Health inspection·September 27, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated, You get a feeling they are talking about you (when staff are speaking Spanish), they keep on talking and ignore you even when you speak to them. During a concurrent observation and interview on 9/24/24 at 12:19 p.m., in the hallway right in front of the dining room (which was a very trafficked area by residents and staff), Unlicensed Staff N, Unlicensed Staff O and Unlicensed Staff P were heard and observed speaking Spanish among each other. The conversation occurred during lunch time, when residents were actively entering and exiting the dining room and were in close proximity or crossing this hallway where the above staff were standing. Unlicensed Staff N, Unlicensed Staff O and Unlicensed Staff P were asked if they were allowed to speak a language other than English in the resident care areas. They stated they were allowed to speak Spanish to Spanish speaking residents only. During an interview with the DSD on 9/26/24 at 9:06 a.m., she stated staff were not allowed to speak a language other than English in resident care areas, unless they were speaking to a resident in his/her native language. The DSD stated the Administrator had recently in-serviced staff on this requirement. Record review of the facility policy titled, Dignity, last revised in February of 2021, indicated, Residents are treated with dignity and respect at all times .The facility culture supports dignity and respect for resident by honoring resident goals, choices, preferences, values and beliefs .When assisting with care, residents are supported in exercising their rights, for example, residents are: e. provided with a dignified dining experience. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 2 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to promptly respond and ensure resolutions for concerns brought-up during resident council meetings for a sample of 13 residents. This failure had the potential to result in unresolved patient care concerns, and feelings of frustration and loss of control for the residents of the facility. Residents Affected - Some Findings: During a resident council meeting attended by 13 residents on 9/25/24 at 10:35 a.m., Resident 2 stated the facility did not always respond or resolve issues discussed during the meetings. Resident 2 also stated when the facility did resolve an issue, it was not done promptly, as it was usually done the day before the next monthly resident council meeting. A review of the July 2024 resident council minutes indicated a meeting was conducted on 7/10/24, in which residents complained they could hear staff speaking in their native language in the halls and residents' rooms, and two residents were upset that staff were speaking in Spanish only. A review of a facility document attached to the July 2024 resident council minutes titled RESIDENT COUNCIL DEPARTMENT RESPONSE FORM indicated, Explanation and/or Response/Actions Taken by Department to Resolve Issue(s) identified .[was left blank as there was no response or explanation to resolve the issue]. Attached to this document was another facility document titled, [Name of Facility] Inservice [training] Attendance Record Sign in Sheet which indicated 8 signatures from staff members. This document did not indicate the subject of the training, the date, the identity of the instructor who provided the training or the timing of the class. Record review of the August 2024 resident council minutes had four resident-care concerns which had no explanation or response. Two of the concerns were about the alarm system to request assistance was being turned off and call lights were taking up to 2 hours to be answered. There was no documented explanation, response, or action taken by the facility to resolve the issues for both concerns. A review of a facility document attached to the August 2024 resident council minutes titled RESIDENT COUNCIL DEPARTMENT RESPONSE FORM indicated, Explanation and/or Response/Actions Taken by Department to Resolve Issue(s) identified .[was left blank as there was no response or explanation to resolve the issue]. Again, documentation of training was provided to a few staff, but the sign-in sheets did not indicate the subjects of the trainings, the dates, the identity of the instructors who provided the trainings or the timing of the classes. In addition, the staff who signed as participants to the training consisted of only morning and evening shift staff. The night shift staff signatures were not present in the documentation. During a concurrent interview and record review with the Activities Director on 9/26/24 at 8:48 a.m., the AD stated when resident council members discussed concerns during their monthly meetings, their concerns were directed to the proper facility department, so they could provide a response or resolution to their concern. During a concurrent interview and record review on 9/26/24 at 9:06 a.m. the Director of Staff Development (DSD) stated she was new to her position as of August 1, 2024. The DSD was presented with the August 2024 resident council minutes which indicated RESIDENT COUNCIL DEPARTMENT RESPONSE FORM(s) were left blank, without responses. The DSD stated she was responsible for providing a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 3 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some response/explanation to these resident care concerns, but she did not, put it in. The DSD confirmed she had provided staff trainings in response to the resident council concerns, but had not documented the subject, date, or time of the trainings, which was required. The DSD also confirmed she had only provided trainings to staff between 2:00 p.m. and 3:00 p.m. The DSD was asked to provide all trainings provided to night shift staff. The DSD was only able to present one training she provided on 8/14/24 at 7:00 a.m. This sign-in sheet indicated only one night shift staff signed as having attended the training. This was confirmed by the DSD. Record review of the facility policy titled, Resident Council revised in February of 2021, indicated, The purpose of the resident council is to provide a forum for .residents, families and resident representatives to have input in the operation of the facility .discussion of concerns and suggestions for improvement .A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 4 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to post the location of the survey results in a easily noticeable manner. This failure decreased the facility's potential to honor the rights of 76 residents to examine the facility's survey results. Residents Affected - Some Findings: During a concurrent interview and record review on 9/25/24 at 12:20 p.m., the Activities Director stated she did not discuss where to find the survey binder during regular resident council meetings. The Activities Director shared with the surveyor the location of the survey binder. The survey binder was observed on the shelf of a small table located in the entrance lobby, covered with dust, and unlabeled with any type of information. There were no postings around this area to indicate the survey binder was there. During a concurrent interview and record review with the Director of Nursing (DON) on 9/25/24 at 12:25 p.m., the DON confirmed the survey binder did not include the survey results of complaints or facility reported incidents investigated after January 2023. During an interview with the Administrator on 9/25/24 at 12:32 p.m., the Administrator confirmed the survey binder had not been updated since January of 2023 and stated he was in the process of labeling the binder so it could be easily identified. Record review of the facility policy titled, Residents' Rights, last revised in February of 2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .examine survey results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 5 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for residents when: Residents Affected - Some 1. Two of three shower rooms were being used as storage; and, 2. The facility's smoking area dirty and unkempt. These failures made the shower rooms and smoking area uncomfortable and not a homelike environment. Findings: 1. During the Resident Council meeting and interviews on 9/25/24, at 10:55 AM, Resident 232 and Resident 2 stated the water in the shower room by the Merlot Hall was scalding hot. The residents stated water in the shower room by the Chablis Hall was cold and the shower room was being used as a storage room. The shower room by the Burgundy Hall was the only shower often used. A review of the Resident Council meeting minutes, dated 5/15/24 at 2:15 PM, indicated residents discussed the shower room at the Chablis Hall was being used as storage instead of being used as extra shower room; the Merlot shower did not work well because the water temperature was difficult to adjust. During an observation of the shower rooms and subsequent interview with an Unlicensed Staff member on 9/26/24, at 2:30 PM, the Chablis Hall shower room was crowded with lifts and shower chairs leaving no room to maneuver a resident in a shower chair to get in to have a shower. The Merlot Hall shower room also stored lifts and chairs leaving little room to allow a resident in a shower chair to pass through to the shower. The Burgundy Hall shower stall was smaller and had 2 shower chairs inside. The Unlicensed Staff member who accompanied the Surveyor confirmed the shower chairs were difficult to maneuver in these rooms because of all the equipment stored in them. The Unlicensed Staff member also stated the Burgundy and Merlot shower rooms were often used. During an interview on 9/27/24 at 10:05 a.m., Unlicensed Staff G stated they had to use the shower in the other halls for residents because they could not get the water to a comfortable temperature in Merlot hall. 2. During a concurrent observation and interview in the facility's smoking area on 9/25/24 at 10:03 a.m., Resident 61 and Resident 228 were observed smoking under the supervision of Unlicensed Staff N. The smoking area was a wooden shed at the back of a patio filled with medical equipment, tarps, and large receptacles of dirty laundry. The smoking area directly faced this patio. There were no plants, greenery, or a pleasant view from where the residents were sitting, except for a few trees. Upon closer observation, it was noted the smoking area was covered with dust, spider webs, old tools, and trash. In addition, the fire blanket (used to extinguish small fires) looked old and had spider webs and sharp pieces of metal rust stuck to it. The metal rust came from the metal box where the fire blanket was stored, as the metal and paint of this box were coming off. These observations were confirmed by Unlicensed Staff N, who acknowledged the shed was dirty and unkempt and the fire blanket was soiled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 6 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 9/26/24 at 2:55 p.m., Resident 61 stated the smoking area was dirty and definitely did not feel like home. Resident 61 stated the back patio where the smoking area was located, was not a nice place to be, but they had no choice. During an interview on 9/27/24 at 1:50 p.m., Resident 14, who confirmed being a smoker, used the following expression to refer to the smoking area, It just sucks. Resident 14 stated the facility had medical equipment outside all the time in this patio, including during the rainy season. Resident 14 stated it did not feel like home. A review of the facility's undated policy titled Homelike Environment, indicated, Residents are provided with a safe, clean, comfortable environment. Facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including a clean, sanitary, and orderly environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 7 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide its residents a safe and functional environment free of accident hazards when water temperatures measured above 120 degreed Fahrenheit (F) in two showers and seven resident rest room faucets. These failures increased the risk of scalds or burns from hot faucet water and showers for a census of 76 residents. Findings: During the Resident Council meeting and interviews on 9/25/24, at 10:55 AM, Resident 232 and Resident 2 stated the water is scalding hot at the shower room by the Merlot Hall. A review of the Resident Council meeting minutes, indicated the following resident concerns were discussed on the following dates: - 1/17/24 at 2:10 PM: Merlot Hall shower still too hot; - 5/15/24 at 2:15 PM: Shower in Chablis being used as storage instead of being used as extra shower room. Merlot shower did not work well, temperature was hard to get just right; - 6/19/24 at 2:06 PM: Maintenance Supervisor responded Chablis shower has a broken valve, plumber called to fix issues with shower; and, - 7/10/24 10:40 AM: Residents still concerned about Merlot's water, but aware plumber was coming. During an observation of the water temperatures at the resident showers with the Maintenance Supervisor (MS) on 9/27/24 at 9:30 AM, the water at Merlot shower measured 128.3 degrees F. When the MS measured the water temperature with the faucet handle turned all the way to the left, the water was 136 degrees F. The MS also measured the water temperature at the Burgundy Hall shower which was 128.8 degrees F. During an interview on 9/27/24 at 9:57 AM, Unlicensed Staff I stated the water temperature at the shower room at Merlot Hall gets too hot, but the one in Burgundy Hall varies. During an interview on 9/27/24 at 10:00 AM, Resident 35 confirmed the water temperature at the shower at Merlot Hall gets scalding hot. During an interview on 9/27/24 at 10:04 AM, Unlicensed Staff J also stated the water in the shower at Merlot Hall was hot. During an observation on 9/27/24 at 10:05 AM with the MS, the water in the restroom between rooms [ROOM NUMBERS] measured 132.3 degrees F. During an interview on 9/27/24 at 10:05 a.m., Unlicensed Staff G stated the hot water in the shower in Merlot Hall has been a problem for about two months. Unlicensed Staff G stated the water was too hot. Unlicensed Staff G stated she had told maintenance about the hot water, and they fixed it, but then it became a problem again. Unlicensed Staff G stated they had to use the shower in the other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 8 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some halls for residents if they could not get the water to a comfortable temperature in Merlot Hall. Unlicensed Staff G stated the water in the other three halls was fine, but the residents preferred the shower at Merlot Hall because it was bigger and had a better hose for the residents to use. During continued observation on 9/27/24 at 10:10 AM and 10:12 AM, water at the restroom between rooms [ROOM NUMBERS] measured 130.6 degrees F and water between rooms [ROOM NUMBERS] measured 131.4 degrees F. During an interview on 9/27/24 at 10:14 a.m., Resident 178 stated the water at her sink and the shower in Merlot Hall had been too hot. Resident 178 verified she felt like she was going to scald her hands when she was washing her hands and the shower was uncomfortably hot. Resident 178 stated, It's really bad (the water in the Merlot shower). Resident 178 stated she was glad to be going home so she can take a shower in her own bathroom. During continued observation on 9/27/24 at 10:15 AM, water in the restroom between rooms [ROOM NUMBERS] measured 129.0 degrees F. During an observation on 9/27/24 at 10:26 AM, the water temperature from the faucet in the rest room between rooms [ROOM NUMBERS] measured 131 degrees F. During an observation on 9/27/24 at 10:28 AM, the water temperature from the faucet in the rest room between rooms [ROOM NUMBERS] measured 133 degrees F. A review of facility's policy titled Safety of Water Temperature revised December 2009, indicated, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents .Water heaters that service resident rooms, bathrooms, common areas, and tubs/shower areas shall be set to temperatures of no more than 120-degrees Fahrenheit (48-degrees Celsius), or the maximum allowable temperature per state regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 9 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet residents needs for three of nine residents (Residents 39, 46 and 53) when: Residents Affected - Some 1. Licensed Nurse A (LN A) did not identify Resident 39 prior to administering his morning medications on 9/24/24. 