North Bay Post Acute
300 Douglas Street · Petaluma, CA · 94952 · 7077636887
98 certified beds For profit - Limited Liability company
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
- Federal penalties on record: $23,685 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
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
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 2 · $142,877 |
Inspection citations (91 in the current record)
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Potential for harm · D April 14, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 1, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 14, 2026 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected May 1, 2026 · Resident Assessment and Care Planning
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Potential for harm · D January 9, 2026
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected February 5, 2026 · Resident Rights
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Potential for harm · D January 9, 2026
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 February 5, 2026 · Resident Rights
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Potential for harm · D January 9, 2026
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 5, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E January 9, 2026
Ensure each resident receives an accurate assessment.
Corrected February 5, 2026 · Resident Assessment and Care Planning
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Potential for harm · E January 9, 2026
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected February 5, 2026 · Resident Assessment and Care Planning
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Potential for harm · D January 9, 2026
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected February 5, 2026 · Resident Assessment and Care Planning
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Potential for harm · D January 9, 2026
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected February 5, 2026 · Quality of Life and Care
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Potential for harm · D January 9, 2026
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 February 5, 2026 · Quality of Life and Care
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Potential for harm · D January 9, 2026
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected February 5, 2026 · Pharmacy Service
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Potential for harm · D January 9, 2026
Provide or obtain dental services for each resident.
Corrected February 5, 2026 · Quality of Life and Care
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Potential for harm · F January 9, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 5, 2026 · Nutrition and Dietary
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Potential for harm · D January 9, 2026
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected February 5, 2026 · Nutrition and Dietary
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Potential for harm · F January 9, 2026
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected February 5, 2026 · Resident Assessment and Care Planning
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Potential for harm · D January 9, 2026
Have policies on smoking.
Corrected February 5, 2026 · Environmental
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Potential for harm · D December 30, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected January 16, 2026 · Pharmacy Service
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Actual harm · G October 22, 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 November 11, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 15, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected August 13, 2025 · Infection Control
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Potential for harm · D July 15, 2025 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected August 13, 2025 · Environmental
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Potential for harm · D April 28, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected May 16, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 25, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected May 12, 2025 · Resident Assessment and Care Planning
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Actual harm · G April 7, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected May 1, 2025 · Resident Assessment and Care Planning
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Potential for harm · D January 17, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected March 13, 2025 · Resident Rights
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Potential for harm · D January 17, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected March 13, 2025 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 7, 2025 | Fine | $23,685 |
| April 30, 2024 | Fine | $119,192 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056120 · certified since November 10, 1969. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.