California ›Petaluma

North Bay Post Acute

300 Douglas Street, Petaluma, CA 94952 · Sonoma County · 98 certified beds · avg 95 residents/day · certified since Nov 10, 1969

Abuse citation flag (CMS)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

1/5
Health inspection rating (on-site)
4
Serious findings on record
$179,613
Fines, last 3 years
4.90
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, facility-wide · Apr 30, 2024 · F-0812 · triggered by a complaint

The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.

Why it matters: Unsafe food handling is one of the most common causes of food poisoning, which can be dangerous for frail residents.

Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.

Corrected: May 24, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Oct 22, 2025 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 11, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Apr 7, 2025 · F-0658 · triggered by a complaint

The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.

Why it matters: Care that falls below professional standards can directly harm a resident's health and recovery.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 1, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jan 18, 2023 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 13, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (91)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Apr 14, 2026D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Apr 14, 2026D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Jan 9, 2026F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jan 9, 2026F · Potential for harm, facility-wideThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jan 9, 2026E · Potential for harm, repeatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jan 9, 2026E · Potential for harm, repeatedThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Jan 9, 2026D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Jan 9, 2026D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jan 9, 2026D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Jan 9, 2026D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jan 9, 2026D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jan 9, 2026D · Potential for harm, one-offThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Jan 9, 2026D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jan 9, 2026D · Potential for harm, one-offThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
Jan 9, 2026D · Potential for harm, one-offThe facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Jan 9, 2026D · Potential for harm, one-offThe facility did not have policies on smoking.
Dec 30, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Oct 22, 2025▲ G · Actual harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jul 15, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Jul 15, 2025D · Potential for harm, one-offThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Apr 28, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Apr 25, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Apr 7, 2025▲ G · Actual harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Jan 17, 2025F · Potential for harm, facility-wideThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jan 17, 2025F · Potential for harm, facility-wideThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Jan 17, 2025F · Potential for harm, facility-wideThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Jan 17, 2025F · Potential for harm, facility-wideThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jan 17, 2025F · Potential for harm, facility-wideThe facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them.
Jan 17, 2025F · Potential for harm, facility-wideThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Jan 17, 2025F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 17, 2025F · Potential for harm, facility-wideThe facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation.
Jan 17, 2025E · Potential for harm, repeatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jan 17, 2025E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jan 17, 2025E · Potential for harm, repeatedThe facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Jan 17, 2025E · Potential for harm, repeatedThe facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
Jan 17, 2025D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jan 17, 2025D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jan 17, 2025D · Potential for harm, one-offThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Jan 17, 2025D · Potential for harm, one-offThe facility hired someone with an official finding of abuse, neglect, exploitation, or theft against them. Facilities are not allowed to employ people with such findings.
Jan 17, 2025D · Potential for harm, one-offThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Jan 17, 2025D · Potential for harm, one-offThe facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
Jan 17, 2025D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jan 17, 2025D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jan 17, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jan 17, 2025D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Jan 17, 2025D · Potential for harm, one-offThe facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule.
Jan 17, 2025D · Potential for harm, one-offThe facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
Jan 17, 2025D · Potential for harm, one-offThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
Jan 17, 2025D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Jan 17, 2025D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Jan 17, 2025D · Potential for harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Jan 17, 2025D · Potential for harm, one-offThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
Jan 17, 2025D · Potential for harm, one-offThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jan 17, 2025D · Potential for harm, one-offThe facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Jan 17, 2025D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Dec 23, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Dec 12, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Dec 3, 2024E · Potential for harm, repeatedThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint
Dec 3, 2024E · Potential for harm, repeatedThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint
Sep 16, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
May 15, 2024D · Potential for harm, one-offThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint
Apr 30, 2024▲ L · Immediate jeopardy, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Apr 30, 2024F · Potential for harm, facility-wideThe facility did not dispose of garbage and refuse properly. · from a complaint
Apr 30, 2024F · Potential for harm, facility-wideThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint
Apr 30, 2024F · Potential for harm, facility-wideThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Apr 30, 2024E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Aug 23, 2023D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Aug 11, 2023D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Aug 11, 2023D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Aug 11, 2023D · Potential for harm, one-offThe facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint
Jan 18, 2023▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jan 18, 2023F · Potential for harm, facility-wideThe facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition.
Jan 18, 2023F · Potential for harm, facility-wideThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Jan 18, 2023F · Potential for harm, facility-wideThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service.
Jan 18, 2023F · Potential for harm, facility-wideThe facility did not provide at least one adequately sized room for dining and activities, with good lighting, airflow, and furniture.
Jan 18, 2023E · Potential for harm, repeatedThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jan 18, 2023E · Potential for harm, repeatedThe facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require.
Jan 18, 2023E · Potential for harm, repeatedThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jan 18, 2023E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Jan 18, 2023E · Potential for harm, repeatedThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Jan 18, 2023E · Potential for harm, repeatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jan 18, 2023E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jan 18, 2023E · Potential for harm, repeatedThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Jan 18, 2023E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 18, 2023E · Potential for harm, repeatedThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Jan 18, 2023E · Potential for harm, repeatedThe facility did not have policies on smoking.
Jan 18, 2023D · Potential for harm, one-offThe facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Jan 18, 2023D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jan 18, 2023D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Jan 18, 2023D · Potential for harm, one-offThe facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
Jan 18, 2023D · Potential for harm, one-offThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (32 → 14).

YearCitationsSerious (G–L)Worst severity that year
2023251G ▲
2024111L ▲
2025392G ▲
2026160F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

3 fines totaling $179,613.

DateTypeAmount / length
Oct 22, 2025Fine$36,736
Apr 7, 2025Fine$23,685
Apr 30, 2024Fine$119,192

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.904.313.95top 17% in California; top 15% in the U.S.
Registered Nurse hours0.990.610.69top 11% in California; top 16% in the U.S.
Weekend total nurse staffing4.543.903.50top 14% in California; top 12% in the U.S.
Weekend RN hours (not acuity-adjusted)0.680.510.48top 16% in California; top 17% in the U.S.
Total nursing staff turnover (%)0.036.745.8—
RN turnover (%)0.038.142.9—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.02, RN 0.81, weekend 3.72. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Tanner, BryanIndividual5% or Greater Indirect Ownership Interest50%01/01/2021
Tanner, RenaeIndividual5% or Greater Indirect Ownership Interest50%01/01/2021
Zermatt U.s. Health Services, LLCOrganization5% or Greater Direct Ownership Interest99%01/01/2021
Moore, BrettIndividualOperational/Managerial ControlNOT APPLICABLE01/01/2021
Tanner, BryanIndividualCorporate OfficerNOT APPLICABLE01/01/2021
Zermatt U.s. Health Services, LLCOrganizationOperational/Managerial ControlNOT APPLICABLE01/01/2021

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

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Valley of the Moon Post Acute10.1 miSonoma, CA★★★☆☆2/5abuse
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Sonoma Post Acute10.6 miSonoma, CA★★★★☆3/5
Northvine Postacute Care14.1 miSanta Rosa, CA★☆☆☆☆1/5
Santa Rosa Post Acute14.8 miSanta Rosa, CA★★★☆☆2/5
Apple Valley Post-Acute Rehab14.9 miSebastopol, CA★★★★★4/5
Summerfield Health Care Center15.1 miSanta Rosa, CA★★★★★5/5

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Facility data as of CMS processing date 2026-08-01. CCN 056120.