Health inspection·February 5, 2020

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure necessary treatment and services related to pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) management was implemented for one resident (Resident 23) when Resident 23 remained up in a wheelchair for extended periods of time and her position was not changed at least every two hours. This failure had the potential to worsen Resident 23's pressure ulcer. Residents Affected - Few Findings: A review of Resident 23's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including Stage IV [full thickness of skin and subcutaneous tissue (beneath the skin) is lost and may be covered with dead areas of tissue (eschar/slough)] pressure ulcer, chronic kidney disease (kidneys are damaged and cannot filter blood), dementia (decline in mental capacity affecting daily function), atherosclerosis of aorta (hardening and narrowing of blood vessels diminishing blood flow), and disseminated intravascular coagulation(condition affecting the blood's ability to clot and stop bleeding). During a review of Resident 23's minimum data set (MDS, an assessment tool), dated 12/17/19, the MDS indicated her cognition was severely impaired and she was totally dependent on two persons for bed mobility, transfers, dressing and toileting. During a review of Resident 23's Braden Skin Assessment (an assessment tool for pressure ulcer risk) on 4/3/19, 6/24/19, 9/19/19 and 12/17/19 indicated Resident 23 was at risk for the development of pressure ulcers. During a review of Wound Clinic Physician Orders, dated 8/5/19, for wound #1 Coccyx, the physician order indicated the patient needs to be up in a chair two times daily for one to two hours. During a review of Resident 23's nursing care plan (NCP, an outline of care rendered for the resident based on their needs) for high risk skin breakdown, dated 9/17/19, the care plan indicated to turn and reposition resident at least every two hours and as needed. An additional NCP entry, dated 1/14/19, indicated patient up in wheelchair twice a day for one to two hours. During multiple observations on 2/3/2020 at 8:13 a.m., 9:13 a.m., 9:38 a.m., 10:28 a.m., and 11:09 a.m., Resident 23 was up in her wheelchair with the wheelchair back tilted slightly. No staff members were observed repositioning Resident 23 in her wheelchair and she remained in the slightly tilted back position during the above observations. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 555799 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555799 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Ridge Post Acute 1355 Clayton Road San Jose, CA 95127 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)