Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monterey Post Acute during CMS and state inspections, most recent first.
A resident reported not receiving scheduled pain medication, leading to increased pain and emotional distress. Review of the MAR for the relevant month showed that a 10:00 a.m. medication pass on a specific day was not documented as given, with the system indicating the medications were not administered. The DSD confirmed that there was no notation of administration, refusal, or the resident being out of the building, and an RN verified the absence of documentation for the scheduled dose. Facility policy requires timely administration of medications as prescribed and documentation, including initials on the MAR, whenever medications are given, withheld, refused, or administered at a different time.
A resident with severe cognitive impairment and a history of exit-seeking behavior was able to leave the facility unsupervised and was missing for several hours before being found wandering along a road. Despite interventions such as a wander guard device and hourly visual checks, staff failed to adequately monitor the resident, and the wander guard was found to be nonfunctional. Facility exit doors were inadequately supervised, with one alarmed but unlocked and the entrance code posted publicly, contributing to the resident's ability to elope.
The facility failed to serve fried chicken at the correct temperature during a lunch meal. The morning cook's thermometer read 168°F, while the surveyor's thermometer showed 152°F. Both the dietary manager and the visiting registered dietician confirmed that the chicken should be at 165°F, as per facility policy. This discrepancy had the potential to cause food-borne illness.
The facility failed to follow proper food handling practices, as multiple food items in the refrigerator lacked appropriate labeling, such as opened on or use by dates. A carton of soy milk and a packet of parmesan cheese were among the items without dates, contrary to the facility's policy requiring all refrigerated foods to be covered, labeled, and dated. The dietary manager confirmed the need for proper labeling and mentioned a guide for discarding items.
The facility failed to maintain the dishwasher's water temperature at the required 120 degrees Fahrenheit for both wash and rinse cycles, as observed during a survey. The wash cycle temperatures were recorded below the required level, with only one instance reaching 120 degrees. Interviews revealed inconsistencies in understanding the temperature requirements, and the facility's policy on monitoring and reporting inadequate temperatures was not effectively implemented.
A privacy breach occurred when an RN left a computer screen open and unattended during a medication pass, displaying multiple residents' information. The RN acknowledged the privacy issue, which violated HIPAA regulations requiring the protection of e-PHI from unauthorized access.
A facility failed to provide necessary colostomy care for a resident with quadriplegia and a colostomy. The resident's care plan indicated a need for physician-ordered colostomy care, but no such orders were documented, nor was there evidence of care being performed. The DON confirmed the absence of documentation and orders, acknowledging that licensed nurses should document care and monitor the stoma. This oversight placed the resident at risk for complications.
The facility failed to post required oxygen signage for two residents using oxygen concentrators, posing potential hazards. One resident had an oxygen order for low oxygen or shortness of breath, while the other was observed using a nasal cannula. Staff confirmed the absence of signage, which is necessary due to the flammable nature of oxygen.
A facility failed to routinely assess a resident's arteriovenous fistula (AVF) for bruit, thrill, and signs of infection. The resident, with end-stage renal disease, was scheduled for dialysis three times a week, but there were no physician orders for AVF monitoring. The director of nursing confirmed that checks were only done on dialysis days, contrary to the facility's policy requiring regular monitoring.
The facility did not have an RN on duty for 8 consecutive hours on two days in October and December 2024. The nurse schedule showed no RN was scheduled or on duty on these days, and the administrator confirmed the absence and lack of a waiver for reduced RN hours, despite being aware of the requirement for RN coverage.
The facility failed to document the administration of controlled medications on the MAR for three residents, leading to discrepancies between the CDR and MAR. This issue was confirmed by the ADON, who acknowledged that the medications should have been documented on both records.
A facility failed to monitor side effects and target behaviors for a resident on psychotropic medications, including Seroquel, Bupropion HCL, and Depakote. The resident, diagnosed with Dementia, Alzheimer's, and Schizophrenia, had no documented monitoring of side effects or specified target behaviors for these medications. The DON confirmed the lack of documentation, which is against the facility's policy requiring monitoring for efficacy, risks, benefits, and adverse consequences.
