Inspection·January 9, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident's right to be treated with dignity was rendered for one of two residents (Resident 1) when Resident 1's request not to move to another room was not followed. This failure had the potential to cause emotional distress and a feeling of less self-worth for Resident 1. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included encephalopathy (disorder or damage that affect the brain's structure or function), and psychotic disorder (a mental disorder that affects a person's ability to think and perceive reality) with delusions (having false and unrealistic beliefs). Review of Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 11/2/24 indicated her cognition (the mental process of thinking, learning, remembering, being aware of surroundings, and using judgement) was severely impaired but had a clear speech, made herself to be understood, and understood by others. During an interview with the Social Worker Staff (SWS) on 1/9/25 at 10:50 a.m., she stated that Resident 1 requested to be moved to another room in the morning of 1/3/25 due to previous roommate who passed away, but the notice of room change was not signed yet by Resident 1 at that time. SWS further stated that when she came back in the afternoon on same day to have the Resident 1 sign the notice of room change, Resident 1 was already transferred to another room, and Resident 1 refused to sign. During an interview with the Housekeeping Staff (HS) on 1/9/25 at 10:20 a.m., he stated that on 1/3/25 at around between 5:00 to 5:30 p.m., while helping the Assistant Director of Nursing (ADON) and Transportation Staff (TS) to move Resident 1 to another room, Resident 1 become upset, screaming, and crying and telling them she did not want to be moved to another room. The HS told ADON that it was not a good idea to move Resident 1 to another room at that time, but the ADON continued to instruct them to move Resident 1 to another room. Resident 1 was moved by the above three staff while lying in her bed to another room that time. During an interview with the TS on 1/9/25 at 10:44 a.m., he stated that on 1/3/25 at around between 400 p.m. to 5:00 p.m., while helping the ADON and HS to move Resident 1 to another room, Resident 1 become upset and was screaming and stated she did not want to move to another room. TS told ADON that Resident 1 was upset and screaming and did not want to move to another room, but the ADON told TS We have to. Resident 1 was moved by the above three staff while lying in her bed to another room (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 01/09/2025 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)