Other·January 18, 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 recertification survey on 1/4/19. The facility was licensed for 54 beds. The census at the time of the survey was 49. The sample size was 14.

F687, 483.25(b)(2)(i)(ii) Foot Care had a scope and severity of "G" and F689, 483.25(d)(1)(2) Accidents/Supervision/Devices had a scope and severity of "G". Two Class "B" Citations were also issued. Representing the California Department of Public Health: 32892, Health Facilities Evaluator Supervisor; 40426, Health Facilities Evaluator Nurse; 39949, Health Facilities Evaluator Nurse and 37959, Health Facilities Evaluator Nurse.

F676 SS=D Activities Daily Living (ADLs)/Mntn Abilities CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii)

F676 01/23/2019 §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: 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: BL8K11 Facility ID: CA070000076 If continuation sheet 1 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide the appropriate treatment and services to carry out the activities of daily living when two of 14 sampled residents ( Residents 147 and 42) who were unable to communicate well in English were not provided communication binder/board (folder with words, symbols or pictures used to facilitate communication for resident who are unable to express needs using the English language or with limited language ability). This failure could potentially limit staff's ability FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 2 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 to understand and address Residents 147 and 42's needs and concerns effectively. Findings: 1. A review of Resident 147's clincal record indicated, he had diagnoses including Alzheimer's disease (a progressive disease destroying memory and other important mental functions), cerebral infarction (a brain injury likely caused by a blood clot interrupting blood flow in the brain), the son was the responsible party. A review of Resident 147's Psychosocial Assessment and Social Work Progress Notes dated 12/11/18 indicated, the language spoken as non-English, the communication care plan dated 12/11/18 indicated, communication problem with one interventions to provide communication board. During the initial encounter on 1/3/19 at 9:25 a.m., Resident 147 was unable to communicate when asked simple questions. She stated, can not understand English very much. During a concurrent observation and interview on 1/3/19 at 10:33 a.m., the certified nursing assistant C (CNA C ) was assisting Resident 147 prepare to attend the activities. CNA C stated, Resident 147 had very limited English and had difficulty understanding the staff so they used sign language to ask her needs. CNA C was unable to find any communication binder at Resident 147's bedside. CNA C stated, it could have been easier and it helped with the care if there was a communication board available. During an interview with a family member on 1/3/19 at 11:08 a.m., the family member stated, the resident had difficulty communicating with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 3 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 staff because she mainly speaks a nonEnglish language, with very limited English. During an interview on 1/4/19 at 9:09 a.m., the licensed vocational nurse A (LVN A) stated, Resident 147 could not understand English well and social service was responsible in providing communication board to help residents with communication difficulty. A review of the facility's undated policy, "Communication", indicated if a language or communication barriers exist between facility staff and residents, arrangements shall be made for interpreters or for the use of other mechanisms to ensure adequate communication between resident and personnel. 2. During an interview on 1/2/19 at 10:12 a.m., with Resident 42's responsible party (RP, designated person who makes decisions on the resident's behalf), he stated Resident 42 speaks a non-English language. The RP stated the staff did not speak Resident 42's non-English language. Staff would call the RP to translate but he and his family were not always available. During an interview on 1/3/19 at 3:34 p.m., CNA E confirmed staff did not speak Resident 42's non-English language and Resident 42 did not have a communication device. During an observation on 1/4/19 3:27 p.m., Resident 42 was communicating with registered nurse F (RN F) in her non-English language. Resident 42 gestured with her hands in an agitated manner, but RN F stated she did not know what Resident 42 wanted. No communication device was used. Review of Resident 42's care plan dated 3/29/18, indicated a problem of alteration in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 4 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 communication evidenced by "problems understanding others". The care plan indicated to "provide cueing devices such as communication boards." A review of the facility's undated policy, "Communication", indicated if language or communication barriers exist between facility staff and residents, arrangements shall be made for interpreters or for the use of other mechanisms to ensure adequate communication between resident and personnel.

