Cypress Ridge Care Center
CYPRESS RIDGE CARE CENTER in MONTEREY, CA — inspection on December 23, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Cypress Ridge Care Center
1501 Skyline Drive Monterey, CA 93940
SUMMARY STATEMENT OF DEFICIENCIES
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;
Facility ID: