Health inspection·June 16, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review, the facility failed to ensure one resident (Resident 1) of four samples residents was treated with dignity and respect when Licensed Nurse 1 (LN 1) made a humiliating comment to Resident 1 in front of residents and staff. This failure resulted in Resident 1 feeling embarrassed and humiliated. The findings: A review of Resident 1's admission record indicated admission to the facility in September 2016 with diagnosis which included chronic obstructive pulmonary disease (COPD, a progressive lung disease that makes it difficult to breathe), chronic pain syndrome (persistent pain), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left knee, hoarding disorder (a mental health condition characterized by a person who excessively gathers things) and major depressive disorder (a mental health condition characterized by symptoms like sadness, loss of interest and low energy). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/16/25, indicated Resident 1 had no memory impairment. During an interview on 6/17/25 at 12:07 p.m., Resident 1 stated while she was in the hallway in front of the nurses' station (an area of a health care facility where nurses and other health care staff work behind) and outside of the dining and activities room, LN 1, Stood there and announced- I am not going to give you your medication until you take a shower! Resident 1 stated the comment was made in the presence of other residents and staff members. Resident 1 stated, I don't think I've ever been so god-damned embarrassed. How would you feel if you were in my situation and a ranking nurse said something like that to you in front of everyone. I was humiliated! Resident 1 further stated she did not feel respected. During an interview on 6/16/25 at 12:50 p.m., LN 2 stated, It's important to be sure the resident is protected and to maintain their privacy . It's inappropriate to body shame, or to shame the resident at all . LN 2 confirmed resident care needs should be addressed in private to maintain dignity. During an interview on 6/16/25 at 1:06 p.m., the Assistant Activities Director (AAD) stated a nurse came to her and told her she did not want Resident 1 participating in activities until she [Resident 1] showered. AAD further stated, She (LN 1) brought it up to me a couple of times. She doesn't think the resident should be able to participate if she does not shower. AAD confirmed she heard LN 1 say out loud, You need to take a shower , to Resident 1, while Resident 1 was in the front hallway by Page 1 of 5 555703 555703 06/16/2025 Ridgeway Post Acute 523 Hayes Lane Petaluma, CA 94952

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the dining and activities room. AAD confirmed residents were seated in the area and staff were nearby. AAD stated it was disrespectful to the resident, and further stated, They [residents] all have their rights. They should all be able to participate in activities. Denying the resident of simple needs is not something we should be doing. During an interview on 6/16/25 at 1:20 p.m., the Director of Nursing (DON) stated it is her expectation staff are compassionate and respectful, and further stated, To speak in a manner that is respectful to residents. The DON confirmed it is not acceptable to tell a resident they can not participate in activities until they [resident] showered. The DON stated, If a patient needed to be changed or they smelled, we should ask that patient to walk back to the room to address the issue in private .It's important to maintain privacy. No one wants to be told in front of others that they need to be changed or what needs to be done. The DON confirmed it could be demeaning (causing someone to lose their dignity and the respect of others) to the resident. During an interview on 6/16/25 at 2:02 p.m., the Administrator (ADM) stated, I expect that they [staff] speak to them [residents] in a way that is respectful and compassionate of their situation. The ADM confirmed it is not acceptable to tell a resident they could not participate in activities until they [resident] showered. The ADM further stated, I would not allow it. I think there is a way to help them shower without holding something over their head. The ADM confirmed issues regarding resident's hygienic needs should be addressed in private to maintain the resident's dignity and respect. During a review of a facility's policy and procedure (P&P) titled, Resident Rights, dated 2001 indicated, Employees shall treat all residents with kindness, respect and dignity. During a review of a facility's P&P titled, Dignity, dated 2001 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are encouraged to attend the activities of their choice .Staff speak respectfully to residents at all times .Staff promote, maintain, and protect resident privacy .Demeaning practices and standards of care that compromise dignity are prohibited Staff are expected to promote dignity .