F684 SS=D Quality of Care CFR(s): 483.25

F684 01/23/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to provide podiatry services (the medical care and treatment of the human foot) to one of four residents (Resident 32) when Resident 32 who was diabetic with long big toe nails was not seen by a podiatrist. This failure had the potential to affect resident's foot condition which could results to injury and/or complications. Findings: A review of Resident 32's clinical record indicated he had diagnoses including Type 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 5 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 diabetes mellitus (DM, is a disorder in which blood sugar levels are abnormally high because the body does not produce enough insulin to meet its needs), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) without behavior disturbance. Resident 32 has an order for podiatry care consult and follow up treatment as needed dated 11/2/18. During a concurrent interview and record review on 1/4/19 at 10:23 a.m., the social service director (SSD) showed a copy of residents listed for podiatry treatment dated 1/18/18. The SSD stated Resident 32 was a private pay for podiatry service and her family refused to pay the service fee required for the treatment. During a concurrent observation and interview on 1/4/19 at 10:27 a.m. with certified nursing assistants C (CNA C) and CNA D, they validated Resident 32's left and right big toes were long and thick. During an interview with licensed vocational nurse A (LVN A) on 1/4/19 at 10:29 a.m., LVN A assessed Resident 32 and confirmed Resident 32 needed podiatry care and she would call the doctor for podiatry referral and treatment. During an interview on 1/4/19 at 11:23 a.m., the SSD stated she forgot to document the family refused to pay the podiatric service fee in the Social Service Notes. The SSD also stated she failed to submit to the DON and/or the Administrator the authorization request for the facility to pay for the podiatry services and make the necessary follow-ups. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 6 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 A review of the facility's undated policy, "Podiatry Care", indicated facility provides podiatry care services to residents when and as ordered by the attending physician. The Podiatrist evaluates the resident as to necessary regime of podiatry care and write documentation for the nursing staff to consult and carry out; provides preventative care for people with diabetes, poor circulation and various forms of arthritis, routine foot care including removal of corns, ingrown toenails, calluses and warts, recognition of systemic medical conditions which may first manifest themselves within the foot and alleviation of the effects of these disorders such as inflammation or ulceration.

F687 SS=G Foot Care CFR(s): 483.25(b)(2)(i)(ii)

F687 01/10/2019 §483.25(b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to provide podiatry services (the medical care and treatment of the human foot) for one of four residents (Resident 2) when Resident 2 had long, overgrown, thick toenails with calluses (thickened and hardened part of the skin or soft tissue, especially in an area that has been subjected to friction) on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 7 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 both feet and he was not referred for podiatry treatment which resulted in Resident 2 having pain and discomfort. Resident 2's long and overgrown toenails and calluses affected his mobility and ambulation. Findings: A review of Resident 2's face sheet included diagnoses of anxiety disorder (a mental illness in which a person is so anxious that their normal life is affected), atherosclerotic heart disease (condition affecting the arteries characterized by the deposition of plaques of fatty material on their inner walls) and repeated falls. During the initial tour and observation on 1/02/19 at 10:49 a.m., Resident 2 was in his room sitting on his bed and showed his long, thick, curly, overgrown toenails with calluses on both feet. During the concurrent interview, Resident 2 stated he had requested to the admission coordinator/social services director (AC/SSD) about four months ago for podiatry treatment. Resident 2 stated his toenails were excessively long which made him experience foot pain and made him uncomfortable when putting his socks on and during walking. He stated this situation limited his activities and movements. He stated he was willing to pay the required fees because he himself was not able to trim his toenails. Resident 2 stated the nurses and certified nursing assistants (CNAs) were aware of the long toenails, because they would see it during the time they provided care for him. During a follow-up interview on 1/03/19 at 7:33 a.m., Resident 2 stated he wanted to use his shoes every time he would get up to walk, but his toenails' and foot conditions would make walking and wearing shoes very painful and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 8 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 uncomfortable. During an interview on 1/03/19 at 07:54 a.m., LVN B stated she was aware of Resident 2's long toe nails required a podiatry referral so she included Resident 2 on the list of residents that required a podiatry referral and gave it to the social services director on 11/17/18. During the