Health inspection·January 12, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for four out of fifteen sampled residents (Residents 12, 5, 8 and 31): 1. For Resident 12, there was no comprehensive, person-centered care plan for his side rail or bed rail (bars attached to the side of the bed for safety and mobility aids);2. For Resident 5, she had no bed rail care plan; 3. For Resident 8, staff did not implement a care plan intervention of monitoring oxygen saturation (measurement of how much oxygen is in the blood) every shift. 4. For Resident 31, she had no activity care plan. These failures had the potential to result in the residents, not receiving the intervention and monitoring necessary to maintain their highest level of well-being. Findings: 1.During the initial observation of Resident 12 on 1/6/26 at 12:40 p.m., Resident 12 was laying in his bed. Resident 12 was calm, comfortable, confused and could not answer questions. He had 1/3 left side rail or bed rail up. Review of Resident 12's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) dated 1/8/26 indicated, Resident 12 was readmitted to the facility on [DATE] with the primary diagnosis of catatonic schizophrenia (subtype of schizophrenia characterized by significant disruptions in motor behavior and extreme psychological disturbances). Review of Resident 12's order listing report dated 1/9/26 indicated, Resident 12 had an order to put 1/3 left bed rail up when in bed, to assist resident in bed mobility and/or transfers, last ordered on 1/4/26. Review of Resident 12's care plans indicated, Resident 12 did not have a comprehensive, person-centered care plan for his bed rail. During the concurrent review of Resident 12's care plans and interview with assistant director of nursing/infection preventionist (ADON/IP) on 1/9/26 at 10:20 a.m., ADON/IP acknowledged that Resident 12 had 1/3 left bed rail up when in bed but did not have a comprehensive, person-centered care plan for his 1/3 left bed rail and would have it updated. During the interview with director of nursing (DON) on 1/9/26 at 2:13 p.m., DON verified that the care plan for the bed rail should be comprehensive and person-centered and would follow up on it. Page 1 of 3 555799 555799 01/12/2026 The Ridge Post Acute 1355 Clayton Road San Jose, CA 95127

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of Resident 5's admission record dated 1/8/26 indicated, Resident 5 was admitted to the facility on [DATE] with the primary diagnosis of hemiplegia (paralysis affecting one side of the body, resulting from brain or spinal cord damage), unspecified affecting left dominant side (preference to use this side of the body over the other). Review of Resident 5's order listing report dated 1/9/26 indicated, Resident 5 had an order to put 1/5 bilateral bed rails up when in bed, to assist resident in bed mobility and/or transfers every shift. Resident 5 was discharged to home, 12/23/25 with medications, discharge instructions and home health was set-up. Review of Resident 5's care plans indicated, Resident 5 did not have a comprehensive, person-centered care plan for her bed rails. During the concurrent review of Resident 5's care plans and interview with ADON/IP on 1/9/26 at 11:40 a.m., ADON/IP acknowledged that Resident 5 had 1/5 bilateral bed rails but did not have a comprehensive, person-centered care plan for her bed rails. During the interview with director of nursing (DON) on 1/9/26 at 2:13 p.m., DON verified that the care plan for the bed rails should be comprehensive and person-centered and would follow up on it. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. During an observation on 1/6/26 at 10:28 a.m. Resident 8 was in bed and was on oxygen at 2 liters per minute (L/min, unit of flow rate). Review of Resident 8's clinical record indicated she was under hospice care and depended on supplemental oxygen. Review of Resident 8's physician orders indicated the resident had an order for oxygen at 2 L/min via nasal cannula for shortness of breath and comfort. Review of Resident 8's care plan for oxygen therapy, dated 6/3/25 indicated an intervention, Monitor and record O2 saturation QS [every shift]. There was no documentation that indicated Resident 8's oxygen saturation was monitored and recorded every shift. During an interview on 1/09/26 at 10:11 a.m., the Director of Nursing (DON) confirmed Resident 8 was on oxygen and her oxygen saturation should be taken every shift. The DON stated there was no order for Resident 8's oxygen saturation to be taken every shift. Review of the facility's policy, Oxygen Administration, revised 10/2010 indicated while the resident is receiving oxygen therapy, assess for vital signs, lunch sounds, and oxygen saturation. 4. Review of Resident 31's clinical record indicated she was admitted to the facility on [DATE]. 555799 Page 2 of 3 555799 01/12/2026 The Ridge Post Acute 1355 Clayton Road San Jose, CA 95127

F 0656 Review of Resident 31's activity care plan indicated a created date of 1/6/26. Level of Harm - Minimal harm or potential for actual harm There was no documentation Resident 31 had an activity care plan after her 11/18/25 admission. Residents Affected - Some During an interview on 1/12/26 at 1:42 p.m. the DON stated Resident 31 only had one activity care plan and confirmed it was created on 1/6/26. Review of the facility's policy, Activity Evaluation, dated 2/2023 indicated, An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident . Each resident's activities care plan relates to his/her comprehensive assessment and reflects his/her inidividual needs. 555799 Page 3 of 3