F550 Resident Rights Based on interview and record review, the facility failed to ensure one resident (Resident 1) of four samples residents was treated with dignity and respect when Licensed Nurse 1 (LN 1) made a humiliating comment to Resident 1 in front of residents and staff. This failure resulted in Resident 1 feeling embarrassed and humiliated. The findings: A review of Resident 1's admission record indicated admission to the facility in September 2016 with diagnosis which included chronic obstructive pulmonary disease (COPD, a progressive lung disease that makes it difficult to breathe), chronic pain syndrome (persistent pain), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left knee, hoarding disorder (a mental health condition characterized by a person who excessively gathers things) and major depressive disorder (a mental health condition characterized by symptoms like sadness, loss of interest and low energy). 555703 Page 2 of 5 555703 06/16/2025 Ridgeway Post Acute 523 Hayes Lane Petaluma, CA 94952

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/16/25, indicated Resident 1 had no memory impairment. During an interview on 6/17/25 at 12:07 p.m., Resident 1 stated while she was in the hallway in front of the nurses' station (an area of a health care facility where nurses and other health care staff work behind) and outside of the dining and activities room, LN 1, Stood there and announced- I am not going to give you your medication until you take a shower! Resident 1 stated the comment was made in the presence of other residents and staff members. Resident 1 stated, I don't think I've ever been so god-damned embarrassed. How would you feel if you were in my situation and a ranking nurse said something like that to you in front of everyone. I was humiliated! Resident 1 further stated she did not feel respected. During an interview on 6/16/25 at 12:50 p.m., LN 2 stated, It's important to be sure the resident is protected and to maintain their privacy . It's inappropriate to body shame, or to shame the resident at all . LN 2 confirmed resident care needs should be addressed in private to maintain dignity. During an interview on 6/16/25 at 1:06 p.m., the Assistant Activities Director (AAD) stated a nurse came to her and told her she did not want Resident 1 participating in activities until she [Resident 1] showered. AAD further stated, She (LN 1) brought it up to me a couple of times. She doesn't think the resident should be able to participate if she does not shower. AAD confirmed she heard LN 1 say out loud, You need to take a shower , to Resident 1, while Resident 1 was in the front hallway by the dining and activities room. AAD confirmed residents were seated in the area and staff were nearby. AAD stated it was disrespectful to the resident, and further stated, They [residents] all have their rights. They should all be able to participate in activities. Denying the resident of simple needs is not something we should be doing. During an interview on 6/16/25 at 1:20 p.m., the Director of Nursing (DON) stated it is her expectation staff are compassionate and respectful, and further stated, To speak in a manner that is respectful to residents. The DON confirmed it is not acceptable to tell a resident they can not participate in activities until they [resident] showered. The DON stated, If a patient needed to be changed or they smelled, we should ask that patient to walk back to the room to address the issue in private .It's important to maintain privacy. No one wants to be told in front of others that they need to be changed or what needs to be done. The DON confirmed it could be demeaning (causing someone to lose their dignity and the respect of others) to the resident. During an interview on 6/16/25 at 2:02 p.m., the Administrator (ADM) stated, I expect that they [staff] speak to them [residents] in a way that is respectful and compassionate of their situation. The ADM confirmed it is not acceptable to tell a resident they could not participate in activities until they [resident] showered. The ADM further stated, I would not allow it. I think there is a way to help them shower without holding something over their head. The ADM confirmed issues regarding resident's hygienic needs should be addressed in private to maintain the resident's dignity and respect. During a review of a facility's policy and procedure (P&P) titled, Resident Rights, dated 2001 indicated, Employees shall treat all residents with kindness, respect and dignity. During a review of a facility's P&P titled, Dignity, dated 2001 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are encouraged to attend the activities of their choice .Staff speak respectfully to residents at all times .Staff promote, maintain, 555703 Page 3 of 5 555703 06/16/2025 Ridgeway Post Acute 523 Hayes Lane Petaluma, CA 94952

