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Inspection visit

Inspection

NORTH BAY POST ACUTECMS #05612037 citations on this visit
37 citations recorded

Citations

37 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0552GeneralS&S Dpotential for harm

    F552 - Planning and Implementing Care

    Ensure that residents are fully informed and understand their health status, care and treatments.

  • 0558GeneralS&S Dpotential for harm

    F558 - The right to reside and receive services in the facility with reasonable

    Reasonably accommodate the needs and preferences of each resident.

  • 0578GeneralS&S Dpotential for harm

    F578 - The right to request, refuse, and/or discontinue treatment, to participate in or

    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.

  • 0584GeneralS&S Fpotential for harm

    F584 - Safe Environment

    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.

  • 0606GeneralS&S Dpotential for harm

    F606 - The facility must—

    Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

  • 0607GeneralS&S Fpotential for harm

    F607 - The facility must develop and implement written policies and procedures that:

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  • 0623GeneralS&S Dpotential for harm

    F623 - Transfer and discharge-

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0641GeneralS&S Epotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0644GeneralS&S Dpotential for harm

    F644 - Coordination

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0657GeneralS&S Dpotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0881GeneralS&S Epotential for harm

    F881 - Infection prevention and control program

    Implement a program that monitors antibiotic use.

  • 0658GeneralS&S Dpotential for harm

    F658 - Comprehensive Care Plans

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0685GeneralS&S Dpotential for harm

    F685 - Vision and hearing

    Assist a resident in gaining access to vision and hearing services.

  • 0712GeneralS&S Dpotential for harm

    F712 - Frequency of physician visits

    Ensure that the resident and his/her doctor meet face-to-face at all required visits.

  • 0726GeneralS&S Fpotential for harm

    F726 - Nursing Services

    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.

  • 0742GeneralS&S Dpotential for harm

    F742 - Based on the comprehensive assessment of a resident, the facility must

    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.

  • 0745GeneralS&S Dpotential for harm

    F745 - The facility must provide medically-related social services to attain or

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

  • 0756GeneralS&S Dpotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    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.

  • 0759GeneralS&S Fpotential for harm

    F759 - Medication Errors

    Ensure medication error rates are not 5 percent or greater.

  • 0791GeneralS&S Dpotential for harm

    F791 - Dental Services

    Provide or obtain dental services for each resident.

  • 0812GeneralS&S Dpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0813GeneralS&S Dpotential for harm

    F813 - Food Safety Requirements

    Have a policy regarding use and storage of foods brought to residents by family and other visitors.

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0865GeneralS&S Fpotential for harm

    F865 - Quality assurance and performance improvement (QAPI) program

    Have a plan that describes the process for conducting QAPI and QAA activities.

  • 0867GeneralS&S Fpotential for harm

    F867 - Program feedback, data systems and monitoring

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0912GeneralS&S Epotential for harm

    F912 - Measure at least 80 square feet per resident in multiple resident

    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

  • 0943GeneralS&S Fpotential for harm

    F943 - Abuse, neglect, and exploitation

    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

  • 0760GeneralS&S Dpotential for harm

    F760 - Residents are free of any significant medication errors

    Ensure that residents are free from significant medication errors.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0032GeneralS&S Fpotential for harm

    Provide primary/alternate means for communication.

  • 0353GeneralS&S Dpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0363GeneralS&S Fpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0919GeneralS&S Dpotential for harm

    F919 - Resident Call System

    Meet requirements for the use of electrical equipment.

  • 0920GeneralS&S Dpotential for harm

    F920 - Dining and Resident Activities

    Ensure proper usage of power strips and extension cords.

FAQ · About this visit

Common questions about this visit

What happened during the January 17, 2025 survey of NORTH BAY POST ACUTE?

This was a inspection survey of NORTH BAY POST ACUTE on January 17, 2025. The surveyor cited 37 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at NORTH BAY POST ACUTE on January 17, 2025?

Yes, 37 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are fully informed and understand their health status, care and treatments."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.