Other·September 21, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of an entity reported incident conducted on 9/14/17. For Entity Reported Incident CA00551471 regarding Quality of Care/Treatment, a federal deficiency was identified (see F323). In addition, a Class "B" Citation was issued. Inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 34432, Heath Facilities Evaluator Nurse.

F323 SS=D FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 09/20/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DT0W11 Facility ID: CA070000042 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555060 (X3) DATE SURVEY COMPLETED 09/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE OF SALINAS 350 Iris Dr Salinas, CA 93906 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (1) who were identified as being at risk for elopement and used exit alarm devices (devices attached to a person or wheelchair setting off an audible alarm when passing through an exit of a building), had adequate supervision to prevent the resident from leaving the facility unattended. On 9/4/17 at approximately 12:30 p.m. Resident 1 left the facility, and was located down the street from the facility. This failure had the potential for further resident elopements and possible injury. Findings: Clinical record review for Resident 1 was initiated on 9/13/17. Resident 1 had diagnoses including schizophrenia (a mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others), muscle weakness and was wheelchair bound. Review of Resident 1's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DT0W11 Facility ID: CA070000042 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555060 (X3) DATE SURVEY COMPLETED 09/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE OF SALINAS 350 Iris Dr Salinas, CA 93906 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (MDS, an assessment tool) dated 8/18/17 indicated she had hallucinations (sensations that appear to be real but are created in the mind) and delusions (a belief that is firmly maintained despite being contradicted by what is generally accepted as reality). Review of Resident 1's Wandering Risk Assessment dated 5/19/17 indicated she was at a moderate risk for wandering to potentially dangerous places (outside the facility). Resident 1's Wandering Risk Assessment dated 9/5/17, the day after her elopement, indicated a moderate risk for wandering. Review of Resident 1's Physician Orders dated 8/11/17 indicated the use of an exit alarm device attached to her wheelchair for risk of elopement. Review of the facility's High Risk to Wander list, kept at the receptionist desk, dated 8/27/17, indicated descriptive information and pictures of ten residents including Resident 1, with the direction to "please keep your eyes out for these residents at all times". Review of Resident 1's Care Plan dated 9/4/17 indicated she had an elopement based on an acute delusion of thinking staff is poisoning her. Review of Resident 1's nurses notes written by licensed vocational nurse A (LN A) dated 9/4/17 at 2:30 p.m., indicated on the same morning, Resident 1 refused her morning medications three times saying the medications were poisoned. At 12:40 p.m., LN A was notified the resident had left the front part of the building and gone down the street to bring the resident back to the facility. Review of Resident 1's Physician's Progress FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DT0W11 Facility ID: CA070000042 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555060 (X3) DATE SURVEY COMPLETED 09/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE OF SALINAS 350 Iris Dr Salinas, CA 93906 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Notes dated 9/4/17 at 12:25 p.m. indicated Resident 1 was physically and verbally abusive, saying staff was trying to poison her, and the resident at the time did not have the capacity to understand and make medical decisions. Review of Resident 1's Interdisciplinary Team (IDT) Progress Notes-Behavior, dated 9/5/17, indicated on return to the facility after the elopement Resident 1 stated she desired to go to the hospital because, "You guys are trying to poison me!" The IDT note indicated Resident 1 was sent to the acute care facility for further evaluation, and on return at 4 p.m., refused to get out of the facility van stating, "You guys are poisoning me." The IDT note indicated Resident 1 eventually required a 911 call with three police officers in attendance before she calmed and agreed to return to the facility and take her evening medications and meal. Review of Resident 1's Psychological Consultation dated 9/5/17 indicated Resident 1 reported a "desire to escape" when questioned about the elopement incident of 9/4/17 and was observed as experiencing significant visual hallucinations (seeing things that are not present) and paranoid delusions (a fixed, false belief that one is being harmed by a particular person or group of people). During an interview with the administrator (ADM) on 9/13/17 at 9:15 a.m., she stated she found Resident 1 on the nearest corner of the intersection one block away from the facility at approximately 12:40 p.m. on 9/4/17. Review of Google Maps (an Internet website) showed Resident 1 was found 0.2 miles walking distance from the facility. During an interview and observation with Resident 1 on 9/13/17 at 9:30 a.m., she stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DT0W11 Facility ID: CA070000042 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555060 (X3) DATE SURVEY COMPLETED 09/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE OF SALINAS 350 Iris Dr Salinas, CA 93906 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she did not remember the day the incident happened. Resident 1 stated, "I am not a prisoner here, I had permission, I pay rent here." During an interview with certified nursing assistant B (CNA B) on 9/13/17, at 9:45 a.m., she stated she worked with Resident 1 frequently and sat with Resident 1 when she went outside, for safety reasons. During an interview with CNA C on 9/13/17 at 10:25 a.m., she stated she worked with Resident 1 frequently and she would never let Resident 1 go outside by herself because she is someone who might want to leave. CNA C stated she and CNA B usually took turns going outside with Resident 1. During an interview with CNA D on 9/13/17 at 10:55 a.m., she stated she was assigned to care for Resident 1 on 9/4/17. CNA D stated Resident 1 had to be supervised when she went outside. During an interview with LN A on 9/13/17 at 10 a.m., she stated Resident 1 refused to take her medications on the morning of 9/4/17, stating they were poison. LN A stated Resident 1 was confused and delusional on the morning of 9/4/17. LN A stated when Resident 1 was delusional and confused she should be supervised when she is outside of the building. LN A stated Resident 1 and she agreed to go outside together after lunch. LN A stated when she finished her lunch she was told the assistant director of nursing (ADON) brought Resident 1 outside and the receptionist in the front lobby was watching her. LN A stated Resident 1 was calm so she thought it was okay if she was being watched by the receptionist. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DT0W11 Facility ID: CA070000042 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555060 (X3) DATE SURVEY COMPLETED 09/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE OF SALINAS 350 Iris Dr Salinas, CA 93906 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the ADON on 9/13/17 at 10:35 a.m., she stated she sat with Resident 1 at the front door sidewalk for five minutes and had to leave to answer a telephone call. The ADON stated she would not let Resident 1 go outside by herself unattended so she left Resident 1 in the care of CNA E who was working in the admissions office near the front of the building, and with receptionist F (REC F). During an interview with the ADON on 9:13/17 at 12:15 p.m., she stated she communicated to REC F to keep an eye on Resident 1. The ADON stated she expected REC F to go outside with Resident 1 and to go after her if she left the area. During an interview with the ADM on 9/13/17 at 9:15 a.m., she stated Resident 1 was at risk to wander, had an exit alarm device, had not taken her medications for her mental illness on the morning of the elopement and should not have been outside without someone watching her. During an interview with the ADM on 9/13/17 at 11 a.m., she stated it would be difficult for CNA D to watch a resident because she was inside an office. During an observation on 9/13/17 at 10:50 a.m., of the front door, the sidewalk, and benches near the front door, and the two windows next to the front door indicated the front door sidewalk was fully visible from the receptionist's desk. During an interview with REC F on 9/13/17 at 1:35 p.m., she stated on 9/4/17 she was the receptionist for the day. REC F stated she was told by the nurse to keep an eye on Resident 1 every five minutes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DT0W11 Facility ID: CA070000042 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555060 (X3) DATE SURVEY COMPLETED 09/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE OF SALINAS 350 Iris Dr Salinas, CA 93906 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with REC G on 9/13/17 at 11:30 a.m., she stated she was careful to observe residents who had exit alarm devices or who were on the "High Risk to Wander" list kept at the receptionist's desk. REC G stated a receptionist would know to watch Resident 1 because she had an exit alarm device and was on the above list. Review of the facility's job description for "Receptionist" indicated responsibilities include greeting visitors, answering telephones, and assisting with general administrative support functions of the facility. The job description does not include supervision or observation of residents. Review of the facility's 2012 policy, "Wanderguard, Code Alert etc. Resident Monitoring System", indicated it was the facility's policy to provide a safe and secure environment to ensure the safety of any resident attempting to elope from the facility. It indicated a determination would be made if a resident needs to be placed on a monitoring device system based on the Elopement Risk Assessment. Review of the facility's 2008 policy, "Elopement Prevention", indicated to provide a safe and secure environment and ensure the safety of any resident attempting to elope from the facility. It indicated residents would have an elopement risk evaluation completed and residents determined to be at risk for elopement would have an exit alarm device placed. It indicated if a resident attempted to leave the facility by unauthorized departure, the nearest staff member should intervene or summon the help of others and redirect the resident to return to the building. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DT0W11 Facility ID: CA070000042 If continuation sheet 7 of 7