Inspection·January 22, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's orders for one resident (Resident 1) of two sampled residents when licensed nurses did not communicate Resident 1's treatment orders written by a Wound Care Physician Assistant (PA - a licensed medical professional whose duties include ordering labs, medications, and treatments) for a wound on the left heel to the Attending Physician (a physician who is responsible for a patient's care in a hospital or skilled nursing facility) for approval and a signature. Residents Affected - Few This failure decreased the facility's potential to ensure Resident 1's wound care treatments were ordered and carried out. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with relevant diagnoses including: Type 2 Diabetes Mellitus (a disease that occurs when blood sugar is too high) with Diabetic Polyneuropathy (a complication of diabetes that affects nerves that branch out from the spinal cord to the arms, hands, legs, and feet), Unspecified Severe Protein-Calorie Malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), Essential Hypertension (a condition where blood pressure is elevated and there is no clear cause), Chronic Congestive Heart Failure (a long-term condition where the heart cannot pump enough blood throughout the body), and Peripheral Vascular Disease (a condition in which narrowed blood vessels reduce blood flow to the arms and legs). A review of Resident 1's clinical record included the following documents: A Skin and Wound Evaluation, dated 8/14/24, indicated Resident 1 was admitted to the facility with a stage 3 pressure wound (a deep wound that extends through the entire thickness of the skin) on his coccyx (a small bone located at the end of the spine). A Skin and Wound Evaluation, dated 8/15/24, indicated Resident 1 was admitted to the facility with a suspected deep tissue injury (a pressure injury where the underlying tissues are damaged without a visible open wound, often appearing as a purple or maroon discoloration on intact skin) on the left heel. A Progress Note written by the Wound Care PA on 9/11/24 indicated, debridement was performed today on the left heel wound .For the left heel wound add bacitracin [an ointment used to treat skin infections] to the treatment . (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555703 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 01/22/2025 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)