Inspection·June 4, 2024

F 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Based on interview and record review, the facility failed to ensure one of three Certified Nursing Assistants (CNA) A had a current CNA certificate during the time of employment working as a CNA while providing resident care from August 2023 to April 2024. This deficient practice had the potential for an unqualified CNA to provide care to the residents. Findings: A review of CNA A's employee file indicated that she applied for the CNA position on 7/19/23 and signed the Team Member Handbook Acknowledgement and at-will Agreement as a CNA on 7/26/23. A further review of CNA A's employee file revealed that there was no documentation that indicated she had obtained her CNA certificate. During an interview with CNA A on 3/29/24 at 1:03 p.m., CNA A confirmed she started working as a CNA and worked with several residents after passing the CNA knowledge portion on 8/13/23 and the skill examinations on 8/5/23 even though she did not received her CNA certificate. A review of the facility's work schedule on 3/29/24 indicated that CNA A worked from 7:00 a.m. to 3:30 p.m. and provided care to multiple residents. A review of CNA A's California Certified Nurse Aide Exam Results Report dated 8/5/23 indicated you have passed the skill portion of the Certified Nurse Aide exam .A passing score does not imply certification.You must verify on the registry. A review of CNA A's California Certified Nurse Aide Exam Results Report dated 8/13/23 indicated you have passed the knowledge portion of the Certified Nurse Aide exam .A passing score does not imply certification. You must verify on the registry. During an interview with the Director of Nursing (DON) on 6/4/24 at 10:50 a.m., The DON stated that all CNAs who worked here should have obtained their CNA certificate. During an interview with the Director of Staff Development (DSD) on 6/4/24 at 3:26 p.m., the DSD confirmed that CNA A had not obtained her CNA certificate while providing care to multiple residents.The DSD further stated that CNA A should not have provided direct care until she obtained her CAN certificate and CNA A was removed from the work schedule at the beginning of May 2024. (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 2 Event ID: 056437 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 06/04/2024 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)