2. Resident 39's physician's order and Medication Administration Record (MAR) for a Lidocaine Patch (a topical medication for pain relief) did not follow the medication's package insert instructions for use. 3. The LN B administered a different resident's Metformin (a medication to treat diabetes/high blood sugar) to Resident 46. 4. The LN B administered Tylenol (a pain medication) to Resident 46 but did not document the medication administration on Resident 46's MAR. These failures decreased the facility's potential to safely administer medications and prevent harmful side effects to residents. Findings: 1. During a medication administration observation and concurrent interview with LN A on 9/24/24, at 8:30 a.m., the LN A stated Resident 39 had an order for Lidocaine Patch 5% to be applied daily to the lower left leg. The LN A entered Resident 39's room with the Lidocaine Patch 5%, removed the old Lidocaine Patch 5% from Resident 39's left lower leg, and applied the new Lidocaine Patch 5% to the same location. The LN A did not verify Resident 39's identity prior to removing the old Lidocaine Patch 5% and applying the new Lidocaine Patch 5%. During an interview on 9/26/24, at 10 am, the DON stated the expectation was for nurses to verify the residents' identity using at least two identifiers before administering medications. 2. A review of Resident 39's Physician Orders dated 9/2/24 indicated, Lidocaine Patch 5% Apply 1 patch topically in the morning to left lower leg per additional directions. A review of Resident 39's MAR dated September 2024 indicated, Lidoderm Patch 5% (Lidocaine) Apply per additional directions topically in the morning for left lower leg up to three patches per day. A review of Resident 39's Lidocaine Patch 5% package insert indicated, DOSAGE AND ADMINISTRATION .Apply LIDOCAINE PATCH 5% .for up to 12 hours within a 24 hour period .If irritation or burning sensation occurs during application, remove the patch(es) and do not reapply until irritation subsides. During an interview on 9/24/24 at 11:25 a.m., the LN A stated she did not know what per additional directions meant as written in Resident 39's physician's orders. The LN A further stated she did not know what the indication of up to three patches per day meant on Resident 39's MAR. During an interview on 9/24/24, at 2:20 p.m., the Director of Nursing (DON) stated that Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 10 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0755 Level of Harm - Minimal harm or potential for actual harm 39's Lidocaine Patch 5% should have been applied for a maximum of 12 hours and then removed, per the package insert. The DON stated if the LN A removed an old Lidocaine Patch 5% the morning of 9/24/24 before applying the new one, it meant the previous Lidocaine Patch 5% was left on Resident 39 since the morning of the previous day. The DON stated Resident 39's Lidocaine Patch 5% order was rewritten to clarify only one patch was to be applied daily for a maximum of 12 hours. Residents Affected - Some 3. & 4. During a medication administration observation and concurrent interview with LN B on 9/24/24, at 8:10 a.m., the LN B administered medications to Resident 46. The LN B stated Resident 46 had an order for Metformin 500 mg (milligrams, a unit of measure). The LN B pulled out a package of Metformin pills from the medication cart, removed one pill from the package and administered it to Resident 46. A review of the medication package the LN B removed the Metformin from indicated it was labeled and ordered for another resident. During a concurrent medication administration, the LN B administered Tylenol 650 mg to Resident 46 who had reported pain. During a review of Resident 46's MAR dated September 2024 on 9/24/24 at approximately 9 a.m. indicated no documented evidence the Tylenol 650 mg was administered to Resident 46 on 9/24/24 in the morning. The only documented administration of Tylenol for Resident 46 was dated 9/24/24 at 8:25 p.m. by a different licensed nurse. During a record review and concurrent interview with the DON on 9/26/24 at 10 am, the DON reviewed Resident 46's MAR and confirmed there was no documentation of Tylenol 650 mg administered to Resident 46 in the morning of 9/24/24. A review of the facility's policy and procedure titled Administering Medications, dated 2001, indicated, The individual administering medications verifies the resident's identity before giving the resident his/her medications .The individual administering the medication checks the label THREE (3) times to verify the right resident .Medications ordered for a particular resident may not be administered to another resident .the individual administering the medication records in the resident's medical record: the date and time the medication was administered . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 11 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0761 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation, interview and record review, the facility failed to: Residents Affected - Some 1) Remove an unsampled discharged resident's medication from the medication cart and medications for four residents (Resident 25, Resident 69, Resident 27, and Resident 10) were not placed in their proper storage; and, 2) Maintain the temperature in the medication room between 68 degrees Fahrenheit (F) and 77 degrees F. These failures resulted in Resident 46 being administered Resident 27's medication and decreased the facility's potential to appropriately store medications. Findings: During an observation and inspection of the medication cart for the Burgundy Hall, and concurrent interview with Licensed Nurse B on 9/25/24 at 10:24 AM, the following were noted: - An Unsampled Resident's medication packet of Gabapentin (medication used to treat seizures or nerve pain) 300 mg (milligrams, a unit of weight) capsules was stored among Resident 69's medication. Licensed Nurse B confirmed the unsampled resident's medication was not removed from the cart after discharge from the facility over the weekend. - Resident 25's packet of Tamsulosin hydrochloride (medication used for urinary retention) 0.4 mg capsules was stored among Resident 69's medication. - Resident 27's packet for Metformin (medication used to treat diabetes) 500 mg tablet was among Resident 46's medication. - Resident 10's packet of Pantoprazole (medication used to treat acid reflux) 40 mg tablets was found among Resident 53's medication. Licensed Nurse B confirmed the medications were not in their proper compartments and could not give an explanation but thought the evening nurse returned the medication in the wrong places. A review of the facility's policy titled Discontinued Medications indicated, When medications are discontinued by prescriber order, a resident is transferred or discharged and does not take the medications with him/her .the medications are marked as discontinued and destroyed or returned to the issuing pharmacy .If a prescriber discontinues a medication, the medication container is removed from the medication cart according to state/federal regulations in a timely manner. 