A medication error rate of 11.9% was identified in an LTC facility, where several residents did not receive prescribed medications, and a G-tube was not flushed correctly. The errors were confirmed by an LVN, who acknowledged the unavailability of medications and incorrect procedures, leading to potential health compromises for the residents.
The facility failed to properly label and store medications, including insulin vials and pens, eye drops, and inhalation aerosols, as observed during inspections. Medications lacked open dates and resident identifiers, and a medication cart was left unlocked. Temperature logs for medication storage were incomplete. These deficiencies were confirmed by staff and were not in compliance with facility policies.
A facility failed to follow its infection prevention policy when a nebulizer mouthpiece was found uncovered on a resident's bedside table. An LVN confirmed the mouthpiece should have been cleaned and stored in a plastic bag. The Infection Preventionist also stated the mouthpiece should not be left exposed, as per the facility's infection control program.
A resident's bedside table was found to be damaged, with cracked surfaces and sharp edges, posing a potential risk to safety and psychosocial well-being. The resident, who has multiple health conditions, expressed dissatisfaction with the table's condition. The DON acknowledged the issue and stated that the table needed replacement.
The facility failed to ensure palatable food when undercooked brown rice was served to 18 residents. A lunch test tray confirmed the rice was undercooked, and residents complained about the food quality. The Certified Dietary Manager did not taste the food before serving, and discrepancies were found in the cooking process. The facility's policy on menu adherence was not provided.
A resident with a history of diabetes and poor wound healing experienced a reoccurrence of a right heel wound, but the LTC facility failed to document treatment for five days. Additionally, Weekly Summary Documentations inaccurately indicated the resident had no skin issues, despite the presence of the wound. These actions were not in line with the facility's policies on wound care and documentation.
A resident did not receive Enoxaparin Sodium Injections as ordered due to pending pharmacy delivery. The medication was not administered on multiple occasions, potentially due to late refill orders or delayed pharmacy delivery. Facility policies require timely medication administration and sufficient supply.
A resident with hemiplegia and high fall risk fell during a transfer from bed to shower chair due to inadequate support from a CNA, who failed to use a gait belt or position the shower chair correctly. Other staff confirmed proper procedures were not followed.
A facility failed to document and administer a physician-ordered antibiotic eye drop for a resident with blepharitis symptoms, including eyelid swelling and discharge. The physician intended to prescribe Cipro Ophthalmic drops, but the order was not found in the resident's records, as confirmed by the ADON.
A resident filed a grievance alleging that a nurse shouted at her and touched her leg roughly. The facility failed to report this abuse allegation to the CDPH within the required 24-hour timeframe, resulting in a delay in the investigation. The nurse received a written warning and was suspended.
The facility failed to provide appropriate social services support following an abuse allegation for a resident. An investigation showed no documented evidence of a social services assessment focused on the resident's psychosocial well-being after the abuse allegation. The DON confirmed that there should be 72 hours of nursing monitoring and social services follow-up, but no follow-up notes were found. The facility's job description for the Social Services Director indicated that residents should be assessed for social services needs, but this was not documented.