concurrent interview with CNA C, she stated she was the regular CNA assigned for Resident 2 and her charge nurse was aware of Resident 2's long toenails. During a record review of the podiatry list dated 11/17/18 and a concurrent interview on 1/03/19 at 8:34 a.m., the AC/SSD stated she received from LVN B the list of residents for podiatry referral on 11/17/18 and the list included Resident 2. The AC/SSD stated she did not refer Resident 2 for podiatry treatment because she could have missed it. The AC/SSD checked the list of residents that the podiatrist seen and treated on 8/28/18 and 1/2/19. However, Resident 2 was not on the list of residents seen on those two podiatrist visits. A review of the Social Service Update dated 4/13/18, 7/10/18, and 10/5/18 indicated no podiatry services were provided for Resident 2. A review of the facility's undated policy, "Podiatry Care", indicated the Podiatrist evaluates the resident as to necessary regime of podiatry care and write documentation for the nursing staff to consult and carry out; provides preventative care for people with diabetes, poor circulation and various forms of arthritis, routine foot care including removal of corns, ingrown toenails, calluses and warts, recognition of systemic medical conditions which may first manifest themselves within the foot and alleviation of the effects of these disorders such as inflammation or ulceration. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 9 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F689 Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) SS=G ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/16/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to developed and implement hazard to three out of 14 sampled residents (Resident 195, Resident 32 and Resident 17) when: 1. The facility failed to have fall interventions appropriate to resident's cognitive status for one of 14 sampled residents (Resident 195) when Resident 195 had three falls in the facility. This failure resulted in Resident 195's bump on top of her head after the first fall, a right hip fracture (broken bone on right hip) after the second fall, and a bump and small head skin tear after the third fall. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 10 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 2. The facility failed to assessed for fire hazard for Resident 32. This failure had a potential to cause harm to Resident 32. 3. The facility failed to implement care plan related to seizure (abnormal brain activity) for Resident 17. This failure had a potential to cause harm to Resident 17. Findings: 1. Review of Resident 195's clinical record indicated following admitting diagnoses dated 3/2018 including dementia (a decline in mental capacity affecting daily function), hypothyroidism and glaucoma. Review of Resident 195's minimum data set (MDS, an assessment tool), dated 10/18/18 Section C (MDS section that assess for cognition (process acquiring knowledge and understanding) status), indicated Resident 195 scored a 4 which is according to resident assessment instrument manual as "severely impaired". Section G (MDS section that assesses the need for assistance for activities of daily living), indicated Resident 195 needed one person physical assist for toilet use. Review of Resident 195's nurse practitioner (NP) progress notes dated 8/28/18, 9/16/18, 10/17/18 and 11/29/18 indicated Resident 195 had difficulty in walking and was confused. During an interview with the physical therapist (PT) on 1/3/19 at 9:26 a.m., she stated Resident 195 would be able to ambulate with assistance for safety and the PT confirmed Resident 195 needed to be assisted when going to the rest room. 1a. First Fall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 11 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 Review of Resident 195's post fall assessment dated 4/5/18 indicated Resident 195's roommate reported to staff that Resident 195 fell out of the bed to transfer to the wheelchair on 4/3/18. During an interview with the director of nursing (DON) on 1/4/19 at 7:48 a.m., she stated the fall on 4/3/18 resulted in a bump on the left side of Resident 195's head. Review of Resident 195's care plan for falls dated 4/3/18 indicated under interventions included reminding her to call for help when transferring and reminding her to check the wheelchair brake if using it for support. 1b. Second Fall Review of Resident 195's post fall assessment dated 12/6/18 indicated Resident 195 was found sitting on the floor and indicated Resident 195 was trying to go the bathroom and apparently lost her balance and fell. It further indicated that Resident 195 complained of right hip pain after the fall. Review of Resident 195's acute care hospital's history and physical examination dated 12/6/18, indicated that Resident 195 was admitted to the hospital for intertrochanteric (specific type of hip fracture) hip fracture (broken bone of hip). Review of Resident 195's acute care hospital's discharge summary dated 12/12/18, indicated right hip fracture with gamma nail pinning (broken bone of the hip with screws), dementia, hypertension (high blood pressure), hyperlipidemia (high levels of lipids), hyperthyroid (overactive thyroid), anemia (blood disorder), diabetes (high levels of sugar FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 12 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 in blood). During