 |
| Piners Nursing Home | 8.8 mi | — | 4 | 0 |
| Veterans Home Of California - Yountville - Snf | 9.1 mi | — | 16 | 0 |
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