2. During an observation and concurrent interviews with Licensed Nurse E and the Regional Nurse Resource on 9/25/24 at 2:44 PM, there were two thermometers measuring the ambient (room) temperature of the medication storage room. One thermometer was located on top of the automated drug delivery system (ADDS) and read 81 degrees F. A review of the monthly temperature log indicated the ambient temperature range should be between 68 to 77 degrees Fahrenheit. Upon realizing the temperature was above the expected controlled room temperature, Licensed Nurse E instructed another staff to call the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 12 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Regional Nurse Resource who was immediately available and came to the medication room. The Regional Nurse Resource confirmed the second thermometer which was positioned higher on the wall opposite the ADDS also read 81 degrees Fahrenheit. A review of the facility's undated document, titled Amendments to the facility policy and procedure for the operations . indicated, Controlled room temperature will be defined by United States Pharmacopeia (USP) standards as .60 degrees to 77 degrees Fahrenheit Event ID: Facility ID: 555703 If continuation sheet Page 13 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview and record review, the facility failed to ensure the following: 1. The Certified Dietary Manager (CDM) ensured kitchen staff were competent in their job specific duties; and, 2. The Registered Dietitian (RD) did not have adequate oversight of the kitchen functions. These failures decreased the facility's potential to provide safe food handling and santiation for 76 residents who received preared food from the kitchen. Findings: A review of the facility document titled Diet Order Tally Report dated 9/23/24 showed 76 residents received food prepared in the kitchen. 1. During the CMS recertification survey from 9/23/24 to 9/27/24, [NAME] F did not adhere to the following required job duties: -Appropriate hand hygiene, -Monitoring the cool down process for TCS (time temperature control for safety food), food that need to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, -Adhering to the facility thawing guidelines, -Prevention of the potential for cross contamination while preparing food, -Proper storage of cleaning cloths in a sanitizing solution between uses, -Donning of an appropriate hair restraint, and -Following the facility recipes. Cross reference to F812, examples #1, #2, #3, 4, #5, #6, F803, F802. On 9/26/24 at 9:23 AM an interview was conducted with the CDM. The CDM was asked how she ensured new employees were competent in job specific duties. The CDM stated new employees went through general orientation and competency checklists were filed in the employee's personnel file. When asked how new employees were trained, the CDM stated the new employee shadowed another employee. The CDM further stated the new employee decided when they felt ready to work alone with her approval. The CDM confirmed job specific competency evaluation was not currently implemented. Review of the facility document titled Employee Orientation Checklist dated 8/16/24 for [NAME] F showed storage of personal items, hand washing and gloves use, use of recipes, and taking and recording temperature for trayline were reviewed with [NAME] F; however, the [NAME] F's competency was not evaluated and documented on the orientation checklist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 14 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility document titled Job Description: Dietary Supervisor signed and dated 11/13/23 by the CDM showed, Essential Duties included directs and supervises all dietary functions and personnel, hires, orients, trains, disciplines, and when appropriate, terminated dietary employees. 2. During the CMS recertification survey from 9/23/24 to 9/27/24, multiple issues were observed in the kitchen including: - Proper handwashing was not followed, -The cool down process for time, temperature control for safety (TCS) food, food that need to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored, -The facility thawing process was not followed, -The potential for cross contamination was not prevented, -Cleaning cloths were not stored in a sanitizing solution between uses, - Hair restraints were not utilized, -Food storage guidelines were not followed, -Food preparation equipment and utensils were not clean and in good working order, -Kitchen cleaning equipment was not stored properly, -Kitchen equipment and environment were not clean, - Ice packs intended for resident personal use were stored with food in the freezer section of the resident nourishment refrigerator, -A medication temperature log was used to monitor the temperature of the resident food refrigerator, - The posted time for sanitizing dishes during manual dishwashing was incorrect, -Recipes were not followed, -Trash was not stored appropriately, and -The Ice machine was not clean and manufacturer guidelines were not followed. Cross reference to F812, examples #1, #2, #3, #4, #5, #6, #7, #8, 9, #10, #11, #12, F803, F814, F908. On 9/26/24 at 10:11 AM, an interview was conducted with the RD. The RD was asked about her role in the kitchen. The RD stated she conducted a monthly sanitation audit. The RD provided a copy of the sanitation audit used to evaluate the kitchen. The RD stated the sanitation audit was obtained from the previous company that owned the facility. The sanitation audit was reviewed with the RD. A review of the facility sanitation audits did not address the following areas of concern: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 15 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0801 -Appropriate hand washing performed, Level of Harm - Minimal harm or potential for actual harm -The cool down process for TCS foods was monitored, -The facility thawing process was followed, Residents Affected - Some -Cross contamination was prevented, -Cleaning cloths were stored in a sanitizing solution between uses, -Cleanliness of food preparation equipment and utensils, -Proper storage of kitchen cleaning equipment , - The resident nourishment refrigerator including temperature monitoring log were monitored, - The posted manual ware washing sanitizer submersion time did not reflect the same submersion time of the sanitizing solution used by the facility, -Monitoring of Recipes being followed, -Trash stored appropriately, and -The internal components of the ice machine were inspected and the manufacturer guidelines were followed. The RD confirmed the sanitation audit being used was not complete and should be more thorough. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 16 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to: 1. Follow the recipe for Pacific Rim Pork Roast and Carrots with Parsley and Residents Affected - Some 2. Ensure the resident meals were flavorful, appetizing, and cooked meat was tender for 76 residents who were served food from the kitchen. This deficiency decreased the facility's potential to serve palatable food and could lead to unintended weight loss due to reduced oral intake. Findings: 1. A review of a facility document titled Diet Order Tally Report dated 9/25/24 indicated: 7 residents received a dysphagia mechanical diet, 12 residents received a mechanical soft diet, 5 residents received a puree diet, and 52 residents received a regular diet. In a concurrent observation and interview on 9/24/24 at 11:19 a.m. with the [NAME] F and the Registered Dietician (RD), the [NAME] F stated was going to prepare five servings of pureed Pacific Rim Pork Roast. The [NAME] F was observed to do the following: -Added two pieces of cooked pork roast (one weighed 5 ounces (oz, a measure of weight) and the second weighed 6 oz for a total of 11 oz) into a blender. -Added two cups of water to the blender and blended the mixture. The blended mixture of meat and water appeared very watery. -Added an unmeasured amount of instant mashed potatoes to the blender and blended the mixture again. The blended mixture was observed to be chunky, but the [NAME] F stated the blended mixture was smooth enough. The RD stated the blended mixture was too chunky for pureed meat. The [NAME] F tasted the meat and agreed it was too chunky. The [NAME] F then blended the mixture again until it was a smooth texture. A review of the facility spreadsheet titled Fall Menus dated 9/24/24, indicated a regular serving of Pacific Rim Pork Roast was 3 oz. The spreadsheet also indicated only 5 residents were on a pureed diet. A review of the facility document titled Recipe: Pureed Meats dated 2024 indicated the recipe for 6 servings (at 3 oz each) should have yielded a total of 18 oz. Further review of the recipe for pureed meats indicated the following instructions: 1. Complete the regular recipe. Measure out the total number of portions. 