an interview with the DON on 1/4/19 at 7:48 a.m., she stated Resident 195 was forgetful even though facility never failed to remind Resident 195 to call for help for toileting but she never did. A review of Resident 195's care plan for communication dated 6/24/14, indicated Resident 195 had problems understanding others due to not being an English speaker. During an interview with certified nursing assistant D (CNA D) on 1/4/19 at 1:50 p.m., she stated Resident 195 was forgetful and would try to get up to use bathroom without calling for help. Review of Resident 195's care plan for falls dated 12/5/18/ indicated new interventions included visual monitoring every hour and offer toileting after the second fall. During a follow-up interview with the DON on 1/4/19 at 7:48 a.m., she stated that there was no evidence for visual every hour monitoring and offering toileting for Resident 195 available in the record. 1c. Third Fall Review of Resident 195's post fall assessment dated 12/20/18 indicated Resident 195 tried to get up from her bed to go to the bathroom and fell which resulted to a right head bump with a skin tear to right side of her head. A review of the facility's policy, "Safety and Supervision of Residents" revised 12/2007, indicated "The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 13 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. " 2. During the initial tour on 1/2/19 at 9:40 a.m. with licensed vocational nurse A (LVN A), while Resident 32 was lying in bed, there were two animal stuffed toys (toys with outer fabric sewn from a textile and then stuffed with flexible material such as plush toys, stuffed animals, etc.) kept on top of the lighted fluorescent light over Resident 32's head. During the concurrent interview and observation, LVN A immediately removed the stuffed toys and put them on top of Resident 32's side table. Per LVN A, the toys should not be kept "there" because it could fall and hit Resident 32's head, and it was also considered a fire hazard. During an interview on 1/3/19 at 12:59 p.m., the maintenance supervisor (MS) stated staff were aware that stuffed toys should not be kept on top of the overhead light because it could fall on the resident and it was a fire hazard. 3. During an observation on 1/2/19 11:10 a.m. Resident 17 was seen lying in bed with eyes closed and two upper side rails up. Side rails had no padding. During an interview on 1/3/19 at 3:11 p.m., registered nurse F (RN F) confirmed Resident 17 did not have padded side rails on her bed. RN F also stated side rails should be padded based on Resident 17's diagnosis of Epilepsy and according to Resident 17's care plan. Review of Resident 17's clinical records confirmed a diagnosis of Epilepsy. Resident 17's care plan for potential seizures related to her diagnoses of Epilepsy stated that side rails should be padded. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 14 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 Review of the facility's policy dated 12/2007, "Safety and Supervision of Residents", indicated interventions to reduce accident risks and hazards will be implemented.

F758 SS=E Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 01/25/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 15 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that residents were free from unnecessary psychotropic drugs (medications that are capable of affecting the mind, emotions, and behavior) for three of 14 sampled residents (Residents 6, 11 and 44) when: 1. Resident 6's abnormal involuntary movement scale (AIMS) test required for antipsychotic drug (group of drugs that are used to treat serious mental health conditions such as psychosis as well as other emotional and mental conditions) used was not done. There was no physician's progress notes justifying the continued use of the psychotropic medications when the gradual dose reduction (GDR) evaluation recommendation by the pharmacist was declined. 2. Resident 11 had no physician's progress notes indicating the clinical justification of the continued use of the antidepressant medication when the Pharmacist's gradual dose reduction (GDR) evaluation recommendation was declined. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 16 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 3. Resident 44 had no physician's progress notes indicating the clinical justification for the continued use of the antidepressant medication when the Pharmacist's gradual dose reduction (GDR) evaluation recommendation was declined because the previous dose reduction failed. These failures could result in Resident 6, 11 and 44's continued use of unnecessary drugs. Findings: 1. A review of Resident 6's clinical record indicated, he had diagnoses including paranoid schizophrenia (is the most common type of schizophrenia characterized by delusions (is a mistaken belief that is held with strong conviction even in the presence of superior evidence to the contrary), usually accompanied by hallucinations (sensations that appear to be real but are created within the mind) particularly of the auditory (hearing) variety, and perceptual (ability to interpret or become aware of something through the senses) disturbances. Review of Resident 6's physician's order dated 8/16/18 indicated Resident 6 had an order for Haldol (medication for psychosis) 10 mg. (milligrams, unit of measurement) 1 tablet by mouth two times a day related to