North Bay Post Acute
NORTH BAY POST ACUTE in PETALUMA, CA — inspection on January 17, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 1/13/25 at 9:03 a.m. with Resident 54, Resident 54 stated she was involved in a resident-to-resident altercation on 12/13/24 and has been trying to leave the facility. Resident 54 stated, I don't feel safe here.
During an interview on 1/16/25 at 9:26 a.m. with Resident 54, Resident 54 stated she did not feel safe at the facility and still wanted to transfer to a different facility. Resident 54 stated she had not heard any update in a month.
During an interview on 1/16/25 at 10:01 a.m. with the Social Services Director (SSD), the SSD stated she did not call any facilities to follow-up on transferring Resident 54 since 12/18/24.
The SSD stated it was very important for residents to feel safe at the facility, and she should have seen her more frequently and followed up with transferring Resident 54 to a different facility.
During an interview on 1/16/25 at 11:06 a.m. with the Director of Nursing (DON), the DON stated after Resident 54 stated she did not feel safe, the SSD should have followed up daily to address any psychosocial needs.
During a review of Resident 54's Summary- Resident-to-Resident Incident, dated 12/13/24, Resident 54's Summary- Resident-to-Resident Incident indicated, When asked if [Resident 54] feels safe in the facility, [Resident 54] stated, 'No.' .When asked if [Resident 54] would like to be place in another facility . [Resident 54] stated, 'Yes.'
During a review of Resident 54's Social Services Note, dated 12/17/24, the note indicated Resident 54 did not feel safe at the facility and discussed other facility options with the SSD.
The note indicated the SSD faxed a referral.
056120
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056120 B.
Wing 01/17/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
North Bay Post Acute 300 Douglas Street Petaluma, CA 94952
During an interview on 1/15/25 at 12:55 p.m. with the Director of Nursing (DON), the DON stated nurses were evaluated for medication administration competency upon hire and if there were any errors with competency during medication administration audits (observations to help identify potential and actual medication errors at different stages).
The DON further stated medication administration audits were completed by the Pharmacist (PHARM).
During an interview on 1/16/25 at 3:26 p.m. with the PHARM, the PHARM stated he has not completed medication administration audits and that was not his responsibility.
During a review of Duties and Responsibilities (job description), for RN 3, 4, 5, 6 and LVN 2, the Duties and Responsibilities indicated, Implement and maintain established nursing objectives and standards .
Ensure that established departmental policies and procedures are followed .
Prepare and administer medications as ordered by the physician .
During a review of [facility name] Facility Assessment, dated 1/6/25, the Facility Assessment indicated, .Staff Training/Education & Competencies .
Upon hire skills checks are completed through competency evaluations and are reviewed annually thereafter or as needed.
Performance evaluations are performed annually to ensure staff are meeting the facility standards of performance and conduct .
During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices .
Medications are administered in accordance with written orders .
056120
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056120 B.
Wing 01/17/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
North Bay Post Acute 300 Douglas Street Petaluma, CA 94952
During an interview on 1/15/25 at 12:47 p.m. with the Director of Nursing (DON), the DON stated PHARM was responsible for conducting monthly medication administration audits.
During an interview on 1/16/25 at 3:26 p.m. with PHARM, PHARM denied being responsible for conducting medication administration audits.
During an interview on 1/17/25 at 9:17 a.m. with the Administrator (ADMIN), the ADMIN stated his start of employment was June 2024.
The ADMIN stated he had no knowledge of the medication administration audits to be completed by PHARM and declined to discuss any further issues identified and addressed by QAPI prior to his start of employment because those issues were before my time.
The facility was unable to provide documentation that medication administration was audited by PHARM monthly during February to December 2024.
During a review of the facility's policy and procedure (P&P) titled, QAPI Plan, dated 10/24/24, the P&P indicated, The facility QAPI program is ongoing, comprehensive and addresses all care and services provided by the facility.
056120
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056120 B.
Wing 01/17/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
North Bay Post Acute 300 Douglas Street Petaluma, CA 94952
During a follow-up interview on 1/17/25 at 9:20 a.m. with the ADMIN, the ADMIN stated he was unaware of the existence of the QAA Log (Quality Assessment and Assurance Log, a record of data and current PIPs to be reviewed as part of QAPI).
056120
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056120 B.
Wing 01/17/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
North Bay Post Acute 300 Douglas Street Petaluma, CA 94952
F-F943)
4.
Incomplete Resident's Records (Cross-reference