2. Puree on low speed to a paste consistency before adding any liquid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 17 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Gradually add warm liquid (low sodium broth or gravy). The recipe recommendation for the liquid for 6 servings was 6 oz. to 12 oz (3/4 to 1 and ½ cup), starting with the smaller amount and adding more as needed to achieve the desired consistency. 4. Add stabilizer to increase the density of the pureed food if needed. The recipe recommendation for the stabilizer is 0-6 tablespoons of instant potato . 5. The finished pureed item should be smooth and free of lumps . 6. Equally divide out the finished pureed item back into the number of portions that you started with. Example: 6 servings into blender, 6 servings out. During a concurrent observation of tray line and interview on 9/24/24 at 11:19 a.m., the [NAME] F stated she prepared the carrots with parsley by cooking the carrots in the oven with margarine and water. The [NAME] F stated she did not add salt because she was not allowed to add salt to residents' food. A review of a facility document titled Recipe: Carrots and Parsley dated 2024 indicated for 72 servings the recipe called for 1.5 cup of margarine, 1 tablespoon salt, ½ cup of parsley flakes. The carrots were to be boiled or steamed until tender. Then the margarine was to be poured over the carrots, add salt, and sprinkle with parsley. A review of the facility spreadsheet titled Fall Menus dated 9/24/24, indicated a regular serving of cooked carrots was ½ cup. The spreadsheet also indicated only 5 residents were on a pureed diet. In a concurrent observation of tray line on 9/24/24 at approximately 11:20 a.m., the [NAME] F stated she was going to prepare 12 servings of pureed carrots. The [NAME] F was observed to do the following: -An unmeasured amount of pre-cooked carrots was placed in the blender and blended. -Added ½ cup of milk and blended the mixture until it was a smooth consistency. In an interview on 9/26/24 at 10:11 a.m. the RD stated cooks were instructed to follow the recipes. The RD confirmed the cooked carrot recipe indicated to add salt and [NAME] F should have added salt. A record review of the facility's policy titled Menu Planning, undated, indicated, Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. 2. In an interview on 9/23/24 at 11:30 a.m., Resident 5 stated the meat was tough and lacked flavor. In an interview on 9/24/24 between 9:38 a.m. and 12:58 p.m., Resident 65 stated the facility food lacked flavor. Resident 14 stated the food had no flavor and looked like vomit. Resident 18 stated the cooked meat was tough. Resident 61 stated the eggs were like rubber. On 9/24/24 at 1:15 p.m. a test tray was audited with the Certified Dietary Manager (CDM) and RD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 18 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete The carrots with parsley tasted watery and lacked flavor. The Pacific Rim Pork Roast was difficult to cut using a plastic knife and was tough to chew. The findings were confirmed by the CDM and RD. During a resident council meeting on 9/25/24 at 10:55 a.m., Resident 53 stated the food was bland. Resident 70 complained the meat was undercooked. Resident 230 complained the meat was not tender and the food was not seasoned well. Event ID: Facility ID: 555703 If continuation sheet Page 19 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation and interview, the facility failed to ensure resident food preferences were honored for one resident (Resident 4) of 18 sampled residents when Resident 4 disliked pasta but was served pasta for lunch. This failure decreased the facility's potential to honor residents' preferences. Findings: On 9/23/24 at 12:34 P.M. a lunch meal observation was conducted with Resident 4. Resident 4's lunch meal tray was delivered by Unlicensed Staff J. Resident 4's lunch meal consisted of spaghetti with meat sauce, spinach, dinner roll and ice cream. Unlicensed Staff J confirmed Resident 4 did not like pasta. The Certified Dietary Manager (CDM) was notified and Resident 4's meal tray was removed. The CDM delivered another lunch meal tray with rice instead of pasta. On 9/26/24 at 9:23 A.M., an interview was conducted with the CDM. The CDM was asked who was responsible to ensure resident food preferences were followed. The CDM stated the diet aide was responsible to call out the diet order and check the accuracy of the meal tray according to the meal ticket. The CDM also stated nurses should also check meal trays for diet accuracy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 20 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to ensure food safety and sanitation guidelines were followed when: Residents Affected - Many 1. Proper handwashing was not followed in the kitchen; 2. The proper cool down process of food and Temperature Control for Safety (TCS) process were not monitored; 3. The facility's thawing process for food was not followed; 4. The potential for cross contamination was not prevented; 5. Cleaning cloths were not placed in sanitizing solution between use; 6. Hair restraints were not utilized; 7. Food storage guidelines were not followed; 8. Food preparation equipment and utensils were not clean and kept in good working order; 9. Kitchen cleaning equipment was not stored properly; 10. Kitchen equipment and the environment were not clean; 11. Ice packs intended for resident personal use were stored with food in the resident nourishment refrigerator and a medication temperature log was used to monitor the temperature of the resident nourishment refrigerator; and, 12. The posted time for immersion of dishes in a sanitizing solution during manual dishwashing was inconsistent with the manufacturer's immersion time listed on the instruction label of the sanitizer label or the immersion time specified in the facility's policy and procedure. These failures increased the risk for food borne illness for 76 residents who consumed food prepared in the facility's kitchen. Findings: A review of the facility document titled Diet Order Tally Report dated 9/23/24 indicated 76 residents received food prepared in the kitchen. 1. During an observation of food preparation on 9/24/24 at 11:05 AM, the [NAME] F removed one glove from her hand, immediately touched the lid of the trash can to discard trash with her ungloved hand, and continued food preparation without washing her hands. The [NAME] F was also observed to wipe sweat off her face more than twice with her bare hand without washing her hands and continued with food preparation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 21 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0812 Level of Harm - Minimal harm or potential for actual harm During an interview 9/26/24 at 10:11 AM, the Registered Dietician (RD) stated the [NAME] F should have washed her hands after touching the trash and after touching her face. 2. During the initial tour of the kitchen and concurrent interview with the Certified Dietary Manager (CDM) on 9/23/24 at 9:10 AM, the following were observed in the reach-in refrigerator: Residents Affected - Many -cooked sausage patties in a plastic container with a temperature of 63 degrees Fahrenheit (F), dated 9/23/24; -cooked ham in a plastic container, dated 9/22/24; and, -cooked rice in a plastic container, dated 9/22/24. The CDM stated the sausage patties were left over from breakfast and would be