F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on interview and record review, the facility failed to develop a care plan to address treatment of a
rash for one of five residents (Resident 1). This failure had the potential to place the resident at risk for not
receiving necessary care and services.Findings: Review of Resident 1's clinical record indicated he was
admitted to the facility with diagnoses including neuropathy (disease or dysfunction of one or more nerves,
typically causing numbness or weakness in the hands and feet) and chronic obstructive pulmonary disease
(COPD, a chronic lung disease causing difficulty in breathing). Review of Resident 1's Change of Condition
Note, dated 9/4/25 indicated his skin was fragile and had an erythematous maculopapular rash (reddened
discolored area of skin and elevated lesions) scattered over trunk, back and all extremities. Review of
Resident 1's care plans indicated there was no care plan that addressed Resident 1's rash. During an
interview on 12/23/25 at 3 p.m., the director of nursing (DON) confirmed there was no care plan regarding
Resident 1's rash. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated
12/2016 indicated the comprehensive, person-centered care plan will include measureable objectives and
timeframes and incorporate identified problem areas.
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
12/23/2025
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)
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
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 care and services were provided in accordance with
professional standards of practice for one of three sampled residents (Residents 1) when there was no
documentation that staff informed a clinician (ex. doctor of medicine, MD or nurse practitioner, NP) timely
regarding Resident 1's fractured hip. This failure had the potential to delay care compromising the residents'
health, safety, and overall well-being.Findings: Review of Resident 1's clinical record indicated he was
admitted to the facility with diagnoses including neuropathy (disease or dysfunction of one or more nerves,
typically causing numbness or weakness in the hands and feet) and chronic obstructive pulmonary disease
(COPD, a chronic lung disease causing difficulty in breathing). Review of Resident 1's Nurse's Notes, dated
10/4/25 indicated at approximately 3:50 p.m. on 10/4/25, Resident 1 was found on the floor and complained
of 10/10 (on a scale from 1 to 10, worst pain). Review of Resident 1's Xray, dated 10/5/25 indicated,
.deformity of the right femoral neck area [thigh bone] consistent with subcapital fracture [break in thigh
bone/hip below the head of the femur]. Confirmation with CT or MRI exam is recommended. Review of
Resident 1's progress notes, dated 10/5/25 at 7:14 p.m., indicated, Results sent to MD and placed in box
for review. There was no documentation of the MD's reply on 10/5/25. During an interview on 10/20/25 at
2:45 p.m. with certified nursing assistant (CNA A) stated CNA A took care of Resident 1 on a Monday
(10/6/25) and was informed that he fell on Saturday and was in a lot of pain. During interview and
concurrent record review on 12/24/25 at 11:08 a.m., the director of nursing (DON) stated Resident 1 had a
fall on 10/4/25 at 3:50 p.m., the results of Resident 1's X-ray were received on 10/5/25, and Resident 1 was
sent to the hospital on [DATE] at 12:44 p.m. The DON confirmed Resident 1 was sent to the hospital two
days after his fall. The DON stated the time it took to send Resident 1 to the hospital after his fall was not
ok. Review of the facility's undated policy, Change of Resident's Condition or Status, indicated, Our facility
promptly notifies the resident, his or her attending physician, and the resident representative of changes in
the resident's medical/mental condition and/or status . The policy also indicated the nurse will notify the
resident's attending physician or physician on call when there has been an accident or incident involving
the resident and the need to transfer the resident to a hospital/treatment center;
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056437
If continuation sheet
Page 2 of 2
