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
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.75
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.03
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.38
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.17
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
5.03
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,068
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9995
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.86
Baseline 20.40% · Performance 18.71% · Measure score 5.86 · Achievement 5.86 · Improvement 4.50
Healthcare-associated infections
2.46
Baseline 5.87% · Performance 7.10% · Measure score 2.46 · Achievement 2.46 · Improvement 0
Total nurse turnover
5.64
Baseline 52.63% · Performance 40.62% · Measure score 5.64 · Achievement 5.64 · Improvement 3.82
Adjusted total nurse staffing
4.51
Performance 4.36 hours · Measure score 4.51 · Achievement 4.51 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.41% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 6.38% · Lower 95% interval 7.22% |
| Discharge to community | 64.83% |
50.57%
14.3 pts better
|
Better than the National Rate · Eligible stays 85 · Observed rate 71.76% · Lower 95% interval 57.7% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 59.38% |
95.27%
35.9 pts worse
|
Numerator 19 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 74.07% |
53.69%
20.4 pts better
|
Numerator 20 · Denominator 27 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 18 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 32 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.1% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 41 · Observed rate 4.88% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 11.76% |
8.2%
3.6 pts better
|
Numerator 4 · Denominator 34 |
| Staff flu vaccination coverage | 57.14% |
42%
15.1 pts better
|
Numerator 32 · Denominator 56 |
| Discharge function score | 81.48% |
56.45%
25 pts better
|
Numerator 22 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 22 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 4.5% · 4Q avg 2.4% · Used in QM five-star |
| 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 · Q3 5.0% · 4Q avg 1.4% |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 17.4% |
| 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 · 4Q avg 5.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 2.6% · Used in QM five-star |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 1.2% · Used in QM five-star |
| 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 · Q1 5.3% · Q2 5.3% · Q3 0.0% · 4Q avg 2.7% |
| 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 · Q1 0.0% · Q2 2.9% · Q3 3.5% · 4Q avg 1.6% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · Adjusted 8.7% · Observed 7.4% · Expected 9.5% · Used in QM five-star |
| 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 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 96.9% |
| 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 · Adjusted 18.4% · Observed 14.8% · Expected 19.2% · Used in QM five-star |
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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