Other·February 12, 2018

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding the investigation of two complaints conducted on 1/5/18 through 2/8/18. For Complaint CA00566647 regarding Admission, Transfer & Discharge Rights, a federal deficiency was identified (see F624) with a scope and severity of "D" and a Class "B" Citation was issued. For Complaint CA00566821 regarding Quality of Care/Treatment, the Department did not substantiate a violation of federal or state regulations. Inspection was limited to the specific complaints reported and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 29259, Health Facilities Evaluator Nurse.

F624 SS=D Preparation for Safe/Orderly Transfer/Dschrg CFR(s): 483.15(c)(7)

F624 §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8ZH11 Facility ID: CA070000074 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 02/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to ensure a safe discharge for one of three sampled residents (Resident 1) when the facility did not assess the resident's house, determine the level of home care the resident required, and ensure the resident received the necessary care. These failures resulted in the resident being admitted to the hospital by ambulance the day following her discharge after the in-home health services found her alone, soiled in a recliner, unable to get up, and in an altered state. She was treated for exhaustion and a urinary tract infection and transferred to another long term care facility for further rehabilitation. Findings: Resident 1's clinical record was reviewed and indicated she was admitted to the facility in 5/2017 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke (damage to the brain caused by an interruption of the blood supply). In addition, she had diagnoses of bipolar disorder (a mental disorder marked by alternating periods of elation and depression) and morbid obesity (100 pounds or more over ideal body weight with obesity-related health issues such as diabetes [too much sugar in the blood] or high blood pressure). She was admitted for rehabilitation (the physical restoration of a sick or disabled person by therapeutic measures and reeducation to participation in the activities of a normal life within the limitations of the person's physical disability). Resident 1 was self-responsible and her Minimum Data Set (MDS, an assessment tool), dated 9/3/17, indicated she was cognitively intact. Resident 1's physician ordered physical therapy five days a week on 5/29/17. On FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8ZH11 Facility ID: CA070000074 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 02/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5/30/17, he ordered occupational therapy six days a week and speech therapy five days a week. On 10/4/17, Resident 1 was discharged from physical therapy. The physical therapist (PT) noted Resident 1 was discharged from physical therapy to remain in the facility and to continue to receive rehabilitation in the restorative nurse assistant program (nurse assistant with specialized training who helps residents gain an improved quality of life by increasing their level of strength and mobility). Resident 1 was noted to be impulsive, to misjudge her ability, and to not be safe at home alone. On 10/6/17, Resident 1 was discharged from occupational therapy. The occupational therapist (OT) noted Resident 1 was discharged from occupational therapy to remain in the facility and then to eventually go home. She was noted to have mild cognitive deficits and to need significant support and assistance. On 10/9/17, Resident 1 was discharged home with a three day supply of medication. Her discharge social services note indicated the resident wanted to go home. She was advised in-home health services had not been fully established and her permanent wheelchair and walker had not yet arrived but would be delivered to her home the next day. She claimed she had a caregiver who would be at her house when she arrived. Resident 1's nurse's note at the time of her discharge on 10/9/17 indicated she was discharged by car to her home. Resident 1's hospital admission note, dated 10/10/17, indicated she was admitted to the hospital after the in-home health services found FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8ZH11 Facility ID: CA070000074 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 02/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE her soiled in a recliner and called an ambulance. No caregiver was present and Resident 1 was unable to move her wheelchair into the bathroom and bedroom and was unable to get into her bed. She was noted to be exhausted and to have a urinary tract infection. She was evaluated and treated with antibiotics. The PT determined she needed additional physical therapy for strength training to get up from a sitting to a standing position. On 10/12/17, Resident 1 was transferred to another long term care facility for further rehabilitation. On 10/20/17, the second facility's OT B performed a home evaluation and determined Resident 1 lived in senior community housing. She was able to enter her front door in her wheelchair but she was unable to enter her bedroom or bathroom because the wheelchair was too wide. She was unable to get her wheelchair over the thresholds between each room