Inspection·August 8, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide a comfortable, homelike environment for one of four sampled residents (Anonymous Witness 1) when, after repeated complaints, the facility continued to use a floral-scented air freshener near Anonymous Witness 1's bedroom.This deficient practice resulted in Anonymous Witness 1 experiencing headaches and episodes of throat irritation and had the potential to offend or harm other residents of the facility. Findings:A review of Anonymous Witness 1's admission Record, dated 8/8/25, indicated Anonymous Witness 1 was admitted to the facility on [DATE], with diagnoses including respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body), acute bronchitis (an inflammation of the bronchial tubes, the airways that carry air to your lungs) & pulmonary hypertension (a condition where blood pressure in the pulmonary arteries [vessels carrying blood from the heart to the lungs] is abnormally high).A review or Anonymous Witness 1's Minimum Data Set, Section C (MDS - a standardized, comprehensive evaluation of residents in Medicare and Medicaid certified nursing homes), dated 6/11/25, it indicated Anonymous Witness 1 had a BIMS (Brief Interview for Mental Status- indicates a resident's cognitive (related to a resident's conscious intellectual activity such as reasoning, thinking or remembering) function. The score, ranging from 0 to 15, helps identify potential cognitive impairment and informs care planning) score of 14, indicating no cognitive impairment. During a telephone interview with Anonymous Witness 1 on 8/7/25 at 1:00 pm, Anonymous Witness 1 stated the facility used mechanical air freshener devices about a year prior, and after he complained they were removed. Anonymous Witness 1 stated after the ownership of the facility had changed, the new owner had resumed using air fresheners. Resident 1 described the air freshener scent as a heavy baby powder or clothing detergent smell, which caused Anonymous Witness 1 headaches and throat irritation. Anonymous Witness 1 stated he had complained about this to facility staff, but they had not done anything about it.During an observation on 8/8/25 at 10:35 a.m., a noticeable floral fragrance was noticed in the hallway outside [room [ROOM NUMBER]].During an interview on 8/8/25 at 12:25 p.m. with a facility housekeeper (HK), HK stated she used an air freshener spray in her routine cleaning duties. HK also stated there were several mechanical air freshener devices in the hallways that were maintained by the facility maintenance department. HK stated Anonymous Witness 1 specifically asked her not to use spray air freshener in his bedroom, so she didn't. HK stated she did not know any details about the filler ingredients or chemicals used in the mechanical air freshener devices.During an interview on 8/8/25 at 12:35 p.m. with the Maintenance Assistant ([NAME]), [NAME] stated he started working at the facility a month prior, and he knew nothing about the mechanical air fresheners or what the refills were made of. [NAME] stated that the Maintenance Director knew, but he was out on leave for about a month.During a record review of Anonymous Witness 1's Care Plan Report, printed 8/8/25, it indicated on 6/12/23, the following focus was created, (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 08/08/2025 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)