Schizophrenia manifested by intrusive demanding behavior for demanding cigarettes all the time, delusional thoughts, etc., and Depakote ER (extended release) 500 mg. one tablet by mouth at bedtime related to Schizophrenia manifested by intrusive demanding behavior for demanding cigarettes all the time, delusional thoughts, etc. During a concurrent interview and record review on 1/3/19 at 4:08 p.m. with the director of nursing (DON), she validated the last AIMS (a system used to assess abnormal involuntary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 17 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 movements, such as hand tremors or rhythmic movements of the tongue and jaw, that may result from the long-term administration of psychotropic drugs) test was done on 1/30/17. The DON stated Resident 6's AIMS test should have been done during each quarterly minimum data set (MDS, an assessment tool) because he was on antipsychotics. No AIMS test done when the MDS was done 10/5/18. Review of Resident 6's monthly Psychotropic Drug Evaluation from 9/1/18 to 12/1/18, indicated decreased episodes of delusional thoughts, intrusive demanding behaviors, and calling 911 and reporting the mafia is in the building related to the use of Haldol and Depakote medications for Schizophrenia. Review of Resident 6's Medication Regimen Review (MRR) dated 12/24/18 indicated Pharmacist's recommendation to consider gradual tapering of the Haldol and Depakote medications. The physician signed Resident 6's MRR on 1/3/19 but no documentation by the attending physician to justify the clinical indication for the continued dose of both medications. During a concurrent interview and record review on 1/3/19 at 4:08 p.m. with the DON, she stated the attending physician said he would write his progress notes on the next facility visit. 2. Review of Resident 11's clinical record indicated, he had diagnoses including major depressive disorder (a condition of persistent and intense feelings of sadness for extended periods of time). He had an order for Lexapro (antidepressant) 5 mg. one tablet daily for major depressive disorder manifested by thinking thoughts of death and feeling hopeless dated 8/16/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 18 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 Review of Resident 11's monthly Psychotropic Drug Evaluation of Lexapro from 2/1/18 to 11/30/18, indicated a total of five episodes of depressive behavior manifested by thinking thoughts of death, feeling hopeless. During an interview on 1/04/19 at 9:42 a.m., licensed vocational nurse A (LVN A) and certified nursing assistant C (CNA C) both stated, Resident 11 is usually happy, cooperative and attended activities regularly. During a concurrent interview and record review on 1/4/19 at 3:15 p.m., the DON checked Resident 11's last GDR for Lexapro was in 2016. The MRR dated 9/24/18 indicated, the pharmacist's recommendation GDR for Lexapro. The DON stated, there would be no way to determine if another GDR failed unless another GDR was tried again this time. 3. Review of Resident 44's clinical record he had diagnoses including major depressive disorder. The attending physician had an order for Citalopram Hydrobromide (Celexa, an antidepressant) one tablet by mouth daily for depression manifested by verbalization of sadness dated 12/18/17. Resident 44's MRR dated 4/26/18 indicated, last GDR for Celexa was in 2015. There was no documentation in physician's progress notes regarding the clinical indication for the continued use of Celexa. Review of the facility's April 2007 revised policy, "Tapering Medications and Gradual Dose Reduction", indicated all medications shall be considered for possible tapering. The Attending Physician and staff consider tapering of medications as one approach to finding an optimal dose or determining whether the continued use of a medication is benefiting the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 19 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 resident. If the tapering is considered clinically contraindicated, the continued use should be in accordance with relevant current standards of practice and the physician has documented the clinical rational for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 01/22/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 20 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 Based on observation, interview, and record review the facility failed to properly label drugs and biologicals in one of one medication refrigerator. This failure had the potential for the drug to be administered to another residents. Findings: During a concurrent observation and interview on 1/2/19 at 11:13 a.m., an opened unlabeled multi-use Victoza (drug for the treatment of a chronic condition that affects how the body processes blood sugar) pen was found in the medication refrigerator. Licensed vocational nurse B (LVN B) confirmed, the Victoza pen should be labeled with resident information if removed from the labeled box. During an interview on 1/4/19 at 3:46 p.m. with the director of nursing (DON), she stated, all medications should be labeled and if a medication is removed from a box with multiple medications, the nurse must label the medication with the resident identifier. A review of the facility's policy dated 2007, "Medications and Medication Labels", indicated each medication will be labeled to include resident's name.

