Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
21’23
11’24
39’25
16’26
87 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Apr 14, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Apr 14, 2026 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Jan 9, 2026 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Jan 9, 2026 | D · potential | 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. | Routine |
| Jan 9, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Routine |
| Jan 9, 2026 | E · potential | Ensure each resident receives an accurate assessment. | Routine |
| Jan 9, 2026 | E · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Routine |
| Jan 9, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jan 9, 2026 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Jan 9, 2026 | D · potential | 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. | Routine |
| Jan 9, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jan 9, 2026 | D · potential | Provide or obtain dental services for each resident. | Routine |
| Jan 9, 2026 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jan 9, 2026 | D · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Jan 9, 2026 | F · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Jan 9, 2026 | D · potential | Have policies on smoking. | Routine |
| Dec 30, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Oct 22, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jul 15, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jul 15, 2025 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
| Apr 28, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Apr 25, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Apr 7, 2025 | G · harm | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Jan 17, 2025 | D · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Jan 17, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Jan 17, 2025 | D · potential | 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. | Routine |
| Jan 17, 2025 | F · potential | 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. | Routine |
| Jan 17, 2025 | D · potential | Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Routine |
| Jan 17, 2025 | F · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Routine |
| Jan 17, 2025 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Routine |
| Jan 17, 2025 | E · potential | Ensure each resident receives an accurate assessment. | Routine |
| Jan 17, 2025 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Jan 17, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jan 17, 2025 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Jan 17, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jan 17, 2025 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Jan 17, 2025 | D · potential | Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Routine |
| Jan 17, 2025 | F · potential | 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. | Routine |
| Jan 17, 2025 | D · potential | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Routine |
| Jan 17, 2025 | D · potential | Provide medically-related social services to help each resident achieve the highest possible quality of life. | Routine |
| Jan 17, 2025 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Jan 17, 2025 | D · potential | 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. | Routine |
| Jan 17, 2025 | F · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jan 17, 2025 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Jan 17, 2025 | E · potential | 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. | Routine |
| Jan 17, 2025 | D · potential | Provide or obtain dental services for each resident. | Routine |
| Jan 17, 2025 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jan 17, 2025 | D · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Jan 17, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Jan 17, 2025 | F · potential | Have a plan that describes the process for conducting QAPI and QAA activities. | Routine |
| Jan 17, 2025 | F · potential | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Routine |
| Jan 17, 2025 | F · potential | Provide and implement an infection prevention and control program. | Routine |
| Jan 17, 2025 | E · potential | Implement a program that monitors antibiotic use. | Routine |
| Jan 17, 2025 | E · potential | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| Jan 17, 2025 | F · potential | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Routine |
| Dec 23, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Dec 12, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Dec 3, 2024 | E · potential | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Complaint |
| Dec 3, 2024 | E · potential | 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. | Complaint |
| Sep 16, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| May 15, 2024 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Complaint |
| Apr 30, 2024 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Complaint |
| Apr 30, 2024 | L · harm | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| Apr 30, 2024 | F · potential | Dispose of garbage and refuse properly. | Complaint |
| Apr 30, 2024 | F · potential | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Complaint |
| Apr 30, 2024 | F · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Complaint |
| Jan 18, 2023 | E · potential | Ensure that residents are fully informed and understand their health status, care and treatments. | Routine |
| Jan 18, 2023 | D · potential | Assess the resident when there is a significant change in condition | Routine |
| Jan 18, 2023 | F · potential | Assure that each resident’s assessment is updated at least once every 3 months. | Routine |
| Jan 18, 2023 | E · potential | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | Routine |
| Jan 18, 2023 | E · potential | Ensure each resident receives an accurate assessment. | Routine |
| Jan 18, 2023 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jan 18, 2023 | F · potential | Provide activities to meet all resident's needs. | Routine |
| Jan 18, 2023 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jan 18, 2023 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Jan 18, 2023 | D · potential | Provide care or services that was trauma informed and/or culturally competent. | Routine |
| Jan 18, 2023 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Routine |
| Jan 18, 2023 | D · potential | 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. | Routine |
| Jan 18, 2023 | E · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Jan 18, 2023 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jan 18, 2023 | E · potential | 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. | Routine |
| Jan 18, 2023 | F · potential | 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. | Routine |
| Jan 18, 2023 | E · potential | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Routine |
| Jan 18, 2023 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jan 18, 2023 | E · potential | Develop and implement policies and procedures for flu and pneumonia vaccinations. | Routine |
| Jan 18, 2023 | F · potential | Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Routine |
| Jan 18, 2023 | E · potential | Have policies on smoking. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
North Bay Post Acute
300 Douglas Street, Petaluma, CA 94952 · (707) 763-6887
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 056120
- Certified beds
- 98
- Legal owner
- North Bay Post Acute LLC
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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