Other·March 9, 2020

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 reported incident conducted on 3/3/2020. For Complaint CA00678623 and Entity Reported Incident CA00678592 regarding Resident Abuse; Sexual, a federal deficiency was identified (see F600). A Class "B" Citation was also issued. 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: 26295, Health Facilities Evaluator Manager I.

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 03/19/2020 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 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: 0HDB11 Facility ID: CA070000074 If continuation sheet 1 of 4 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 03/03/2020 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 §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents were free from abuse when two of two residents (Residents 1 and 2) were allegedly sexually battered by certified nursing assistant A (CNA A). This failure resulted in emotional trauma for Resident 1 and Resident 2. Findings: Review of Resident 1's admission sheet indicated she was admitted to the facility on 5/12/2015 with diagnoses of aphasia (loss of ability to understand or express speech, caused by brain damage), hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) on right dominant side and CVA (ischemic stroke is caused by a blood clot that blocks or plugs a blood vessel). Review of Resident 1's Progress Notes dated 3/1/2020 at 12:10 a.m., written by licensed vocational nurse A (LVN A) indicated at 10:25 p.m. "writer was notified by CNA that another CNA allegedly behaved inappropriately with a resident." Review of Resident 2's admission sheet indicated she was admitted to the facility on 12/16/2011 with diagnoses of CVA, dementia (memory loss), nonpsychotic mental disorder and mayor depressive disorder. Review of Resident 2's Progress Notes dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0HDB11 Facility ID: CA070000074 If continuation sheet 2 of 4 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 03/03/2020 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 3/1/2020 at 12:17 a.m., written by LVN A indicated at 10:25 p.m. "writer was notified by CNA that another CNA allegedly behaved inappropriately with a resident." In an interview on 3/3/2020 at 2:09 p.m., LVN A stated in the night of 2/29/2020 after 10:00 p.m. he was approached by CNA B who stated CNA A "spanked" Resident 2 on the bare buttocks and CNA A pinched the breast and twisted the nipple of Resident 1. LVN A stated he went to Resident 1 who nodded her head to the question of pain and nodded yes for the question if something happened to her. LVN A stated he went to Resident 2 who stated she was not in pain, but the slapping happened. In an interview on 3/3/2020 at 2:51 p.m., CNA B stated in the night of 2/29/2020 she wanted to change Resident 2 and she needed CNA A for assistance. Resident 2 was positioned on her side and CNA A held her. She stated she needed a pad and left the room. When she returned she could hear a slapping sound and Resident 2 told CNA A "stop hitting my butt". Since the curtain was pulled she was not able to see what she heard. CNA B asked CNA A what he had done and his response was only that he chuckled. When they left the room Resident 1 called for help and they both entered her room. Resident 1 needed her top to be changed. We both pulled her top off and CNA A had one hand on her shoulder and with the other hand he pinched the nipple and said "titty twist". Resident 1 giggled in nervousness, which she would do when she felt uncomfortable. CNA B stated she asked CNA A why he did this and he responded, "don't tell anybody". During an interview with Resident 1 on 3/3/2020 at 3:50 p.m., when approached if she would like to talk regarding the incident she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0HDB11 Facility ID: CA070000074 If continuation sheet 3 of 4 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 03/03/2020 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 stated "no" and became emotional and had teary eyes. Concurrently, the director of nursing (DON) approached Resident 1 again regarding the incident and Resident 1 did not say anything, only shook her head from side to side. During an interview on 3/3/2020 at 3:30 p.m., Resident 2 stated CNA A leaned over her but did not physically touch her. Review of a Police Department's "Primary Narrative" dated 3/1/2020, indicated [CNA A] was arrested for sexual battery and elder abuse after he was observed inappropriately touching a resident's breast at the facility. During review of the facility's policy and procedure, "Abuse Prevention Program", dated August 2011, indicated under "Policy Statement": Our residents have the right to be free from abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0HDB11 Facility ID: CA070000074 If continuation sheet 4 of 4