Health inspection·May 2, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete nursing (ADON), he confirmed there was no care plan developed for Resident 2's dysphagia. He stated, he should have developed a comprehensive person-centered care plan and implemented interventions in place to prevent aspiration or choking events for Resident 2 after being discharged from the hospital. Review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, updated 9/2013, the P&P 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. Event ID: Facility ID: 056437 If continuation sheet Page 2 of 4 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 056437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Ridge Care Center 1501 Skyline Drive Monterey, CA 93940 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow care plan and physician's order to apply Triamcinolone cream (a corticosteroid used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) to one of three sampled residents (1). This failure had a potential to delay the improvement and/or resolution of Resident 1's skin problem. Residents Affected - Some Findings: Review of Resident 1's admission record indicated he admitted facility on 1/20/10 and had diagnoses including rash and other nonspecific skin eruption. Review of Resident 1's physician order, dated 11/29/22, indicated physician prescribed, Triamcinolone Acetonide Cream 0.1 % (Triamcinolone Acetonide (Topical)) apply to affected area topically every day and evening shift for general for general body rashes. Apply to legs, arm creases and any areas of rash /redness. Review of Resident 1's plan of care for generalized body rash, dated 9/28/22, indicated to provide treatment per physician's orders. Review of Resident 1's three months' electronic treatment administration record (ETAR) from 4/1/24 to 4/8/24, 3/1/24 to 3/31/24 and 2/1/24 to 2/29/24, the eTAR indicated he was scheduled to have Triamcinolone cream at 9 a.m. and 6 p.m. There were no documented evidence indicating Resident 1's had been applied the treatment nor any refusal for applying Triamcinolone Acetonide Cream on 4/7/24 and 4/8/24 at 9 a.m., 3/1/24, 3/3/24, 3/4/25, 3/7/24, 3/8/24, 3/12/24, 3/14/24, 3/15/24, 2/26/24 and 2/27/24. During an interview on 4/8/24, at 3:25 p.m., with the registered nurse A (RN A), he confirmed that he did not apply Triamcinolone Acetonide External Cream to Resident 1 in the morning for 4/8/24 and he was uncertain what type of cream (Triamcinolone cream) Resident 1 need to be applied every morning. During an interview and observation on 4/8/24, at 3:37 p.m., with Resident 1, he stated that he had an anti-itching cream (Triamcinolone cream) that should be applied twice a day, but staff did not apply Triamcinolone cream to him in the morning on 4/7/24, and 4/8/24 and also in the past. Resident 1 was observed lying on his side, with back exposed, noted pink rashes all over his back. During an interview on 4/17/24, at 10 a.m., with the director of nursing (DON), the DON stated, he had provided in-service to nursing staff regarding applying Triamcinolone cream to Resident 1. During an interview and record review on 5/2/24, at 11 a.m., with the assistant director of nursing (ADON), Resident 1's ETAR were reviewed from February to April 2024. The ADON confirmed there were missing treatment not done and he stated staff should have followed physician's order to apply Triamcinolone cream to Resident 1. He further stated, Triamcinolone cream normally should be applied by treatment nurse and the floor nurse would apply them to Resident 1 when the treatment nurse was not around. Review of the facility's policy and procedure (P&P) titled, Registered Nurse Job Description, dated 9/2018, the P&P indicated, Monitor medication passes and treatment schedules to ensure that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056437 If continuation sheet Page 3 of 4 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 056437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Ridge Care Center 1501 Skyline Drive Monterey, CA 93940 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 0658 Level of Harm - Minimal harm or potential for actual harm medications are being administered as ordered and that treatments are provided as scheduled. Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056437 If continuation sheet Page 4 of 4