Failure to Administer and Document Scheduled Pain Medication
Penalty
Summary
Failure to provide scheduled pain medication occurred when a resident did not receive their ordered medications as documented on the Medication Administration Record (MAR). During an interview, the resident reported not receiving his medications on 2/13/26, which he stated caused increased pain over the weekend. Review of the resident’s February 2026 MAR showed that medications scheduled for 10:00 a.m. on 2/14/26 were not administered, with the MAR displaying a red indicator for that time, signifying the medications were not given. The Director of Staff Development confirmed that if medications had been administered, refused, or if the resident had been out of the building, the MAR would show documentation and a green background, but none was present. RN A also confirmed there was no documentation that the 10:00 a.m. medications were given on 2/14/26. The facility’s medication administration policy, dated 2001, states that medications are to be administered in a safe and timely manner as prescribed, and that any withheld, refused, or rescheduled doses must be documented, with the administering individual initialing the MAR after each medication is given. This lack of administration and documentation of the resident’s scheduled pain medications resulted in the resident experiencing increased pain and emotional distress.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of exit-seeking behavior, and multiple psychiatric and neurological diagnoses was able to leave the facility without staff awareness or supervision. The resident was missing from the facility for several hours and was later found wandering unprotected along a road, eventually being located approximately three miles away. The resident's medical records indicated a history of wandering, exit-seeking, and recent admission with poor adjustment, as well as a history of substance abuse and homelessness. The care plan identified the resident as an elopement risk and included interventions such as a wander guard device and hourly visual checks. Despite these interventions, facility staff failed to adequately monitor the resident. Monitoring records showed that checks for exit-seeking behaviors and the function and placement of the wander guard device were ordered and documented, but the resident was still able to elope. Upon return, it was discovered that the wander guard device was not functioning. Additionally, the facility's entrance/exit doors were found to be inadequately supervised during certain hours, with one exit door alarmed but unlocked, and the entrance door code posted publicly. There was no receptionist present to supervise the entrance door overnight, and staff acknowledged that more frequent visual checks could have been performed. The resident was evaluated at a local emergency department after being found, presenting with increased confusion and alcohol intoxication. The facility's policy required systematic monitoring and management of residents at risk for elopement, including assessment, intervention, and monitoring for effectiveness. However, the failure to ensure the effectiveness of interventions and adequate supervision directly led to the resident's unsupervised exit and subsequent elopement.
Failure to Serve Chicken at Safe Temperature
Penalty
Summary
The facility failed to serve food at an appetizing temperature for one of the seven food items served during a lunch meal, specifically fried chicken. During an observation, the morning cook measured the temperature of the fried chicken at 168 degrees Fahrenheit using his thermometer, while the surveyor's thermometer read 152 degrees Fahrenheit. Both the morning cook and the surveyor acknowledged that the correct temperature for chicken should be 165 degrees Fahrenheit. Interviews with the dietary manager and the visiting registered dietician confirmed that the chicken should be at 165 degrees Fahrenheit, as per the facility's policy on food preparation and service. This discrepancy in temperature had the potential to cause food-borne illness due to the chicken not being at the correct temperature.
Improper Food Labeling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, as observed during a survey. Multiple food items in the refrigerator were found without appropriate labeling, such as opened on or use by dates, which is against the facility's policy. Specifically, a carton of soy milk was half full with an open cap but lacked a date, and a packet of parmesan cheese had no date written on it. Additionally, a container of grated cheese had a date of 1-28-25, but it was unclear whether this was the received date or the use by date. During an interview, the dietary manager confirmed that all food items should have both a received date and an opened on date, and mentioned that there is a guide posted on the refrigerator for discarding items, with dairy products to be discarded one week after opening. The facility's policy requires all refrigerated foods to be covered, labeled, and dated, which was not followed in this instance.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwasher's water temperature consistently reached the required 120 degrees Fahrenheit for both the wash and rinse cycles, as observed during a survey. On two separate occasions, the dishwasher was tested, and the wash cycle temperatures were recorded below the required 120 degrees, with temperatures reaching only 110, 95, and 108 degrees Fahrenheit. The rinse cycle temperatures varied, reaching 124, 131, and 144 degrees Fahrenheit, with only one instance of the wash cycle reaching the required 120 degrees. Interviews with the dietary manager and the regional registered dietician revealed inconsistencies in understanding the dishwasher's temperature requirements. The dietary manager initially stated that the dishwasher should not exceed 130 degrees, but later expressed a desire for the temperature to reach 120 degrees for both cycles. The regional registered dietician indicated that the dishwasher needed to be run three times to achieve the desired wash cycle temperature. The facility's policy required operators to check and record temperatures for each cycle and report inadequate temperatures immediately, which was not effectively implemented, leading to the deficiency.
