Monterey Care Center

In the surveyor’s words

From the most serious findings on record at Monterey Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 10, 2025

  THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility incident report, resident and staff interview, and facility policy review, the facility failed to ensure a resident was safely transferred by a mechanical lift. This resulted in Actual Harm on 05/27/25 when one staff attempted to transfer Resident #103 from the wheelchair to the bed with the mechanical lift and the strap to the lift pad tore and Resident #103 dropped to the floor. Resident #103 was observed by staff to have one missing tooth, and one tooth was broken in half at the time of the incident. Resident #103 was sent to the hospital and returned to the facility with no other injuries noted. […]

• No harm, potential for more than minimal, widespreadF812Apr 1, 2025

  Based on observation, record review, and staff interviews, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility except one (Resident #34) who was ordered nothing by mouth (NPO) and didn't receive food from the kitchen. The facility census was 111. Findings include: Observation of the kitchen on 03/31/25 at 11:20 A.M. revealed Staff #41 was preparing lunch trays without wearing a beard restraint over his beard. Interview on 03/31/25 at 11:20 A.M. Staff #41, verified he wasn't wearing a beard restraint, and one was required when preparing food for the residents. Interview on 03/31/25 at 11:26 A.M. […]

• No harm, potential for more than minimal, widespreadF812Nov 24, 2024

  Based on observation and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents who received food from the kitchen. The facility identified one resident (#60) who consumed nothing by mouth. The facility census was 108. Findings include: Observations and interview on 11/18/24 at 9:30 A.M. with Dietary Manager (DM) #118 revealed an area in the center of the kitchen was about an inch lower than the rest of the kitchen. This area contained cooking equipment such as the oven, fryer, and soup kettle. In this area, the floor (which was supposed to be a red tile) had a thick black build up, and had a large amount of food and other debris including a dome lid, plastic utensils, and French fries. […]

• No harm, potential for more than minimal, widespreadF880Nov 24, 2024

  Based on record reviews, staff interview, review of the Centers for Disease Control and Prevention, and review of the facility policy, the facility failed to ensure the Water Management Program was timely and appropriately implemented to prevent the spread of Legionella. This had the potential to affect all 108 residents residing in the facility. Findings include: Review of the facilities Water Management Program logs revealed no evidence of testing or interventions to prevent Legionella were present prior to 10/2024. Interview with the Administrator on 11/19/24 at 10:27 A.M. confirmed there was no record of water testing, flushing, or any other Legionella prevention measures being conducted prior to 10/2024. […]

• No harm, potential for more than minimal, widespreadF921Nov 14, 2023

  Based on observation and interview, the facility failed to provide a safe and sanitary environment for residents who use the facility shower rooms. This had the potential to affect all 118 residents in the facility. Findings included: Observation on 11/13/23 at 10:30 A.M. of the shower room at the corner of the South and East hallways revealed three large, untied garbage bags on the floor with soiled linens, three small tiles missing from the floor, the back wall of the shower had a black, filmy substance on it, a container of sharps that was overfilled, several large, red biohazard bags piled in the front left corner, a pair of used gloves on the sink, a rancid odor, and several linens were laying out on an over the bed table in the right front corner. Interview on 11/13/23 at 10:35 A.M. […]