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.
(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 3
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
01/12/2026
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)
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].
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555799
If continuation sheet
Page 2 of 3
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
01/12/2026
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555799
If continuation sheet
Page 3 of 3