Privacy Breach of Resident Records
Penalty
Summary
The facility failed to maintain the privacy of a resident's clinical records when a registered nurse (RN) left a computer screen open and unattended during a medication pass. On February 10, 2025, at 4:20 p.m., a medication cart containing an open laptop was left unattended in the hallway outside a resident's room. The laptop displayed information about multiple residents while RN E left to wash her hands at the nurse's station after taking residents' blood sugar levels. During an observation and interview with RN E at 4:34 p.m., she confirmed that the laptop was on and displaying residents' information, acknowledging that it should have been closed to prevent privacy issues. This incident was a violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which requires the protection of electronic protected health information (e-PHI) from unauthorized access.
Failure to Provide Colostomy Care
Penalty
Summary
The facility failed to provide necessary colostomy care for a resident who required such services. The resident, who was admitted with a colostomy and quadriplegia, did not have any physician orders for colostomy care documented in their clinical record. The care plan for the resident indicated a risk for complications related to altered elimination due to the colostomy, and it specified that colostomy care should be provided as ordered by a physician. However, a review of the resident's Physician Order Sheet and Treatment Administration Record (TAR) for February 2025 revealed no documentation of physician orders or evidence that colostomy care was being performed. During an interview, the Director of Nursing (DON) confirmed the absence of physician orders for the resident's colostomy care and acknowledged that licensed nurses should document colostomy care on the TAR and monitor the stoma each shift. The facility's policy on colostomy care, revised in October 2010, outlined the need to record the date and time of care, any skin issues, and the signature of the person providing care. The lack of documentation and physician orders for colostomy care placed the resident at risk for complications such as infection, skin breakdown, and pain.
Failure to Post Oxygen Signage for Residents
Penalty
Summary
The facility failed to provide proper oxygen care and treatment services for two residents, leading to a deficiency in safety protocols. Resident 25 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. During an observation, it was noted that the nasal cannula was inside a plastic bag and not in use. The resident had an order for oxygen at 2 L/min via nasal cannula as needed for low oxygen or shortness of breath. A Licensed Vocational Nurse confirmed the absence of the required oxygen signage, and the Infection Preventionist stated that signage is necessary for safety due to the flammable nature of oxygen. Similarly, Resident 224 was observed using a nasal cannula connected to an oxygen concentrator, but there was no visible signage outside the door indicating oxygen use. Interviews with a Licensed Vocational Nurse and the Assistant Director of Nursing confirmed that signage should be present for residents using oxygen. The lack of signage for both residents posed potential hazards and accidents, as oxygen is highly flammable and requires clear identification to prevent smoking or other dangerous activities near the oxygen source.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to routinely assess the arteriovenous fistula (AVF) for a resident who required dialysis services. The resident, who had end-stage renal disease and other medical conditions, was scheduled for dialysis treatment three times a week. However, there were no physician orders in place to assess and monitor the resident's AVF for bruit and thrill, or for signs and symptoms of infection. This lack of orders and monitoring was confirmed during an interview with the director of nursing (DON), who acknowledged that nursing staff should check the AVF every shift, every day. Observations and record reviews revealed that the nursing staff only monitored the AVF on dialysis days, and there was no documentation of checks on non-dialysis days. The facility's policy on hemodialysis catheters indicated that signs of infection and patency should be checked at regular intervals, but this was not being followed. The DON confirmed the absence of physician orders and the need for regular monitoring, highlighting a deficiency in the facility's care for the resident's dialysis access site.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on duty for 8 consecutive hours on two separate days during the months of October and December 2024. Specifically, the facility's nurse schedule documents indicated that no RN was scheduled or on duty on October 31, 2024, and December 18, 2024. During an interview, the administrator confirmed the absence of an RN on these dates and acknowledged that the facility did not have a waiver for reduced RN nursing hours. The administrator also stated that the facility was aware of the requirement for an RN to provide resident care for 8 hours a day, 7 days a week.