used the following day. The CDM confirmed the ham and the rice were cooked on 9/22/24. A record review of a document titled, Cool Down Log, and dated September 2024 did not have a record of any food items monitored for the cool down process. During an interview on 9/25/24 at 9:52 AM, the [NAME] F stated the cool down process she usually did was to put the leftover food in an ice bath and wait for the temperature of the food to reach 40 degrees F. The [NAME] F confirmed she did not document the cool down process on the cool down log for the leftover food items. During an interview on 9/26/24 at 10:11 AM, the RD stated leftover cooked foods should be cooled to the appropriate temperature and monitored on the cooling log. A review of the facility's policy and procedure titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, indicated the cook should note the menu item, date, time, temperature, and cook's initials on the Cool Down Log. The policy further indicated the CDM, will visually monitor the food service employees and review and sign all logs prior to filing. During a concurrent observation and interview on 9/25/25 at 9:45 AM, the [NAME] F confirmed there was not a cooling log present for ambient (room temperature) items such as tuna salad and egg salad. During an interview on 9/26/24 at 9:23 AM, the CDM confirmed she had not added or conducted an in-service (training) on the ambient cool down log. During an interview on 9/26/24 at 10:11 AM, the RD confirmed the cool down process for ambient temperature foods was not monitored and documented on the cool down log. A record review of a document titled, Good for Your Health Menus, dated September 2, 2024, through September 29, 2024, included two dinner menus with salads made from ambient temperature foods. A review of the facility's policy and procedure titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Food Safety, dated 2023, indicated, PHF (Potentially Hazardous Food) or TCS (Time/Temperature Control for Safety) food shall be cooled within 4 hours to 41 degrees or less, if prepared from ingredients at ambient temperature, such as reconstituted food and canned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 22 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0812 tuna. Level of Harm - Minimal harm or potential for actual harm 3. During the initial tour of the kitchen and concurrent interview with the CDM on 9/23/24 at 9:10 AM, the following were observed in the reach-in refrigerator: Residents Affected - Many -40 pounds of chicken thighs with a received date of 9/20/24; and, -20 pounds of frozen pork loin, undated. The CDM confirmed the chicken thighs did not reflect a date when they were removed from the freezer. When asked why the 20 pounds of pork loin did not have a date, the CDM asked [NAME] F to clarify. The [NAME] F stated the pork loins were pulled from the freezer today and put in the refrigerator. The [NAME] A further stated the pork loins were not dated because the wrapper had ice on it. A review of the facility's policy and procedure titled, Thawing of Meats, dated 2023, indicated meat can be thawed in a refrigerator of 42 degrees or colder. The policy also indicated staff should, Label defrosting meat with pull and use by date. 4. During an observation on 9/23/24 at 9:10 AM, the [NAME] F had a personal glass of water in the cooking space and a personal pen on a food preparation surface. During an interview on 9/23/24 at 10:11 AM, the CDM confirmed the personal water glass and pen belonged to the [NAME] F and there was no designated space for the employees' personal items or beverages. During an observation on 9/23/24 at 11:33 AM, the [NAME] F was drinking a beverage during food preparation. During an observation on 9/24/24 at 12:05 PM, the [NAME] F was drinking soda during the lunch meal tray service. During an interview on 9/26/24 at 10:11 AM, the RD confirmed there was no designated space in the kitchen for employees' personal items. The RD further stated employees should have put personal items in the employee break room or the refrigerator in the dietary services office. A review of the facility's policy and procedure titled, Employee Personal Items, dated 2023, indicated, Employees bringing in personal items from outside .will not be kept in the kitchen. During an observation and interview on 9/25/24 at 11:54 AM, the [NAME] F was cutting a cooked piece of chicken using the green cutting board. When asked if the green cutting board was for chicken, the [NAME] F stated she was in a rush and did not have time to use the correct cutting board for chicken which was the brown one. During an interview on 9/26/24 at 10:11 AM, the RD confirmed cooked chicken should only be cut on the brown cutting board. A review of the facility's policy and procedure titled, Sanitation, dated 2023, indicated, Separate cutting boards are to be used for preparing meats and vegetables. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 23 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0812 Level of Harm - Minimal harm or potential for actual harm 5. During an observation of the lunch meal food preparation on 9/25/24 at 11:54 AM, the [NAME] F left a soiled cleaning rag on the food preparation counter, not stored in sanitizing solution. During an interview on 9/26/24 at 10:11 AM, the RD confirmed cleaning rags should be stored in the sanitizing solution between uses. Residents Affected - Many According to the USDA Food Code 2022 Section 3-304.14 (B) (1), cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution at a concentration specified under 4-501.114. 6. During an observation on 9/23/24 at 9:07 AM, the Dietary Aid K (DA K) had a full beard which was not covered by a beard net. During an observation of food preparation on 9/24/24 at 11:19 AM, the [NAME] F wore a chef's cap which did not contain her hair. The [NAME] F's hair was loose and fell to the middle of her back. In a concurrent observation and interview, the RD confirmed [NAME] F should have had a hair net on. During an interview on 9/26/24 at 10:11 AM, the CDM confirmed the facility did have hair and beard nets and all kitchen employees were expected to don appropriate hair restraints when they were in the kitchen. A review of the facility's policy and procedure titled, Dress Code, indicated, Hair net for hair, if hair is long (over the ears or longer) and, If applicable, beards and mustaches (any facial hair) must wear beard restraint. 7. During the initial tour of the kitchen and concurrent interview with the CDM on 9/23/24 at 9:10 AM, the following were observed in the reach in refrigerator: -a container of marinara sauce with the use by date of 9/20/24; -a container of pudding with the use by date of 9/19/24; and, -health shakes (supplemental shakes) in a bin undated. The CDM confirmed the above observations. During a continuation of the initial tour and concurrent interview on 9/23/24 with the CDM, the following were observed in the dry storage area: -a box of baking powder with an expiration date of 8/2023; -a large bin of flour that was not sealed, not clean, or dated; -a partially open, cardboard box of black eye peas, with an open date of 1/6/24 and use by date of 6/1/24; -an unlabeled bin of brown rice; -a bin of white rice with a use by date of 6/9/24; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 24 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0812 -a bin of pearled barley with a lid that does not fit tightly; Level of Harm - Minimal harm or potential for actual harm -a dented can of tomato paste on the shelf with canned goods; -a small undated plastic container of thickener with a scoop stored inside the container. Residents Affected - Many The CDM confirmed the above observations. A review of the facility's policy and procedure titled, Procedure for Refrigerated Storage, dated 2023, indicated, Supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are place in the refrigerator. A review of the facility's policy and procedure titled, Storage of Food and Supplies, dated 2023, indicated, Dry bulk foods .should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized .scoops should not be left in the containers .bins/containers are to be labeled, covered, and dated. 