15 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Petaluma, CA
3-star overall rating with 2-star inspections with $63,135 in total fines with 15 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
101 Monroe Street, Petaluma, CA
(707) 763-4109
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
99
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1980-11-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.53
Registered nurse staffing
LPN hours / resident day
1.06
Licensed practical nurse staffing
Aide hours / resident day
2.40
Nurse aide staffing
Weekend hours
3.49
Weekend nurse staffing
RN turnover
64%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.3
0.7 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| 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 | 96.2% |
98.2%
2 pts worse
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
1.6%
4 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.6% |
6.8%
0.8 pts worse
|
11.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.8% |
4.1%
3.3 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.5% |
13.7%
5.2 pts better
|
19.6%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
14.2%
2.5 pts better
|
16.7%
5 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 | 5.3% |
11.0%
5.7 pts better
|
16.3%
11 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
10.7%
5.7 pts better
|
14.9%
9.9 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 | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.5% |
10.9%
7.4 pts better
|
19.8%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.7%
2.9 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.0%
5.7 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.1% |
11.2%
3.9 pts worse
|
12.0%
3.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.3% |
93.2%
4.9 pts worse
|
79.7%
8.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.1% |
23.2%
10.1 pts better
|
23.9%
10.8 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Pharmacy Service (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-17
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-01-17
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-01-17
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2026-01-17
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-17
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-17
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-01-17
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-01-17
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2026-01-17
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-17
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-01-17
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-15
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-12-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-15
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-12-15
Fire Safety
Develop a communication plan.
Corrected 2024-12-15
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-12-15
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-15
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-15
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-12-15
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-15
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-07-01
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-07-01
Fire Safety
Use approved construction type or materials.
Corrected 2021-07-01
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-07-01
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-07-01
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-07-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-01
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-07-01
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-07-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-07-01
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-01
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-07-01
Inspection history
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-23
Health
Dispose of garbage and refuse properly.
Corrected 2026-01-15
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-15
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-01-15
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-15
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-01-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-15
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-01-15
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2026-01-15
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 2026-01-15
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2026-01-15
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-15
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-28
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-16
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-25
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-29
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-03-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-25
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-20
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-20
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-20
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-12-20
Health
Provide appropriate foot care.
Corrected 2024-12-20
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-04
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-04
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-22
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-20
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-10-06
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-06
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-15
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-05-26
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-14
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-14
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 2021-07-12
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-07-12
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 2021-07-12
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-12
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-07-12
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2021-07-12
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-07-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-07-12
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-07-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-07-12
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2021-07-12
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-07-12
Penalties and ownership
Fine · fine $34,034
Fine
Fine · fine $21,658
Fine
Fine · fine $7,443
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Contracted Managing Employee · Individual
Nearby options
Petaluma, CA
1-star overall rating with 1-star inspections with abuse icon flag with $142,514 in total fines with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Petaluma, CA
5-star overall rating with 4-star inspections with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Petaluma, CA
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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