Controlled Medication Documentation Deficiency
Penalty
Summary
The facility failed to ensure that controlled medications were fully accounted for on the medication administration record (MAR) for three residents. For Resident 4, a Hydromorphone tablet was signed out of the Controlled Drug Record (CDR) but not documented on the MAR. Similarly, for Resident 58, three Tramadol tablets were signed out of the CDR but not recorded on the MAR on three separate occasions. Resident 67 had two Oxycodone tablets signed out of the CDR but not documented on the MAR. These discrepancies were verified by the Assistant Director of Nursing (ADON) during a concurrent interview and record review. The facility's policy and procedures require that the individual administering the medication initials the MAR after giving each medication. The failure to document the administration of these controlled medications on the MAR had the potential for unauthorized access to medications by residents and visitors. The ADON acknowledged the discrepancies and confirmed that the medications should have been documented and signed off on both the CDR and MAR.
Failure to Monitor Psychotropic Medication Effects and Target Behaviors
Penalty
Summary
The facility failed to monitor side effects and target behaviors for a resident receiving psychotropic medications, which compromised the ability to determine the effectiveness of these medications. The resident, who was admitted with diagnoses including Dementia with behavior disturbance, Alzheimer's disease, and Schizophrenia, was prescribed Seroquel, Bupropion HCL, and Depakote. However, there was no documentation of side effects monitoring for any of these medications, nor were target behaviors specified for Bupropion HCL and Depakote. During an interview with the Director of Nursing (DON), it was confirmed that there was no documentation of side effects or target behavior monitoring for the resident's psychotropic medications. The facility's policy requires that all medications used to treat behaviors must have a clinical indication and be monitored for efficacy, risks, benefits, and adverse consequences. The DON acknowledged that nurses should monitor for side effects and target behaviors every shift and document this information, which was not done in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 11.9% during a medication administration observation, exceeding the acceptable threshold of 5%. This was due to five medication errors occurring out of 42 opportunities. Specifically, Resident 7 did not receive three prescribed medications: Amlodipine Besylate, Acidophilus Xtra, and Methenamine Hippurate. Resident 63 did not receive Ferrous Gluconate as scheduled, and Resident 75 did not receive Ferrous Sulfate as scheduled. Additionally, the nursing staff failed to flush Resident 67's gastrostomy tube with the correct amount of water as ordered by the physician. The errors were confirmed through interviews with the Licensed Vocational Nurse (LVN) involved, who acknowledged the unavailability of the medications and the incorrect procedure followed for the G-tube flushing. The facility's policy and procedure for administering medications were not adhered to, as medications were not administered in a safe and timely manner, nor in accordance with prescriber orders. The failure to administer medications as prescribed had the potential to compromise the health of the residents by not providing the full therapeutic effect of the medications.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during inspections and interviews. An insulin vial was found in the medication refrigerator without an open date or vial flip-off cap, which was confirmed by the Assistant Director of Nursing (ADON). Additionally, an insulin pen was found expired in the medication cart without any patient-specific labeling, and several insulin pens in different medication carts lacked open dates. Licensed Vocational Nurses (LVNs) confirmed these observations, acknowledging that the lack of labeling was not in accordance with the facility's policy. Further deficiencies were noted in the labeling and storage of other medications. Several bottles of Artificial Tears and a bottle of Brimonidine 0.2% Eye drops were found without open dates or resident identifiers. An Albuterol Sulfate HFA Inhalation Aerosol also lacked a resident identifier. The Pharmacy Consultant confirmed that medications should have open dates and resident names on the bottles. Additionally, the medication storage temperature log was incomplete, with no temperature monitoring recorded for two specific days, as confirmed by the ADON. The facility also failed to maintain secure storage of medications. A medication cart was left unlocked in the hallway, which was confirmed by a Registered Nurse (RN), who stated that the cart should always be locked. An open bottle of mucus relief DM tablets was found in the medication storage room without an open date, which was confirmed by the ADON. These practices had the potential to lead to medication errors and reduced potency of medications, as they were not in compliance with the facility's policies and procedures.
