Other·June 10, 2019

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 6/4/19. For Entity Reported Incident CA00639759 regarding Misappropriation of Property / Pharmaceutical Services, federal deficiencies were identified (see F602 and F755). For F755, a Class "B" citation was also 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: 37883, Health Facility Evaluator Supervisor.

F602 SS=D Free from Misappropriation/Exploitation CFR(s): 483.12

F602 06/14/2019 §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This REQUIREMENT is not met as evidenced 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: NIUZ11 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 06/04/2019 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 by: Based on interview and record review, the facility failed to ensure two of two residents (Residents 1 and 2) were free from misappropriation of resident property when narcotic medications belonging to the residents were diverted (the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) by registered nurse 1 (RN 1). This failure had the potential to negatively affect the health and well-being of the residents. Findings: During an interview with the administrator (ADMIN) and the director of nurses (DON) on 6/3/19 at 3:54 p.m., the DON stated RN 1 called her at approximately 8:00 a.m. on 5/30/19 and requested to meet with her. The DON stated during the meeting with the ADMIN and DON, RN 1 "confessed to removing hydrocodone [Norco, a narcotic pain medication / controlled substance] from residents' supply on the night shift." The DON further stated that RN 1 told the ADMIN and DON she had been "consuming" Norco from the supply of the two residents [Resident 1 and 2] for sleep issues related to tooth pain during the months of April and May of 2019. A review of the clinical record for Resident 1 indicated she was admitted to the facility on 10/29/16 with diagnoses including chronic embolism and thrombosis of unspecified deep veins (blood clots in the vein causing swelling, cramping, and pain), anxiety disorder (feelings of uneasiness, worry, and fear), and major depressive disorder (persistent feeling of sadness and loss of interest). Resident 1 had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NIUZ11 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 06/04/2019 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 an order dated 7/18/18 for Norco 10/325 mg (milligram, a unit of dose) every four hours PRN (as needed) for moderate pain. During the month of May 2019, RN 1 documented 6 instances of administering Norco on the night shift to Resident 1. A review of the clinical record for Resident 2 indicated he was admitted to the facility on 1/4/19 with diagnoses including abdominal aortic aneurysm (an enlarged area in the lower part of the aorta, the major blood vessel that supplies blood to the body), basal cell carcinoma (skin cancer), and pressure ulcer of the sacral region (sore caused by sustained pressure near the small of the back). Resident 2 had an order dated 1/27/19 for Norco 5/325 mg every six hours PRN for moderate pain. During the month of May 2019, RN 1 documented 14 instances of administering Norco on the night shift to Resident 2. During a concurrent interview with the DON, she confirmed the documented instances of administering Norco to Residents 1 and 2 and noted above. During a subsequent interview with the ADMIN, she stated she interviewed Resident 1 who told her she did not have pain at night and did not take pain medication at night. The ADMIN further stated she interviewed Resident 2 who told her he did not have pain at night and does not take anything at night. During a subsequent interview with the DON, she stated the local law enforcement agency was notified of the drug diversion per facility policy and the value of the stolen narcotics was approximated at $300. A review of the facility's policy, "Drug Diversion" revised 3/2018, indicated "Potential/confirmed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NIUZ11 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 06/04/2019 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 theft/diversion of controlled substance is reportable to the local law enforcement agency, appropriate licensing board, and state agency."

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 06/14/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NIUZ11 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 06/04/2019 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 facility failed to prevent drug diversion (the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) by registered nurse 1 (RN 1) when narcotic pain medication [Norco] was taken from the pharmaceutical supply of two residents (Residents 1 and 2). This failure had the potential to negatively affect the health and well-being of the residents. Findings: During an interview with the administrator (ADMIN) and the director of nurses (DON) on 6/3/19 at 3:54 p.m., the DON stated RN 1 called her at approximately 8:00 a.m. on 5/30/19 and requested to meet with her. The DON stated during the meeting with the ADMIN and DON, RN 1 "confessed to removing hydrocodone [Norco, a narcotic pain medication / controlled substance] from residents' supply on the night shift." The DON further stated that RN 1 told the ADMIN and DON she had been "consuming" Norco from the supply of the two residents [Resident 1 and 2] for sleep issues related to tooth pain during the months of April and May of 2019. A review of the clinical record for Resident 1 indicated she was admitted to the facility on 10/29/16 with diagnoses including chronic embolism and thrombosis of unspecified deep veins (blood clots in the vein causing swelling, cramping, and pain), anxiety disorder (feelings of uneasiness, worry, and fear), and major depressive disorder (persistent feeling of sadness and loss of interest). Resident 1 had an order dated 7/18/18 for Norco 10/325 mg (milligram, a unit of dose) every four hours PRN (as needed) for moderate pain. During the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NIUZ11 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 06/04/2019 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 month of May 2019, RN 1 documented 6 instances of administering Norco on the night shift to Resident 1. A review of the clinical record for Resident 2 indicated he was admitted to the facility on 1/4/19 with diagnoses including abdominal aortic aneurysm (an enlarged area in the lower part of the aorta, the major blood vessel that supplies blood to the body), basal cell carcinoma (skin cancer), and pressure ulcer of the sacral region (sore caused by sustained pressure near the small of the back). Resident 2 had an order dated 1/27/19 for Norco 5/325 mg every six hours PRN for moderate pain. During the month of May 2019, RN 1 documented 14 instances of administering Norco on the night shift to Resident 2. During a concurrent interview with the DON, she confirmed the documented instances of administering Norco to Residents 1 and 2 and noted above. During a subsequent interview with the ADMIN, she stated she interviewed Resident 1 who told her she did not have pain at night and did not take pain medication at night. The ADMIN further stated she interviewed Resident 2 who told her he did not have pain at night and does not take anything at night. During a subsequent interview with the DON, she stated the local law enforcement agency was notified of the drug diversion per facility policy. A review of the facility's policy, "Drug Diversion" revised 3/2018, indicated "Potential/confirmed theft/diversion of controlled substance is reportable to the local law enforcement agency, appropriate licensing board, and state agency." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NIUZ11 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 06/04/2019 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) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NIUZ11 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA070000042 (X5) COMPLETE DATE If continuation sheet 7 of 7