Other·October 10, 2018

F000 INITIAL COMMENTS

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 investigation of a complaint and entity report incident conducted on 10/2/18. For Complaint CA00605634 regarding Physical Environment; No Hot Water, a federal deficiency was identified (see F684). A Class "B" citation was also issued. For Entity Report Incident CA00605681 regarding Quality of Care/Treatment, the Department did not substantiate a violation of federal or state regulations. Inspection was limited to the specific complaint and entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 38174, Health Facilities Evaluator Nurse.

F684 SS=D Quality of Care CFR(s): 483.25

F684 10/31/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive 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: TKM211 Facility ID: CA070000074 If continuation sheet 1 of 5 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 10/02/2018 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 assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide care and services for four sampled residents when 1. During an interruption of the hot water supply, the facility staff did not have coordination to follow-up on the issue which resulted in multiple residents not getting their showers as scheduled as well as, for as Resident 1, he had refused peri-care using cold water even though he felt "dirty", Resident 2 and 3 were provided cold water during their bed baths. 2. For Resident 4, the facility failed to implement their Shower/Tub Bath policy when Resident 4 was not provided showers as indicated on the shower schedule and Care Plan (identifies residents' concerns and outlines the care and services needed to meet their needs). This failure had the potential to negatively affect the residents' psychosocial well-being and health. Findings: 1. During an observation and interview on 9/28/18 at 9:35 a.m., certified nursing assistant A (CNA A) was asked if he had any scheduled residents for showers. CNA A indicated, he had one but he did not give it because "there's no hot water in the shower today." Showers A/B in the south area unit was tested with CNA A. CNA A indicated the water was taking longer to have hot water and after about two minutes of testing, shower B did not produce hot water. CNA A said licensed vocational nurse B (LVN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TKM211 Facility ID: CA070000074 If continuation sheet 2 of 5 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 10/02/2018 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 B) was made aware. During an observation and interview with CNA C on 9/28/18 at 9:45 a.m., CNA C indicated the facility did not have hot water in the bathroom and showers for two days since 9/27/18 in the morning. The bathroom sink was tested with CNA B, it did not produce hot water. CNA B stated the director of staff development (DSD) knew about the problem. During an interview with LVN B on 9/28/18 at 9:50 a.m., LVN B indicated since 9/27/18 in the morning, she was aware that there was no hot water in the facility and she did not know why. During an interview with Resident 1 on 9/28/18 at 9:55 a.m., Resident 1 stated he was aware that there was no hot water today and said, "I would rather not be cleaned using cold water even though I felt 'dirty'". During an interview with Resident 2 on 9/28/18 at 10:00 a.m., Resident 2 stated, "I felt like a cold rag today", during a bed bath. During an interview with Resident 3 on 9/28/18 at 10:10 a.m., Resident 3 said, "I felt cold being cleaned with cold water" During an interview with CNA D on 9/28/18 at 10:20 a.m, CNA D stated she would have used wipes during bed baths but the residents felt not "totally clean". CNA D said the DSD was aware since 9/27/18 in the morning about no hot water supply. During an interview with the DSD on 9/28/18 at 10:30 a.m., she indicated on 9/27/18 around the afternoon, the maintenance director (MD) told her that due to construction in the kitchen, the hot water supply would be off for a period of time. The DSD stated the MD did not give a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TKM211 Facility ID: CA070000074 If continuation sheet 3 of 5 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 10/02/2018 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 time when the hot water supply would be available. The DSD indicated she was not aware that during the night on 9/27/18, the facility did not have hot water. The DSD also indicated that during the time that facility did not have hot water, she gave instructions to nursing staff to use a moist towelette for residents to clean their hands and ask residents' permission to provide them cold water during peri-care or body wash because "some patients maybe ok with cold water". The DSD stated she did not inform the administrator (ADM) because it was the MD's job to inform the ADM. During an interview with ADM on 9/28/18, at 10:40 a.m., he confirmed he was not notified about the interruption of the hot water supply on 9/27/18. The ADM stated because of the construction in the kitchen, the circulating pump that provides hot water was turned off by the construction crew and the ADM confirmed no one had checked to see if it was turned back on. During a telephone interview with the MD on 9/28/18 at 11:25 a.m., he confirmed on 9/27/18 the hot water supply was interrupted and an announcement was made to the staff and the DSD. The MD stated he did not know that there was no hot water supply until 9/28/18. He said the construction crew were supposed to turn on the hot water supply on 9/27/18 before the end of the day and the MD confirmed he did not follow-up on it. During an interview with Resident 4's family member (FM) on 9/28/18 at 11:50 a.m., the FM stated in the morning of 9/27/18,Resident 4 was already up in the "sling" (a type of lift used to provide secure support to the residents during transfer) for a shower when CNA D came into the room and said there was no hot FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TKM211 Facility ID: CA070000074 If continuation sheet 4 of 5 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 10/02/2018 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 water in the shower room. The FM expressed disappointment about seeing Resident 4 in the situation of being up in the sling and was not provided her shower on 9/27/18. The FM said through out the day on 9/27/18 there was no hot water in the shower and bathrooms. During a follow-up interview and record review with the DSD on 9/28/18 at 12:25 p.m., the North and South stations shower schedule for the morning and afternoon shift was reviewed. The DSD confirmed on 9/27/18, all residents except the empty beds did not receive their showers as scheduled. 2. During an interview with Resident 4's FM on 9/28/18 at 11:50 a.m., the FM expressed concerns that Resident 4 had one shower since her admission on 8/25/18. Review of Resident 4's clinical record indicated she was admitted to the facility on 8/25/18 with a diagnoses including stroke. Her care plan dated 8/25/18 indicated shower and bathing schedule at least two times a week as indicated. Her shower schedule indicated every Monday and Thursday in the morning shift. Review of facility's revised 10/10 policy, "Shower/ Tub Bath", indicated the purpose of this procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .. if the resident refused the shower/tub bath, the reason(s) why and the intervention taken and notify the supervisor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TKM211 Facility ID: CA070000074 If continuation sheet 5 of 5