Sonoma Post Acute
678 2nd Street West · Sonoma, CA · 95476 · 7079381096
83 certified beds For profit - Corporation Chain: Pacs Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- No federal fines or payment denials in CMS’s 3-year window.
- Inspection results have improved across recent cycles.
The composite number cleared 72 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.64 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.60 | 0.55–0.75 |
| Weekend hours / resident-day | 3.01 | ≈ weekday level |
| Nursing turnover / year | 44% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (32 in the current record)
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Actual harm · G April 22, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 27, 2026 · Quality of Life and Care
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Potential for harm · D November 14, 2025 · found via complaint
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected January 5, 2026 · Resident Rights
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Potential for harm · D August 1, 2025 · found via complaint
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected August 14, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 1, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected August 14, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 22, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected July 31, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 18, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected August 8, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 16, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected June 16, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 20, 2025 · found via complaint
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected April 7, 2025 · Resident Rights
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Potential for harm · E January 30, 2025 · found via complaint
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected February 5, 2025 · Resident Rights
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Potential for harm · D June 13, 2024 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected June 20, 2024 · Quality of Life and Care
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Immediate jeopardy · L March 30, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Corrected April 24, 2022 · Quality of Life and Care
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Potential for harm · D March 30, 2022
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected April 24, 2022 · Resident Assessment and Care Planning
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Potential for harm · E March 30, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 24, 2022 · Resident Assessment and Care Planning
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Potential for harm · E March 30, 2022
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected April 24, 2022 · Resident Assessment and Care Planning
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Potential for harm · F March 30, 2022
Provide activities to meet all resident's needs.
Corrected April 24, 2022 · Quality of Life and Care
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Potential for harm · E March 30, 2022
Provide enough food/fluids to maintain a resident's health.
Corrected April 24, 2022 · Quality of Life and Care
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Potential for harm · E March 30, 2022
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected April 24, 2022 · Quality of Life and Care
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Potential for harm · E March 30, 2022
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected April 24, 2022 · Nursing and Physician Services
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Potential for harm · E March 30, 2022
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 April 24, 2022 · Nursing and Physician Services
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Potential for harm · E March 30, 2022
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 24, 2022 · Pharmacy Service
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Potential for harm · E March 30, 2022
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected April 24, 2022 · Pharmacy Service
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Potential for harm · E March 30, 2022
Ensure medication error rates are not 5 percent or greater.
Corrected April 24, 2022 · Pharmacy Service
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Potential for harm · E March 30, 2022
Ensure that residents are free from significant medication errors.
Corrected April 24, 2022 · Pharmacy Service
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Potential for harm · F March 30, 2022
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected April 24, 2022 · Nutrition and Dietary
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Potential for harm · F March 30, 2022
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected April 24, 2022 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055268 · certified since January 1, 1967. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.