Pine Ridge Care Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when Resident 2 struck her on the left cheek.This failure had the potential to result in serious physical harm to Resident 1.Findings:A review of Resident 1's admission record indicated she was admitted in 5/19 with the diagnosis of cognitive impairment (persistent function deficits that can impact a person's ability to think, learn and remember).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/16/25, indicated she had severe cognitive impairment.A
review of Resident 1's nursing note, dated 8/13/25 and written by Licensed Nurse 1 (LN 1), indicated a staff person had reported to him she had witnessed Resident 1 being struck in the left cheek by Resident 2.A
review of Resident 2's admission record indicated he was admitted in 8/20 with the diagnosis of dementia (a progressive state of decline in mental abilities).A review of Resident 2's MDS, dated [DATE REDACTED], indicated he had severe cognitive impairment.A review of Resident 2's nursing note, dated 8/13/25 and written by LN 1, indicated a staff person had reported to him she had witnessed Resident 2 strike Resident 1 in the left cheek.During an interview on 9/8/25 at 11:56 a.m. with Activities Assistant 1 (AA 1), AA 1 stated she had been in the dining room on 8/13/25 and witnessed Resident 2 strike Resident 1 in her left cheek as he wheeled himself past her in his wheelchair. AA 1 stated Resident 1's cheek was a little red but she had not cried out in pain.During an interview on 9/8/25 at 12:39 p.m. with the Social Services Director (SSD), the SSD stated she was aware of the incident that had occurred between Resident 1 and Resident 2 on 8/13/25. The SSD agreed Resident 1 had suffered abuse by Resident 2 and confirmed it was the facility's responsibility to keep all residents safe.During an interview on 9/8/25 at 1:24 p.m. with LN 1, LN 1 stated he assessed Resident 1 on 8/13/25 after she had been struck by Resident 2 and her left cheek was slightly reddened after the incident but there were no complaints of pain.During a review of the facility's policy titled, Abuse Prevention Program, undated, the policy stipulated, Our residents have the right to be free from abuse.This includes physical abuse.
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
Event ID:
PINE RIDGE CARE CENTER in SAN RAFAEL, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN RAFAEL, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PINE RIDGE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.