Monterey Healthcare & Wellness Centre, LP

In the surveyor’s words

From the most serious findings on record at Monterey Healthcare & Wellness Centre, LP, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 20, 2024

  Based on observation, interview, and record review, the facility failed to prevent two of two residents (Residents 1 and 2) who were assessed at high risk for elopement (an act of leaving a care facility or safe area independently without notifying anyone) from leaving the facility in accordance with the facility's policy for elopement and residents' plan of care by failing to: 1. Provide adequate monitoring and supervision to ensure Resident I, who had fluctuating capacity to understand and make decisions, and was assessed at risk for elopement with diagnoses of suicidal ideation (thinking about killing yourself) did not elope from the facility on 9/10/2024 during a change of shift [evening shift and night shift) at 11 PM from Patio I. 2. […]

• No harm, potential for more than minimal, widespreadF880Mar 27, 2026

  Based observation, interview, and record review, the facility failed to implement proper infection control for 66 of 66 sample residents per the facility's Water Management Plan for the Prevention of Waterborne Pathogens (bacteria, viruses, or parasites found in contaminated water) by failing to ensure: 1. The Water Heater 1's mercury temperature gauge (a glass tube filled with mercury that can be used to measure changes in temperature) was not broken and functional. 2. The Water Heater 2's mercury temperature gauge reading was maintained at 110 degrees Fahrenheit ( F, a unit of temperature), not at 145 F. 3. The water temperature reading at Nursing Station A ranged from 86 F - 105 F, which was below the 110 degrees Fahrenheit as indicated on the facility's Water Management Program. […]

• No harm, potential for more than minimal, patternF656Mar 27, 2026

  Based on observation, interview, record review, the facility failed to develop and implement a comprehensive-person centered care plan for three of three sample residents (Resident 9, 35, and 5) by failing to ensure: 1. The care plan was not implemented for Resident 9 with a history of hemolytic anemia (a blood disorder where the red blood cells [RBC] are destroyed faster than the bone marrow can replace them, leading to fatigue, jaundice [yellowing of skin], and dark urine) to monitor the resident for signs and symptoms of anemia (a blood condition where there is not enough healthy RBC or hemoglobin [HGB, protein that carries blood to the tissues; normal range 11 - 16 grams per deciliter (g/dL)]). […]

• No harm, potential for more than minimal, patternF812Mar 27, 2026

  Based on observation, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety for the facility's one of one kitchen used by 66 residents when the facility did not ensure the dishwasher machine thermometer was functioning properly. This deficient practice had the potential to spread foodborne illnesses throughout the facility through dishes that were not sanitized properly. Findings: During an interview with the Dietary Supervisor (DS) on 3/24/26 at 9:18 AM and concurrent observation of the facility's kitchen, the facility's dishwashing machine was observed. […]

• No harm, potential for more than minimal, patternF726Feb 14, 2025

  Based on interview and record review, the facility failed to provide appropriate competencies in skills and techniques necessary to care for one of one resident (Resident 11) reviewed for competent nursing staff to care for resident with a diagnosis of Post-Trauma Stress Syndrome (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) that was identified through the resident assessments. This failure resulted in Resident 11 not receiving the appropriate skills related to his trauma and PTSD as identified through his resident assessments. […]