Health inspection·April 28, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement its abuse policy when Certified Nursing Assistant B (CNA B) was allowed to return to work after a physical and sexual abuse allegation was made against him, and prior to the facility completing their abuse investigation. Residents Affected - Few This failure caused Resident 1 to feel unsafe, and potentially placed other residents, who were cared for by CNA B, at risk of abuse. Findings: During an interview on 4/25/25 at 2:50 p.m., the Administrator stated Resident 1 had reported that CNA B had pushed her and had jumped on her roommate. The Administrator stated the facility's investigation into the incident was in process (not finished). The Administrator stated Resident 1's roommate (Resident 2) screamed when CNAs provided ADL (Activities of Daily Living; care such as eating, dressing, bathing, and toileting) care and Resident 1 may have inferred she was being abused. When asked how Resident 1 and Resident 2 were being protected during the investigation, Administrator stated he had immediately suspended CNA B. Review of Resident 1's MDS (Minimum Data Set - a federally mandated resident assessment tool) dated 2/10/25, her BIMS (Brief Interview for Mental Status; an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 13 (cognitively intact). During an interview on 4/25/25 at 3:15 p.m., Resident 1 stated the previous night (4/24/25), CNA B had not fed Resident 2 (the roommate) her meal; she stated CNA B also pushed her (Resident 1) shoulder. Resident 1 stated two months earlier, CNA B was on top of Resident 2 on the bed; she stated the curtains were pulled around the bed but she could see through an opening in the material. Resident 1 stated if CNA B returned to the facility, she would not feel safe. During an interview on 4/25/25 at 4:20 p.m., the Social Worker (SW) stated Resident 1 reported to them that she was giving Resident 2 a sandwich, but CNA B took it away and pushed her. The SW also stated Resident 1 had alleged staff had grabbed Resident 2, threw her on the bed, men had sex with Resident 2, and she heard Resident 2 screaming. SW stated the facility suspended CNA B. During an interview on 4/28/25 at 3:10 p.m., Resident 1 stated she had seen CNA B in the building over the weekend (4/26-4/27/25) but he was not taking care of the three women in her room. When asked if she felt safe, Resident 1 stated, hell no! Review of CNA B's Employee Timesheet (dated 04/16/2025 - 04/30/2025) indicated on, Sat [Saturday] (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056120 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056120 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Bay Post Acute 300 Douglas Street Petaluma, CA 94952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)