F791 SS=D Routine/Emergency Dental Srvcs in NFs CFR(s): 483.55(b)(1)-(5)

F791 01/25/2019 §483.55 Dental Services The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(b) Nursing Facilities. The facility§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 21 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 §483.70(g) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; §483.55(b)(2) Must, if necessary or if requested, assist the resident(i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; §483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; §483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and §483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. This REQUIREMENT is not met as evidenced by: 2. During an interview on 1/2/19 10:12 a.m. with Resident 42's responsible party (RP, designated person who makes decisions on resident's behalf) stated, approximately four to five months ago, Resident 42 had a referral for a dentures but nothing had been done until FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 22 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 today. Review of Resident 42's clinical record showed, a dental treatment recommendation dated 7/24/18 for an immediate denture and surgical removal of erupted tooth. The clinical record did not contain documentation that any followup had been done. During a concurrent interview and record review on 1/3/19 at 3:58 p.m., The SSD stated, the referrals could take 2-3 months and a follow-up calls should be documented in the clinical records. The SSD confirmed she had received Resident 42's treatment recommendations for dentures on 7/24/18 and there was no documentation of follow-up. A review of the facility's undated policy, "Dental Care", indicated "Social services shall assist the resident in obtaining access to appropriate dental services." In addition, social services shall document all interventions to assist the resident with dental care. Based on observation, interview, and record review, the facility failed to follow up the dental appointment recommended by the dentist for two of 14 sampled residents (Residents 2 and 42). This delay in dental care had resulted to pain and discomfort in resident's mouth and gums. Findings: 1. During a concurrent observation and interview on 1/2/19 at 10:56 a.m., Resident 2 was noted to have several missing upper and lower front teeth and the remaining teeth was observed embedded in the gums. Resident 2 stated he was very concerned about his dental health and had been waiting to see the dentist. Resident 2 stated his mouth and gums were hurting and had used his gums in chewing his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 23 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 food. Review of Resident 2's clinical record indicated, the dental notes dated 12/3/18 included the treatment and recommendation for "ASAP FMX / Tx plan /SRP's" (ASAP, as soon as possible; FMX, Full mouth series is a complete set of intraoral X-rays taken of a patients' teeth and adjacent hard tissue; Tx, treatment; SRP, Scaling and root planing is a deep cleaning below the gumline used to treat gum disease). There was no documentation that these recommendations were followed-up. During a concurrent interview and record review on 1/4/19 at 11:22 a.m. with the social service director (SSD), she confirmed the findings and stated she would call the dentist to schedule a dental follow-up regarding the above recommendations. During an interview on 1/4/19 at 12:49 p.m., the licensed vocational nurse B (LVN B) stated, if the dental recommendation indicated "ASAP", then it needed to be addressed right away.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 01/16/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 24 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 25 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure infection control procedures were followed when one of two glucometers was not properly disinfected. This failure had the potential to place residents and staff at risk for the spread of infectious diseases. Findings: During an observation on 1/2/19 at 3:26 p.m., licensed vocational nurse B (LVN B) obtained Resident 17's blood sugar reading with the use of a glucometer machine (a medical device used to determine amount of sugar in the blood). LVN B wiped the glucometer with a sanitizing cloth then immediately wiped the glucometer with tissue paper. LVN B then returned the glucometer to the medication cart. During an interview on 1/2/19 at 3:30 p.m., LVN B confirmed she did not follow the manufacturer's instruction for disinfection which stated to allow the treated surface to remain wet for two full minutes. Review of the facility's undated policy, "Cleaning of Non-Critical Patient Devices". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 26 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (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 indicated glucometer machines must be cleaned and disinfected after each use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 27 of 28 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: _______________ 555799 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE RIDGE POST-ACUTE 1355 Clayton Rd San Jose, CA 95127 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F912 Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) SS=B ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/04/2019 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the resident rooms (Rooms 101-107, 109, 110, 114-118, 120, and 121) measured at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive in the facility. Findings: The room measurement indicated multiple resident rooms were less than 80 square feet per resident. Rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 114, 115, 116, 117, 118, 120, and 121 were all 2-bed rooms, which measured 69.51 square feet per resident. None of the rooms were observed to inhibit the staff from providing care or the residents from receiving adequate care. The staff and the residents moved freely in the rooms. Wheelchairs and gerichairs (medical recliners) were easily accommodated. The residents and the staff stated the square footage of the rooms was not a concern. Continuance of the room waiver is recommended. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BL8K11 Facility ID: CA070000076 If continuation sheet 28 of 28