Infection Control Breach with Nebulizer Mouthpiece
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy when an uncovered nebulizer mouthpiece was found on a resident's bedside table. During an observation, the mouthpiece was noted to be exposed, which was confirmed by a Licensed Vocational Nurse (LVN). The LVN acknowledged that the mouthpiece should have been cleaned, washed, dried, and stored in a plastic bag to prevent infection. The Infection Preventionist also confirmed that the nebulizer mouthpiece should not be left exposed. The facility's policy, dated September 18, 2023, mandates maintaining an infection prevention control program to ensure a safe and sanitary environment, which was not followed in this instance.
Damaged Bedside Table Poses Risk to Resident
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for Resident 17, as evidenced by the condition of his bedside table. The table was observed to be damaged, with the surface material cracked and brownish material exposed beneath the original surface. Additionally, the plastic material that contours the edges of the tray table was broken, leaving sharp plastic edges exposed. This condition was noted during an observation on February 10, 2025, at 10:18 a.m., while Resident 17 was lying upright in bed with the table positioned in front of him. Resident 17, who was admitted to the facility with multiple diagnoses including Parkinsonism, epilepsy, major depressive disorder, and anxiety disorder, expressed dissatisfaction with the condition of his bedside table, describing it as 'ugly' and 'not smooth.' The Director of Nursing (DON) confirmed the poor condition of the table during an observation and interview on the same day, acknowledging that the table needed to be replaced. The failure to maintain the bedside table in a safe and sanitary condition had the potential to impact Resident 17's psychosocial well-being and self-esteem.
Undercooked Brown Rice Served to Residents
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, specifically when brown rice was undercooked and served to 18 residents. This issue was identified through observations, interviews, and record reviews. During a lunch test tray conducted with the Certified Dietary Manager (CDM), it was confirmed that the brown rice was undercooked and had a rough texture. The CDM admitted to not tasting the food prior to serving on that day. Resident interviews corroborated the issue, with complaints about the rice being undercooked and the chicken being tough. Further investigation revealed discrepancies in the cooking process. The Dietary Cook (DC) stated that the brown rice was cooked for one hour, although the facility's recipe indicated a shorter cooking time using a convection oven. The CDM acknowledged that there was no recipe for cooking brown rice for one hour and that the Registered Dietician (RD) was responsible for checking lunch trays. However, the RD stated that the CDM was responsible for tasting the food. The facility's document on Cook/Kitchen Staff duties emphasized the importance of preparing and serving meals that are palatable and appetizing, yet the policy for following menus was not provided upon request.
Failure to Document and Treat Resident's Wound
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident with a right heel wound. The resident, who had a history of diabetes and poor wound healing, experienced a reoccurrence of a previously resolved right heel wound. Despite the reoccurrence being documented on 6/6/24, there was no documentation of treatment being provided until 6/11/24, five days later. This lack of documentation and treatment was confirmed during an interview with a licensed nurse, who acknowledged the absence of records indicating treatment during this period. The facility's policy on Skin Integrity Management required the implementation of wound care treatments as indicated, which was not adhered to in this case. Additionally, the facility failed to accurately complete Weekly Summary Documentations for the resident. Despite the resident having a documented right heel wound, the Weekly Summary Documentations incorrectly indicated that the resident did not have skin issues on several occasions. This discrepancy was confirmed during a review of the resident's medical record with a licensed nurse. The facility's policy on Guidelines for Charting and Documentation required documentation to be concise, accurate, and complete, which was not followed, leading to inaccurate assessments of the resident's condition.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received a prescribed medication, Enoxaparin Sodium Injection, as ordered by the physician. The resident, who was admitted with multiple fractures and a dislocated hip, had a physician's order for the medication to be administered subcutaneously every 12 hours to prevent deep vein thrombosis. However, the medication was not documented as administered on several occasions in December 2023 and January 2024, as it was pending delivery from the pharmacy. During an interview, a licensed nurse confirmed that the medication was not administered because it had not been delivered from the pharmacy. The nurse acknowledged that the failure could have been due to either the nurses not ordering the medication refills on time or the pharmacy not delivering the refills on time. The facility's policies on medication administration and pharmacy services indicated that medications should be administered according to established schedules and that residents should have a sufficient supply of their prescription medications.
