Inspection·May 21, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents received the necessary care and services for four of six residents (2, 3, 4, and 5) when their wounds did not receive weekly assessment. This failure resulted in undetermined wound status and could negatively affect the progress of their wound healing. Residents Affected - Some Findings: Review of Resident 2's admission Record indicated he was admitted to the facility on [DATE] and discharged on 1/30/24. Review of Resident 2's 1/2024 Treatment Administration Record (TAR) indicated Resident 2 had a sacrococcygeal (the region at the base of the spine) wound during his stay at the facility. Review of Resident 2's clinical record indicated Resident 2 had only one Comprehensive Skin Evaluation/Assessment done on 1/24/24 and one Skin and Wound Evaluation done on 1/29/24. Review of Resident 3's admission Record indicated she was admitted to the facility on [DATE] and discharged on 2/14/24. Review of Resident 3's 1/2024 and 2/2024 TARs indicated Resident 3 had a pressure injury (the breakdown of the skin due to pressure) on her left buttock during her stay at the facility. Review of Resident 3's clinical record indicated Resident 3 had no Comprehensive Skin Evaluation/Assessment and no Skin and Wound Evaluation done. Review of Resident 4's admission Record indicated he was admitted to the facility on [DATE] and discharged on 1/19/24. Review of Resident 4's 12/2023 and 1/2024 TARs indicated Resident 4 had a pressure injury on his coccyx (the area at the small bone at the bottom of the spine) during his stay at the facility. Review of Resident 4's clinical record indicated Resident 4 had only one Comprehensive Skin Evaluation/Assessment done on 12/22/23 and no Skin and Wound Evaluation done. Review of Resident 5's admission Record indicated she was admitted to the facility on [DATE] and discharged on 5/10/24. Review of Resident 5's TARs, from 2/2024 to 5/2024, indicated Resident 5 had a wound on her right coccyx buttocks during her stay at the facility. Review of Resident 5's clinical record indicated Resident 5 had no Comprehensive Skin Evaluation/Assessment done and had only one Skin and Wound Evaluation done on 4/15/24. During an interview with the director of nursing (DON), on 5/21/24, at 4:50 p.m., he confirmed that Resident 2 had only one Comprehensive Skin Evaluation/Assessment done on 1/24/24 and one Skin and Wound Evaluation done on 1/29/24; Resident 3 had no Comprehensive Skin Evaluation/Assessment and no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056437 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 056437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Skin and Wound Evaluation done; Resident 4 had only one Comprehensive Skin Evaluation/Assessment done on 12/22/23 and no Skin and Wound Evaluation done; and Resident 5 had no Comprehensive Skin Evaluation/Assessment done and had only one Skin and Wound Evaluation done on 4/15/24. The DON stated the wound assessment/evaluation should be done every week. Review of the facility's policy, Skin Assessment: Best Practice, dated 9/8/22, indicated A weekly skin assessment is completed one a week and describes the current condition of the patient's skin. Event ID: Facility ID: 056437 If continuation sheet Page 3 of 3