Other·May 28, 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 a complaint conducted on 5/23/19. For Complaints CA00635050 and CA00637795 regarding Admission, Transfer and Discharge Rights, a federal deficiency was identified (see

F626). A class "B" citation was also issued for F626. Inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 34432, Health Facilies Evaluator Nurse.

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately 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: 4N4X11 Facility ID: CA070000076 If continuation sheet 1 of 5 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 05/23/2019 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 upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to permit one of five sampled residents (1) to return to the first available bed in the facility after an evaluation was completed in the emergency department (ED) of a general acute care hospital (GACH). In addition, the facility failed to issue a written notice of discharge to Resident 1's responsible party (RP) or to the ombudsman. These failures resulted in Resident 1's unnecessary 24-day stay in an acute care setting and violation of Resident 1's rights. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4N4X11 Facility ID: CA070000076 If continuation sheet 2 of 5 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 05/23/2019 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 clinical record for Resident 1 indicated a diagnosis of unspecified dementia (a disease marked by loss of thinking, memory and reasoning skills) without behavioral disturbance. A review of the minimum data set (MDS, an assessment tool) dated 2/2/19 indicated Resident 1 had a brief interview of mental status (BIMS) score of four (scores of 07 indicated severe mental impairment) and required one-person assistance for hygiene, toileting and dressing. A review of Resident 1's "Nurses Notes" dated 4/21/19 at 8:45 p.m., indicated Resident 1 was transferred via a 911 ambulance to the ED of a GACH for psychiatric evaluation and treatment following an episode of aggressive behavior, the evening of 4/21/19. A review of Resident 1's "Notice of Bedhold" dated 4/21/19, indicated Resident 1 would be permitted to retain her bed in the facility for seven days after transfer to GACH. A review of the facility's census for 4/22/19 indicated a female bed was available for her to be readmitted to the facility. A review of Resident 1's "Physician's Orders" dated 4/22/19 at 9:24 a.m., indicated an order to discharge Resident 1 from the facility for appropriate placement (to another skilled facility) due to being a danger to herself and others. A review of Resident 1's "Social Work Progress Notes" dated 4/22/19, indicated the director of social services (DSS) reported to the GACH's discharge planner Resident 1 would not be accepted back but was discharged from the facility and the GACH should find appropriate placement related to Resident 1 being a danger to herself and to others. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4N4X11 Facility ID: CA070000076 If continuation sheet 3 of 5 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 05/23/2019 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 Resident 1's GACH report: "Inpatient Medicine Discharge Summary" dated 5/15/19 at 10:53 a.m., indicated Resident 1 was admitted to GACH on 4/21/19 and was discharged on 5/15/19. The report indicated Resident 1 did not require GACH admittance for medical or psychiatric issues but only for placement as skilled nursing facility (SNF) refused to accept her back. The report indicated since admitted, Resident 1 was cooperative and pleasant, did not have any behavior issues, took all medications and was compliant with nursing care. During an interview with the director of nursing (DON) on 4/26/19 at 3 p.m., she stated Resident 1 was transported to the ED GACH on 4/21/19 for psychiatric evaluation related to increasing aggressive behavior. The DON stated GACH staff notified the facility Resident 1 was ready to return to the facility, but facility staff informed them they would not be accepting Resident 1 back to the facility. The DON stated they were not planning to readmit Resident 1. However they were waiting for the results of an appeal hearing to be held on 5/1/19 regarding the discharge. A review of the "Refusal to Readmit Appeal" dated 5/1/19 at 1:15 p.m., indicated on 4/23/19, Resident 1's responsible party filed an appeal to assert Resident 1's right to readmission. The appeal indicated the facility must permit a resident to return and resume residence in the facility while an appeal is pending. The appeal indicated in a final decision dated 5/14/19, the facility failed to meet Resident 1's readmission requirements: failed to readmit Resident 1 to her former bed during a bed-hold period; and failed to follow its written policies permitting Resident 1 to return to the first available bed in a semi-private room. The final decision dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4N4X11 Facility ID: CA070000076 If continuation sheet 4 of 5 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 05/23/2019 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 5/14/19, signed by the hearing officer, indicated the facility must immediately offer to readmit Resident 1 to the facility. During an interview with the DON on 5/21/19 at 9:15 a.m., she stated the facility readmitted Resident 1 to the facility on 5/15/19. A review of Resident 1's "Physician Orders" indicated facility admission orders dated 5/15/19. During an observation of Resident 1 on 5/21/19 at 10:20 a.m., Resident 1 was sitting in her wheelchair in the activity room, among other residents; She appeared calm and replied "hello" when greeted. During a phone interview with the DON on 5/22/19 at 2:30 p.m., she stated the facility did not have a policy on discharge and transfer of a resident except for a policy regarding the correct documentation required for a discharge of transfer. The DON stated she was not aware the facility was supposed to readmit a resident while an appeal to readmit is pending. The DON stated the facility did not have a formal notice of discharge form at the time of Resident 1's discharge but the facility created one after the 5/1/19 appeal hearing. The DON stated the facility was informed during the hearing, they needed to issue a notice a discharge for facility initiated discharges. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 4N4X11 Facility ID: CA070000076 If continuation sheet 5 of 5