Cycle 1
Health 2024-10-11 · Fire 2024-10-11
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Sonoma, CA
Valley Of The Moon Post Acute
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
347 Andrieux St, Sonoma, CA
(707) 935-5122
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
27
Certified beds
Average residents
26
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-12-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing
LPN hours / resident day
1.75
Licensed practical nurse staffing
Aide hours / resident day
2.65
Nurse aide staffing
Weekend hours
4.17
Weekend nurse staffing
RN turnover
40%
Annual RN turnover
Total nurse turnover
20%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
1.6%
0.8 pts worse
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
6.8%
5.4 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.4% |
13.7%
3.7 pts worse
|
19.6%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 5.3% |
14.2%
8.9 pts better
|
16.7%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 2.6% |
11.0%
8.4 pts better
|
16.3%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 0.0% |
10.7%
10.7 pts better
|
14.9%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.2%
About the same
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.7% |
10.9%
8.2 pts better
|
19.8%
17.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
4.7%
3.1 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
11.2%
2.5 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.9% |
93.2%
3.7 pts better
|
79.7%
17.2 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.4% |
23.2%
4.8 pts better
|
23.9%
5.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-28 · Fire 2023-07-28
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-10-16 · Fire 2019-10-16
18 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-11
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-05
F · Potential for more than minimal harm
2023-07-28
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-07-28
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-28
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-28
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-31
E · Potential for more than minimal harm
2019-10-16
E42 · Emergency Preparedness Deficiencies
Fire Safety
Meet the requirements of an integrated health system.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-10-16
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-10-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-10-16
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-10-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-31
D · Potential for more than minimal harm
2019-10-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-10-11
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-10-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-10-11
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-05
F · Potential for more than minimal harm
2023-07-28
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-09-04
E · Potential for more than minimal harm
2023-07-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-04
E · Potential for more than minimal harm
2023-07-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-04
E · Potential for more than minimal harm
2023-07-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-09-04
E · Potential for more than minimal harm
2023-07-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-04
G · Actual harm
2019-10-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-12-13
G · Actual harm
2019-10-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-12-13
F · Potential for more than minimal harm
2019-10-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-12-13
F · Potential for more than minimal harm
2019-10-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-12-13
F · Potential for more than minimal harm
2019-10-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-12-13
E · Potential for more than minimal harm
2019-10-16
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-12-13
E · Potential for more than minimal harm
2019-10-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-12-13
E · Potential for more than minimal harm
2019-10-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2020-01-14
E · Potential for more than minimal harm
2019-10-16
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-12-13
E · Potential for more than minimal harm
2019-10-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-12-13
E · Potential for more than minimal harm
2019-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-16
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-01-14
D · Potential for more than minimal harm
2019-10-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-16
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-16
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2019-12-13
Penalties and ownership
What sits behind the stars
Ownership
Mather, Kelly
Corporate Officer · Individual
Sendaydiego, Fe
Operational/Managerial Control · Individual
Sonoma Valley Health Care District
Operational/Managerial Control · Organization
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