Vineyard Post Acute
101 Monroe Street · Petaluma, CA · 94954 · 7077634109
99 certified beds For profit - Limited Liability company Chain: Pacs Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $55,692 in fines in the last 24 months.
- 3 citations involved actual harm to residents.
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
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
$55,692 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
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 | 3.94 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.48 | 0.55–0.75 |
| Weekend hours / resident-day | 3.47 | ≈ weekday level |
| Nursing turnover / year | 40% | median 45% |
| Fines (3-yr window) | 3 · $63,135 |
Inspection citations (47 in the current record)
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Potential for harm · D March 30, 2026 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected April 22, 2026 · Resident Rights
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Potential for harm · D March 30, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 22, 2026 · Quality of Life and Care
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Potential for harm · D March 10, 2026 · found via complaint
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 March 29, 2026 · Pharmacy Service
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Potential for harm · D January 22, 2026 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected February 23, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 18, 2025
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected January 15, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 18, 2025
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 January 15, 2026 · Quality of Life and Care
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Potential for harm · E December 18, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected January 15, 2026 · Pharmacy Service
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Potential for harm · E December 18, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected January 15, 2026 · Pharmacy Service
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Potential for harm · E December 18, 2025
Ensure that residents are free from significant medication errors.
Corrected January 15, 2026 · Pharmacy Service
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Potential for harm · E December 18, 2025
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 January 15, 2026 · Pharmacy Service
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Potential for harm · D December 18, 2025
Provide or get specialized rehabilitative services as required for a resident.
Corrected January 15, 2026 · Quality of Life and Care
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Potential for harm · D December 18, 2025
Provide and implement an infection prevention and control program.
Corrected January 15, 2026 · Infection Control
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Potential for harm · E December 18, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected January 15, 2026 · Environmental
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Potential for harm · E December 18, 2025 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 15, 2026 · Nutrition and Dietary
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Potential for harm · F December 18, 2025 · found via complaint
Dispose of garbage and refuse properly.
Corrected January 15, 2026 · Nutrition and Dietary
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Potential for harm · D September 16, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected November 28, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 22, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected May 16, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 11, 2025 · found via complaint
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 March 25, 2025 · Resident Rights
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Potential for harm · E February 25, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 29, 2025 · Infection Control
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Actual harm · G February 13, 2025 · found via complaint
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 March 5, 2025 · Quality of Life and Care
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Potential for harm · D February 12, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected February 25, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E November 23, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected December 20, 2024 · Resident Rights
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Potential for harm · D November 23, 2024
Ensure each resident receives an accurate assessment.
Corrected December 20, 2024 · Resident Assessment and Care Planning
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Potential for harm · D November 23, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected December 20, 2024 · Quality of Life and Care
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Potential for harm · E November 23, 2024
Ensure that residents are free from significant medication errors.
Corrected December 20, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 12, 2025 | Fine | $34,034 |
| November 22, 2024 | Fine | $21,658 |
| September 5, 2023 | Fine | $7,443 |
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 555120 · certified since November 7, 1980. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.