8. During the initial tour of the kitchen and concurrent interview with the CDM on 9/23/24 at 9:59 AM, the following were observed: -the knife holder was not clean; -the can opener was not clean and the blade was worn; -one small frying pan had thick black residue on the inside and outside which came off when touched, and the non-stick coating had peeled off; -three additional frying pans had thick hard black residue on the inside; -one additional frying pan had a greasy residue on the cooking surface; -two muffin pans had thick black residue on it; -three large baking pans had black residue on it; and, -the shelf storing all the pans was not clean. The CDM confirmed the above observations. During an observation and concurrent interview on 9/24/24 at 11:05 AM, the RD confirmed the green and the brown cutting boards were heavily marred and needed to be replaced. According to the USDA Food Code 2022, Section 4-601.11, Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A) Equipment, food contact surfaces, and utensils shall be clean to sight and touch, (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to USDA Food Code 2022, Section 4-501.11, .Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 25 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0812 container is opened. Level of Harm - Minimal harm or potential for actual harm 9. During the initial kitchen tour with the CDM on 9/23/24 at 10:30 AM, the following were observed: -the chemical storage closet with no space to store mops or brooms; Residents Affected - Many -a mop bucket with a dirty wet mop inside the bucket, stored on the pavement outside the kitchen door; and, -one squeegee and one broom stored on the ground outside the kitchen door. The CDM confirmed the above observations. During an observation on 9/25/24 at 10:24 AM, a broom and mop were stored outside the kitchen lying on the ground. During an interview on 9/26/24 at 2:25 PM, the CDM and the RD agreed it was not acceptable to store the brooms and mops outside. According to the USDA Food Code 2022 Section 6-501.113, .Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be (B)Stored in an orderly manner that facilitates cleaning the area used for storing the maintenance tools. 10. During an observation and concurrent interview with the CDM on 9/23/24 at 10:11 AM, the wall adjacent to the food preparation sink was not clean, the paint was peeling, and a small hanging rack with measuring cups and thermometers was hung on the dirty wall. The CDM confirmed the wall was not clean and the paint was peeling. The CDM stated clean items should have been stored in a clean area. During an observation and concurrent interview with the CDM on 9/23/24 at 10:15 AM, three ceiling vents and the ceiling were not clean. The CDM confirmed the vents and ceiling were not clean. During an observation and concurrent interview with the RD on 9/24/24 at 9:20 AM, the plate warmer had visible debris on the interior of the warmer at the bottom of the metal enclosure. The RD stated the Maintenance Supervisor (MS) was been responsible for cleaning the plate warmer. During an interview on 9/25/24 at 9:35 AM, the MS stated he cleaned the kitchen and vents, but he did not clean the plate warmer. The MS also stated he tried to clean the vents every month, but it was only him and he had asked for assistance. The MS further stated he had not known it was his duty to clean the plate warmer. During an interview on 9/26/24 at 9:23 AM, the CDM stated cleaning duties were built into the job duties of the kitchen staff. CDM further stated there had not been a check list to determine if cleaning tasks had been completed. A review of the facility's policy and procedure titled Walls, Ceilings, and Light Fixtures, indicated, Walls and ceilings must be free of chipped and or peeling pain and walls and ceilings must be washed thoroughly at least twice a year. Heavily soiled surfaces must be cleaned more frequently, as necessary. It is important to repair peeling paint areas as soon as they appear. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 26 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the facility's policy and procedure titled, Sanitation, dated 2023, indicated, The Maintenance Department will assist Food and Nutrition Services as necessary in maintaining equipment and the FNS Director [CDM is the title in this facility] will write the cleaning schedule in which they designate by job title and/or employee who is to do the cleaning task. 11. During an observation of the resident nourishment refrigerator with the CDM on 9/23/24 at 11:35 AM, personal care ice packs were stored in the freezer compartment adjacent to resident food items. A log titled, Medication Refrigerator Log was posted on the outside of the refrigerator. The CDM removed the ice packs from the freezer section of the refrigerator. During an interview on 9/23/24 at 11:42 AM, the Licensed Nurse M (LN M) confirmed he was responsible for checking the temperature in the resident nourishment refrigerator and recording the temperature on the log posted on the refrigerator door. The LN M confirmed the medication refrigerator log indicated temperatures must be at or below 46 degrees F but agreed the refrigerated food items must be at or below 41 degrees F. The LN M also stated it was not acceptable for personal care ice packs to be stored with resident food. A review of the facility's policy and procedure titled, Procedure for Refrigerated Storage, indicated the refrigerator temperature should be at 41 degrees F or less. 12. During an observation and concurrent interview with the CDM and the DA K on 9/24/24 at 9:35 AM, a poster above the manual dish ware sink indicated, Sanitize using hot water: dishes must be immersed in hot water for 45 seconds. The CDM and DA K both stated they had not known how long dishes needed to be immersed in the sanitizing solution during manual washing. A review of the facility's policy and procedure titled, 3-Compartment Procedure for Manual Dishwashing, indicated, The third compartment is for sanitizing .immerse all washed items for 1 minute. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 27 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on interview and review, the facility failed to ensure facility staff and resident visitors were educated on safe food handing practices and food brought to the facility from the outside for resident consumption had the option to be heated. These failures had the potential for unsafe food handling which could lead to food borne illness and resident preferences not honored regarding food temperature for 76 residents who resided in the facility. Residents Affected - Some Findings: On 9/25/24 at 3:31 PM an interview was conducted with Licensed Nurse L (LN L). The LN L was asked to describe the process when visitors brought food from the outside for residents. The LN L confirmed outside food was never heated and if food was removed from the refrigerator, it must be discarded. When asked if she had been trained on safe food handling LN L stated the Director of Staff Development (DSD) was responsible for training. On 9/25/24 at 3:37 PM an interview was conducted with the Director of Nursing (DON). The DON confirmed food from outside could not be heated. When asked if facility staff and visitors were educated on safe food handling practices, the DON was unable to answer. On 9/25/24 at 4:00 PM an interview was conducted with the DSD. The DSD stated she had worked for the facility for approximately two months. The DSD stated she had not given in-service training on safe food handling to facility staff. The DSD stated she would check the in-service records of the previous DSD for any training on safe food handling. Review of the facility policy titled Personal Food Storage updated 3/28/24 indicated, Individuals will be educated in safe food handling and storage techniques by designated facility staff as needed. Staff will examine food for quality (visual, smell, packaging) to identify potential concerns .Staff will provide information on safe food storage and handling as deemed appropriate .All food warm/cold must be eaten in one sitting, or the patient's family may take the leftovers home. The facility will not store any food that needs to be reheated .Facility will not heat any outside food. Review of the facility document titled Food Safety for Your Loved One undated indicated, .raw eggs or dishes made with raw eggs for consumption (i.e. eggnog, poached eggs) are not permitted. There was no safe food handling information was included. Review of the facility document titled Inservice Attendance Record Sign in Sheet titled Storing Food in the Refrigerator dated 7/9/24 did not include an instructor title or signature, a summary of the material covered, a lesson plan to show the information reviewed or any way employees' competency was measured such as test. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 28 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain a sanitary storage area when one dumpster was overflowing with trash and its lid was unable to be closed, and the immediate area was strewn with trash and dirty resident equipment. This failure increased the potential to harbor and breed pathogens (organisms causing disease) and attract pests (insects and rodents). Residents Affected - Some Findings: During a concurrent observation and interview with the Maintenance Supervisor (MS) on 9/23/24 at 10:37 AM, the following were observed in the outside trash storage area: - empty cardboard boxes on the ground, - two mop buckets stored on the ground with dirty mops inside the buckets, - a broom, a squeegee, and an electric floor cleaner stored on the ground, - an overturned milk crate with an uncoiled hose underneath it on the ground, - debris, litter, plastic bags, and a wash rag on the ground, - a paint roller in a plastic bag on the ground, - an empty chemical container on the ground, - two bedframes, three wheelchairs, three commodes, one mattress, and other unidentified resident equipment piled up on the pavement, - an uncoiled hose laying on the dirt, - a pile of supplies on the ground covered by a tarp with dirty rags, a bolster, an uncoiled extension cord, and a rug on top, - a ladder stored leaning against the facility roof, - a caution sign laying on it's side on the ground, - three large bins of laundry filled to the brim with plastic bags of dirty laundry, and - one of four dumpsters had trash overflowing which caused the lid to be propped open and unable to close. The MS confirmed the dirty linen bins were very full and stated they had been picked up every night for cleaning at the sister facility. The MS confirmed the dumpster lid was not closed and the dumpsters were emptied three times per week. The MS confirmed the trash area was not clean and there were items stored on the ground. The MS further stated the resident equipment was piled up outside waiting to be cleaned. The equipment was cleaned every Thursday and stored in a shed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 29 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation in the kitchen on 9/23/24 at 11:38 AM, used soda cans were stored in an open plastic container on top of a bucket underneath a counter. During an interview on 9/25/24 at 11:28 AM, the Administrator confirmed dirty resident equipment had been kept outside. The Administrator stated the deep cleaning schedule was every Thursday, but maybe they needed to do it more often. The Administrator reviewed pictures taken of the trash area and confirmed it was not acceptable to have all that stuff out there. According to the USDA Food Code 2022, Section 5-501.110 Storing Refuse, Recyclables, and Returnables, Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. According to the USDA Food Code 2022, Section 5-501.113 Covering Receptacles, Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the food establishment. According to the USDA Food Code 2022, Section 6-501.114 Maintaining Premises, Unnecessary Items and Litter, The premises shall be free of: (B) Litter. According to the USDA Food Code 2022, Section 5-501.115 Maintaining Refuse Areas and Enclosures, A storage area and enclosure for refuse, recyclables, or returnables shall be maintained free of unnecessary items, as specified under § 6-501.114, and clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 30 of 31 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 555703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeway Post Acute 523 Hayes Lane 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and facility document and policy and procedure review, the facility failed to ensure essential equipment was maintained in proper working order when the ice machine was not clean and the manufacturer's guidelines were not followed. This failure had the potential for equipment to not function the way it was intended. Residents Affected - Some Findings: On 9/23/24 at 11:04 AM, an observation of the facility ice machine located in the kitchen dry storeroom and concurrent interview was conducted with the Maintenance Supervisor (MS). The MS stated he cleaned the ice machine monthly and that the ice machine was last cleaned on 8/13/24. Upon inspection of the internal components of the ice machine, the ice harvester (area ice was produced) curtain, ice sensor and ice harvester had black residue that came off when wiped with a paper towel. The MS confirmed the findings. The MS was asked how he cleaned the ice machine. The MS stated he removed all internal components and cleaned them with a mixture of ice machine cleaner and water. The MS stated he filled up a bucket with half ice machine cleaner and half water. He used the cleaner mixture to wash the internal components then puts the ice machine components in the dish machine three times. The MS stated he cleaned the internal components of the ice machine that cannot be removed with the ice machine cleaner and water mixture. Lastly, the MS stated he put sanitizer undiluted directly in the machine and ran the cycle. When asked about step 3 of the ice machine cleaning instructions, the MS stated he skipped that step because he didn't know the model number of the ice machine. On 9/26/24 at 10:11 AM, an interview was conducted with the RD. The RD was asked how she ensured the cleanliness of the ice machine. The RD stated she wiped the inside of the ice bin to test for the ice machine cleanliness. The RD was asked if she inspected the internal components of the ice machine. The RD stated she was not aware how to inspect the internal components of the ice machine. Review of the facility policy and procedure titled Ice Machine Cleaning Procedure dated 2023 indicated, .the ice machine needs to be cleaned and sanitized monthly. The internal components are cleaned monthly per the manufacturer's recommendations. Review of the ice machine manufacturer's undated cleaning instructions indicated, Step 3: Press the clean switch. Water will flow through the water dump valve and down the drain. Wait until the water trough refills and the display indicates add solution, then add the proper amount of ice machine cleaner. A chart is included which shows how much ice machine cleaner to use depending on the ice machine model .Remove parts for cleaning . Step 6: Mix a solution of cleaner and lukewarm water .one gallon water to 16 ounces cleaner. Step 7: Use cleaner/water mixture to clean all components .Rinse all components with clean water. Sanitizing Procedure: Step 9: Mix a solution of two ounces sanitizer with three gallons of water. Liberally apply the solution to all surfaces for the removed parts or soak the removed parts in the sanitizer/water solution. Do not rinse parts after sanitizing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555703 If continuation sheet Page 31 of 31