and out onto the patio. She required assistance to get through the doorways, over the thresholds, and over the carpets in the living room and bedroom. She also required assistance to use the bathroom, including the toilet, sink, and shower. She required assistance to transfer in and out of bed, on and off of chairs and a sofa, and to use the kitchen. She was unable to manage laundry, shopping, cooking, and cleaning. Inhome health care was recommended. On 11/27/17, she was discharged home with a caregiver and in-home services. During an interview on 1/24/18, at 10:27 a.m., the social services director (SSD) stated Resident 1 insisted on going home before her rehabilitation was completed. She stated Resident 1 had her own caregiver and home health care services would be provided. She also stated medical equipment, including a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8ZH11 Facility ID: CA070000074 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 02/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE special walker and a bariatric wheelchair, had been ordered but had not yet been delivered at the time of Resident 1's discharge. The SSD stated she thought the rehabilitation department and the home health agency had performed a home evaluation prior to the resident's discharge. During an interview on 1/24/18, at 12:15 p.m., OT A reviewed Resident 1's clinical record and stated she was unable to find any documentation of a home evaluation. She stated she thought a home evaluation should have been performed before Resident 1's discharge because she was leaving prematurely and was not ready or safe to go home. During an interview on 1/24/18, at 12:45 p.m., the director of nurses (DON), reviewed Resident 1's clinical record and stated she was unable to find any documentation of a home evaluation. She stated the facility does not perform home evaluations on all discharged residents but she thought one should have been performed on Resident 1. During an interview on 1/25/18, at 1 p.m., OT B from the long term care facility where Resident 1 was transferred on 10/12/17 stated she provided care for the resident after she was admitted. She stated Resident 1 was unable to care for herself and could not get up from a standing position. She stated Resident 1 stayed another month and a half for further rehabilitation and gained strength. OT B also stated she performed a home evaluation prior to Resident 1's discharge from the second long term care facility. She stated Resident 1 lived in a senior apartment on the first floor. She stated although Resident 1's wheelchair would fit through the front door, it FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8ZH11 Facility ID: CA070000074 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 02/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was too wide to fit through the bathroom and bedroom doors and she could not get over any of the thresholds in her home without assistance. She stated Resident 1 needed assistance with all of the activities of daily living and she recommended a caregiver and inhome health services. During an interview on 1/31/18, at 9:45 a.m., the rehabilitation director (RD) reviewed Resident 1's clinical record and stated she was discharged from physical therapy on 10/4/17 and was scheduled to continue rehabilitation in the RNA program until she went home. He stated she was not considered safe to be at home when she was discharged from physical therapy. The RD stated a home evaluation was not done when she was discharged from physical therapy because the physical therapists thought she was staying in the facility for RNA. He stated a home evaluation should have been done before Resident 1 was discharged and he did not know why an evaluation was not performed. During an interview on 1/31/18, at 12:10 p.m., with the assistant director of nurses (ADON), she stated in-home health services were to be provided for Resident 1 after she went home. She stated she spoke to the resident, the caregiver, and the nurse from the in-home services agency shortly after the resident arrived home and was told the caregiver was spending the night. The ADON stated she did not know the caregiver's name. She stated when she spoke to the nurse from the in-home services agency the next day, the nurse advised when she returned, no caregiver was present and the resident was sitting in her recliner covered in urine and feces. The ADON stated the nurse told her Resident 1 said the caregiver left during the night and she was sending the resident to the hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8ZH11 Facility ID: CA070000074 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 02/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 1/31/18, at 1:15 p.m., the licensed vocational nurse (LVN) who discharged Resident 1 stated she did not recall how the resident got home but she charted the resident went home in a car so she must have gone home with a caregiver. She stated she did not recall the caregiver's name. The LVN also stated she did not recall speaking to Resident 1's treating physician or advising him physical therapy did not think the resident was safe to go home. She stated she did not know whether a home evaluation was performed. She stated she had an order to discharge the resident so she discharged her. The