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Complaint Investigation

Cypress Ridge Care Center

April 24, 2026 · Monterey, CA · 1501 Skyline Drive
Citations 1
CMS Rating 4/5
Beds 99
Provider ID 056437
Healthcare Facility
Cypress Ridge Care Center
Monterey, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

CYPRESS RIDGE CARE CENTER in MONTEREY, CA — inspection on April 24, 2026.

Found 1 citation. 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

FF0558
Resident Rights Deficiencies

During a review of Resident 1's minimum data set (MDS, an assessment), dated 3/3/26, it indicated that his brief interview for mental status (BIMS) was 10 and his toilet transfer was coded three for partial/ moderate assistance (helper does less than half the effort).

Review of Resident 1's clinical record indicated three falls in 2025 and one fall on 2/14/26.

During an interview on 4/20/26, at around 11:35 a.m. to 11:55 a.m., with Resident 1 in his room, Resident 1 stated no one was responding to his call lights and he waited too long for getting help, so he had falls in the bathroom several times.

While during the interview, he pressed the call light and waited for 15 minutes with no one responding to his call lights.

During an interview on 4/22/26, at around 11:20 a.m., with Resident 2, Resident 2 was lying in bed with oxygen in use through a nasal cannula. Resident 1 was asked about the call light taking how long to respond and he stated, They do not come after pressing a call light.

During an observation and interview 4/22/26 1:40 p.m., Resident 1 was assessed by the nurse practitioner (NP) after an incident fall from using the toilet without assistance by the CNA at around 1:25 p.m. Resident 1 stated no one come to assist him after pressing the call light, so he transferred himself to use the shared restroom, then he fell down with no injury.

During an interview on 4/24/26, at 1:20 p.m., with Resident 3, Resident 3 stated the call light response would depend on how many staff working on the floor and usually took 20 minutes to 45 minutes to respond to her call lights.

During an interview on 4/24/26, at around 12:40 p.m., with the director of Nursing (DON) and assistant director of nursing (ADON) regarding call light responses. DON was validated above findings that the call lights were not responded to timely for Resident 1. A review of the facility's policy and procedure (P&P) titled, Answering the call light, dated 2001, the P&P indicated, The purpose of this procedure is to ensure timely response to the resident's requests and needs.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MONTEREY, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CYPRESS RIDGE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.