Failure to Ensure Safe Transfer of Resident
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer from bed to shower chair, as the Certified Nursing Assistant (CNA A) did not provide appropriate physical assistance and support according to the resident's needs. The resident, who had a medical history of hemiplegia, hemiparesis, abnormal gait, and muscle weakness, was assessed as high risk for falls. Despite this, CNA A did not use proper techniques or equipment, such as a gait belt, and did not position the shower chair close enough to the resident, resulting in the chair being kicked backward and the resident falling to the floor. Interviews with other staff members, including another CNA and a Licensed Vocational Nurse (LVN), indicated that proper procedures for transferring residents include using a gait belt and ensuring the shower chair is positioned close to the resident. The Director of Staff Development acknowledged that CNA A should have provided more support by placing a hand under the resident's armpit and ensuring the shower chair was appropriately positioned. The facility's policies on personal nursing care and safe lifting and movement of residents emphasize the need for staff to assist residents according to their needs and to be trained in the use of manual and mechanical lifting devices.
Failure to Administer Prescribed Antibiotic Eye Drops
Penalty
Summary
The facility failed to ensure that a physician's order for an antibiotic eye drop was documented and administered for a resident experiencing symptoms of blepharitis. The resident had complained of right upper lid swelling and discharge, leading the physician to plan for the administration of Cipro Ophthalmic drops. However, a review of the resident's records showed no documentation that the antibiotic was ordered or given. Interviews conducted with the physician and the assistant director of nurses (ADON) confirmed the oversight. The physician indicated that he would have ordered the antibiotic due to the resident's symptoms, while the ADON, upon reviewing the records, found no evidence of such an order. This lapse in documentation and administration of the prescribed treatment had the potential to cause health complications for the resident.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required 24-hour timeframe. Resident 1, who had no cognitive impairment and was self-responsible, filed a grievance on 1/27/24, alleging that a nurse shouted at her and touched her leg roughly. Despite the grievance being documented on the same day, the facility did not report the incident to the California Department of Public Health (CDPH) until 2/2/24. This delay in reporting resulted in a delay in the investigation of the abuse allegation. Resident 1 had been admitted to the facility following a motor vehicle accident and required high doses of opiates for chronic pain. The grievance detailed that the nurse entered Resident 1's room shouting and touched her leg roughly. The nurse received a written warning and was suspended from 2/2/24 to 2/7/24. During an interview, the Assistant Director of Nurses acknowledged the delay in reporting and confirmed that the grievance should have been reported within 24 hours, as per the facility's policy revised in August 2022.
Failure to Provide Social Services Support After Abuse Allegation
Penalty
Summary
The facility failed to provide appropriate social services support following an abuse allegation for a resident. An investigation into an employee-to-resident abuse allegation was conducted, and a review of the resident's medical record showed no documented evidence of a social services assessment focused on the resident's psychosocial well-being after the abuse allegation. During an interview, the Director of Nursing (DON) stated that there should be 72 hours of nursing monitoring every shift and social services psychosocial follow-up for 72 hours after an incident. However, the DON could not find any social services follow-up notes for the incident. The facility's job description for the Social Services Director indicated that residents should be assessed upon admission, quarterly, and upon a change of condition for social services needs, with thorough and timely psychosocial history and assessment completed for each resident. This documentation was not found in the resident's records.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monterey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cypress Ridge Care Center | 0.1 mi | ★★★★★ | 4 | 0 |
| Canterbury Woods | 1.6 mi | ★★★★★ | 11 | 0 |
| Forest Hill Manor Health Center | 1.6 mi | ★★★★★ | 2 | 0 |
| Westland House | 1.8 mi | ★★★★★ | 6 | 0 |
| Oceanview Post Acute | 1.9 mi | ★★★★★ | 15 | 0 |
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