Inspection·December 19, 2024

F 0554 their neck pain. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/18/2024 at 8:04 AM, Registered Nurse (RN) #2 acknowledged Resident #52 kept Biofreeze medication at their bedside. RN #2 stated she did not know if a self-administration of medication assessment had been completed. Residents Affected - Few During an interview on 12/18/2024 at 1:37 PM, the Director of Nursing (DON) stated she was not aware Resident #52 had medication at their bedside. The DON stated Resident #52 had not been assessed to keep the Biofreeze at their bedside. According to the DON, the nurse should not have given the medication to the resident to keep at their bedside as the interdisciplinary team had not met to discuss if the resident was safe and able to self-administer the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 2 of 4 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore a gown and gloves when they provided incontinence care to 2 (Resident #34 and Resident #66) of 18 sampled residents. Residents Affected - Few Findings included: A facility policy titled Enhanced Barrier Precautions, effective 08/06/2024, revealed, Enhanced Barrier Precautions (EBP) - used in conjunction with the standard precautions and expand the use of PPE [personal protective equipment] to donning of gown and gloves during high-contact resident care activities and in situations of expected exposure to blood, body fluids, skin breakdown, or mucous membranes that provide opportunities for transfer of MDROs [multidrug-resistant organisms] to staff hands and clothing to reduce transmission. The policy specified, 4. Facility staff shall perform hand hygiene and in cases when standard precautions may not be sufficient, will don gown and gloves before performing high-contact resident care activities. The list below is not all-inclusive, and activities requiring EBP are on a case by case basis as determined by the facility * Device care or use: PICC/MID [peripherally inserted central catheter/midline] line, urinary catheter, feeding tube, tracheostomy/ventilator * Wound care on chronic wounds requiring a dressing * Bathing/showering * Dressing and/or Transferring where contact with bodily fluids is likely * Providing hygiene where standard precautions may not be sufficient * Changing soiled linens * Changing briefs or assisting with toileting. 1. An admission Record revealed the facility admitted Resident #66 on 11/07/2024.According to the admission Record, the resident had a medical history that included a diagnosis of retention of urine. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2024, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #66 was dependent on staff for lower and upper body dressing. The MDS indicated the resident was dependent on staff for toileting hygiene and had an indwelling catheter. Resident #66's care plan included a focus area initiated 12/02/2024, that indicated the resident had an activity of daily living self-care performance deficient related to impaired mobility, weakness, deconditioned, and multiple medical problems. During an observation on 12/17/2024 at 2:01 PM, Certified Nurse Aide (CNA) #3 and CNA #4 assisted Resident #66 with repositioning. CNA #3 and CNA #4 wore gloves and no gowns. CNA #3 handed CNA #4 the resident's urinary catheter bag and assisted the resident to turn in bed. CNA #3 was also noted to hold the resident's urinary catheter bag and adjusted the resident's catheter tubing. During an interview on 12/17/2024 at 2:02 PM, CNA #3 stated she did not wear a gown because she did not empty the resident's urinary catheter bag. According to CNA #3, she only needed to wear a gown when she emptied the resident's urinary catheter bag. During an interview on 12/17/2024 at 2:13 PM, CNA #4 stated she did not wear a gown when she assisted CNA #3 to reposition Resident #66. Per CNA #4, she only needed to wear a gown when she emptied the resident's urinary catheter bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 3 of 4 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 056072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Petaluma Post-Acute Rehabilitation 1115 B 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/18/2024 at 8:20 AM, the Infection Preventionist stated staff should use personal protective equipment for high contact activities for residents on enhanced barrier precautions. 2. An admission Record revealed the facility admitted Resident #34 on 02/25/2019. According to the admission Record, the resident had a medical history that included diagnoses of chronic kidney disease and retention of urine. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required substantial/maximal assistance with toileting hygiene, was frequently incontinent of bowel, and had an indwelling catheter. Resident #34's care plan included a focus area initiated 11/14/2024, that indicated the resident was at high risk for developing complications to include a urinary tract infection due to the presence of a catheter related to obstructive uropathy. During an observation on 12/17/2024 at 2:22 PM, Certified Nurse Aide #5 did not wear a gown when she provided incontinence care to Resident #34. During an interview on 12/18/2024 at 8:20 AM, the Infection Preventionist stated staff should use personal protective equipment for high contact activities for residents on enhanced barrier precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056072 If continuation sheet Page 4 of 4