LVN stated she did not know Resident 1 had a urinary tract infection but she does not recall her exhibiting any symptoms. She stated she knew Resident 1 was bipolar, confused, and impulsive. During an interview on 2/2/18, at 9:30 a.m., the home health nurse (HHN) stated she was asked by her agency's account executive (AE) to check on Resident 1 and see if the resident had arrived home safely since she was already visiting another patient in the same apartment complex. She stated she arrived at Resident 1's apartment at about 5:30 p.m. the day the resident was discharged. The HHN stated when she arrived, Resident 1 was in the apartment with the caregiver. She stated she talked to the resident and the caregiver and was advised they had just ordered pizza for dinner and the caregiver was spending the night. The HHN stated she did not know the caregiver's name. She also stated Resident 1 was sitting in a recliner and appeared to be cognitively intact. The HHN stated she did not assess the apartment or the resident at that time because she was scheduled to perform the assessments the next day. She stated she thought the resident was safe because the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8ZH11 Facility ID: CA070000074 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 02/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE caregiver was spending the night. The HHN stated she returned to Resident 1's apartment the next day at about noon. She stated the resident's front door was open and the caregiver was not present. The HHN stated Resident 1 was still sitting in her recliner. She stated the resident had soiled herself and was in an altered state. The HHN stated she called an ambulance and had Resident 1 transferred to the hospital because she was obviously unable to care for herself. She stated she did not think this was a safe discharge. During an observation and interview on 2/2/18, at 11 a.m., Resident 1 stated she did not think her discharge from the facility was safe. She stated the facility never assessed her apartment. Resident 1 stated she did not go home in a car with a caregiver. She stated she was transported to her home by the facility's bus without a caregiver and the bus driver wheeled her into her apartment. Resident 1 stated shortly after she arrived at home, one of the certified nurses aides (CNA) from the facility came over and stayed with her for about three hours. She stated there was no other caregiver present and she did not recall the CNA's name. She stated she asked the CNA to order a pizza for their dinner and the CNA went home at about 8 p.m. Resident 1 stated she was sitting in her recliner at the time and she could not get out of it. She stated she could not get to the bathroom and she soiled herself. Resident 1 stated a nurse came the next day, told her she was not safe, and sent her to the hospital. The resident stated she did not think this was a safe discharge because she could not get out of her recliner or into the bathroom or the bedroom because her wheelchair was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8ZH11 Facility ID: CA070000074 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 02/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE too wide. Resident 1 stated the hospital sent her to another facility where she received additional rehabilitation for another month. She stated the other facility assessed her home and determined her wheelchair would not fit and she needed care at home. Resident 1 stated her church provided a caregiver. She stated after she went home for the second time with a caregiver, the caregiver thought she needed more help than the caregiver could provide. She stated she was then sent back to the hospital where she remains while she waits for long term placement. During a telephone interview on 2/6/18, at 10:50 a.m., the AE from the home health agency stated he received a request from the facility to provide some nursing services for Resident 1. He stated he does not recall the specifics of the request or who at the facility made the request. He stated he does not recall asking one of the agency's nurses to check on the resident while she was providing care for another patient in the same apartment complex. Review of the facility's 11/2012 policy, "Discharging the Resident", indicated when a resident is discharged home, the facility should ensure the resident receives teaching and the necessary supplies and equipment. Review of the facility's 11/2010 policy, "Discharge Summary and Plan", indicated the discharge summary will include a description of the resident's physical and mental status including determining the resident's need for staff assistance and assistive devices. The post-discharge summary will identify the specific resident needs and include a description of the necessary services and how FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8ZH11 Facility ID: CA070000074 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056437 (X3) DATE SURVEY COMPLETED 02/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CYPRESS RIDGE CARE CENTER 1501 Skyline Dr Monterey, CA 93940 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the resident will access the services. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C8ZH11 Facility ID: CA070000074 If continuation sheet 10 of 10