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and protect resident privacy .Demeaning practices and standards of care that compromise dignity are prohibited Staff are expected to promote dignity . Based on interview and record review, the facility failed to ensure one resident (Resident 1) of four sampled residents was treated with dignity and respect when Licensed Nurse 1 (LN 1) stated to Resident 1, I am not going to give you your medication until you take a shower! in front of residents and staff. This failure resulted in Resident 1 feeling embarrassed and humiliated. Findings: A review of Resident 1's admission record indicated admission to the facility in September 2016 with diagnosis which included hoarding disorder (a mental health condition characterized by a person who excessively gathers things) and major depressive disorder (a mental health condition characterized by symptoms like sadness, loss of interest and low energy). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/16/25, indicated Resident 1 had no memory impairment. During an interview on 6/17/25 at 12:07 p.m., Resident 1 stated while she was in the hallway in front of the nurses' station (an area of a health care facility where nurses and other health care staff work behind) and outside of the dining and activities room, [LN 1] Stood there and announced, 'I am not going to give you your medication until you take a shower!' Resident 1 stated the comment was made in the presence of other residents and staff members. Resident 1 stated, I don't think I've ever been so god-damned embarrassed. How would you feel if you were in my situation and a ranking nurse said something like that to you in front of everyone? I was humiliated! Resident 1 further stated she flet disrespected. During an interview on 6/16/25 at 12:50 p.m., LN 2 stated, It's inappropriate to body shame, or to shame the resident at all . LN 2 confirmed resident care needs should be addressed in private to maintain dignity. During an interview on 6/16/25 at 1:06 p.m., the Assistant Activities Director (AAD) stated LN 1 told her she did not want Resident 1 participating in activities until she [Resident 1] showered. AAD further stated, [LN 1] brought it up to me a couple of times. She doesn't think [Resident 1] should be able to participate if she does not shower. AAD confirmed she heard LN 1 say out loud, You need to take a shower , to Resident 1 while Resident 1 was in the front hallway by the dining and activities room. AAD confirmed residents were seated in the area and staff were nearby and could have overheard. AAD stated it was disrespectful to Resident 1 and further stated, [Residents] all have their rights. They should all be able to participate in activities. Denying the resident of simple needs is not something we should be doing. During an interview on 6/16/25 at 1:20 p.m., the Director of Nursing (DON) stated staff were expected to be compassionate and respectful, and further stated, To speak in a manner that is respectful to residents. The DON confirmed it was unacceptable to tell a resident they could not participate in activities until they [residents] showered. The DON stated, If a patient needed to be changed or they smelled, we should ask that patient to walk back to the room to address the issue in private .It's important to maintain privacy. No one wants to be told in front of others that they need to be 555703 Page 4 of 5 555703 06/16/2025 Ridgeway Post Acute 523 Hayes Lane Petaluma, CA 94952

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few changed or what needs to be done. The DON confirmed it could be demeaning (causing someone to lose their dignity and the respect of others) to the resident. During an interview on 6/16/25 at 2:02 p.m., the Administrator (ADM) stated, I expect that they [staff] speak to them [residents] in a way that is respectful and compassionate of their situation. The ADM confirmed it was unacceptable to tell a resident they could not participate in activities until they [residents] showered. The ADM further stated, I would not allow it. I think there is a way to help them shower without holding something over their head. The ADM confirmed issues regarding resident's hygienic needs should be addressed in private to maintain the resident's dignity and respect. During a review of a facility's policy and procedure (P&P) titled, Resident Rights, dated 2001 indicated, Employees shall treat all residents with kindness, respect and dignity. During a review of a facility's P&P titled, Dignity, dated 2001 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are encouraged to attend the activities of their choice .Staff speak respectfully to residents at all times .Staff promote, maintain, and protect resident privacy .Demeaning practices and standards of care that compromise dignity are prohibited Staff are expected to promote dignity . 555703 Page 5 of 5