Health inspection·January 8, 2026

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat one resident (Resident 1) with respect and dignity when Resident 1's personal motorized wheelchair was taken from her after she had difficulty returning to the facility after an outing to see a movie.This failure caused the resident to lose her independence and subjected her to the discomfort of a facility wheelchair that was not appropriate for her medical conditions.Findings:A review of Resident 1's admission record indicated admission to the facility on [DATE] with relevant diagnoses of Multiple Sclerosis (MS - a disease that causes breakdown of the protective covering of nerves. MS can cause numbness, weakness, trouble walking, vision changes and other symptoms), Contractures of right and left knee (chronic loss of joint mobility caused by structural changes in non-bony tissue, including muscles and tendons), and Kyphosis (an excessive forward rounding of the upper back).A review of Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool which facilities use to screen and identify memory, orientation, and judgement status of the resident) score of 15 indicated Resident 1 had no cognitive impairment (thinking, learning, and memory skills were fully functioning).During an interview on 1/7/26 at 4:16 p.m., Resident 1 stated she was very mobile until two weeks ago. Resident 1 stated the past two weeks had been a particularly rocky time in her life. Resident 1 explained she had gone to a movie using her motorized wheelchair by way of a specialized public transportation service, but the transportation company never arrived to take her back to the facility. Resident 1 stated she called the facility and was instructed to call 911. She was transported to the hospital with the emergency services and then back to the facility the next morning. Resident 1 stated upon her return to the facility the Administrator (ADM) informed her she was grounded.During a concurrent observation and interview on 1/8/26 at 2:48 p.m., Resident 1 was observed sitting in her bed tilted slightly to the side with cushions used to prop her up. Resident 1 stated she had her own motorized wheelchair which came with her to the facility, but she did not know where her wheelchair was. Resident 1 also stated she had asked about the location of her personal wheelchair, and no one would tell her where it was. Resident 1 stated she wanted her personal wheelchair as the facility wheelchair she was given as a replacement was very uncomfortable.During an interview on 1/8/26 at 4:15 p.m., the ADM stated Resident 1's personal motorized wheelchair was in the facility. The ADM acknowledged he told Resident 1 she could not have her motorized wheelchair, and Resident 1 was provided with a manual wheelchair to use instead. The ADM stated Resident 1 left the facility in the evening using her own transport service and was unable to get back to the facility. The ADM was unable to arrange transport back to the facility due to the late hour so Resident 1 was transported to a local hospital via emergency services. Resident 1 returned to the facility the following morning. The ADM stated the Interdisciplinary Team (IDT - a coordinated group of healthcare professionals from different clinical and support disciplines who work together to plan, deliver, and evaluate patient care) met and the Medical Doctor (MD) Page 1 of 2 055850 055850 01/08/2026 Pine Ridge Care Center 45 Professional Center Pkwy San Rafael, CA 94903

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few agreed to revoke Resident 1's ability to leave the facility on a pass. The ADM stated Resident 1 left the facility a second time using her motorized wheelchair and specialized public transportation service and was unable to get back to the facility. Resident 1 called 911, was transported to a local hospital, and returned to the facility the following morning. The ADM stated the only option he had to keep Resident 1 safe had been to deny her access to her motorized wheelchair.During an interview on 1/9/25 at 9:14 a.m., Resident 1 stated the manual wheelchair she had been given by the facility was very uncomfortable because of her MS and scoliosis (a condition where the spine curves abnormally to the side). Resident 1 stated she had been in the manual wheelchair and her arm got stuck behind the wheelchair and it took a long time for staff to help her. Resident 1 also stated she had edema (a collection of fluid) in her legs, and she had been unable to elevate her legs in the manual wheelchair to alleviate the edema.A review of the facility's policy and procedure titled, Resident Rights, undated, indicated The Company protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination. prior to or upon admission, a representative of the admitting office will provide the resident with a written copy of resident rights.A review of a document which was included in Resident 1's admission packet to the facility included an outline of resident's specific rights and indicated, the resident has the right to use and retain personal possessions.unless to do so would infringe upon the rights or health and safety of other residents. 055850 Page 2 of 2