Inspection·June 3, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 one of three sampled residents (Resident 1) a homelike environment when the window sill and blinds were in need of repair and there was peeling paint on a wall in his room. These failures had the potential to negatively impact Resident 1's comfort and create an environment that was not homelike. Findings: A review of Resident 1's admission record indicated he was admitted in 10/24 with organ-limited amyloidosis (a condition characterized by the presence of proteins lodged in the body's tissues which can affect the entire body and cause a large range of varying symptoms, including appetite loss to bleeding). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/18/25, indicated he had no memory impairment. During a concurrent interview and observation on 6/3/25 at 1:41 p.m. with Resident 1 in his room, the window sill of his room's window had two areas of missing or damaged wood, each approximately 6 inches (in., a unit of measurement) in length. Resident 1 stated staff had damaged it when they had moved beds in and out of the room. Horizontal blinds covering the window were missing approximately 4 in. of each blind strip along the right side of the blind and this occurred down two-thirds of the blind. Resident 1 stated that because the blinds were damaged they let more sun in the room and made it warmer. An area on the room's wall measuring approximately 12 x 12 in. above the television had peeling paint and areas where the peeling paint had been painted over. Resident 1 stated these conditions made him feel like he was, Living in a dump. During a concurrent interview and observation on 6/3/25 at 2:09 p.m. with Certified Nurse Assistant 1 (CNA 1) in Resident 1's room, CNA 1 confirmed the window sill and blinds were damaged and there was peeling paint above the television. CNA 1 agreed they were in need of repair, the room was not homelike and if this were her room she would not have wanted it to look like this. During an interview on 6/3/25 at 2:16 p.m. with the Administrator (ADM), the ADM stated he expected resident rooms were maintained in good repair. The ADM agreed the damaged window sill and blinds, along with the peeling paint in Resident 1's room needed to be addressed by the facility. During a review of the facility's policy titled, Homelike Environment, dated 2001, the policy (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 06/03/2025 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)