Monterey Palms Health Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF684Jul 21, 2026

  Based on interview and record review the facility failed to provide the necessary care and services for two of six residents reviewed (Resident 1 and 2) when:1a. For Resident 1, nursing staff failed to notify the physician of changes in vital signs, as indicated in the physician orders, on December 6, December 13, December 16, and December 22, 2025;1b. For Resident 1, nursing staff failed to administer Milk of Magnesia (medication used for constipation) as indicated in the physician orders on December 1 - 2, December 5 - 6, December 12 - 13, December 15, December 18, and December 25, 2025; and 2. […]

• No harm, potential for more than minimal, patternF761May 14, 2026

  Based on observation, interview, and record and document review, the facility failed to ensure proper labeling and storage of medications that met the requirements of the facility's policy and procedures consistent with State and Federal law and manufacturer's specifications by: 1. Not maintaining the temperature of the medication room, specified by the drug manufacturers, at or below 77 F (Fahrenheit, unit of temperature measurement) in one of one medication room inspected;2. Storing residents' prescription medications without a pharmacy label in one of two medication carts inspected;3. Storing and not removing timely an expired, open, multi-dose vial of Humulin R (medication to control high blood sugar) in one of two medication carts inspected; and4. […]

• No harm, potential for more than minimal, patternF802May 14, 2026

  Based on observation, interview, and record review, the facility failed to ensure dietary staff were trained and competent to carry out the functions of the department safely and effectively when1. Diet Aide 1 did not follow standard practice to clean the soil meal cart.2. [NAME] 3 unable performed spoon testing for pureed diet and fork testing for Minced and Moist diet. (Cross reference 805)These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food), choking and/or aspiration and further in a medically compromised 85 out of 85 sample residents who received foods from the kitchen.During a review of FDA (Food & Drug Administration) Food Code, 2022, the FDA Food Code indicated, Failure to maintain clean wash, rinse, and sanitizing… […]

• No harm, potential for more than minimal, patternF803May 14, 2026

  Based on observation, interview, and record review, the facility failed to ensure1. [NAME] 1 used the right scoop served Minced and Moist meat during lunch on 5/11/2026.2. [NAME] 2 used the right scoop served pureed dessert during lunch on 5/11/2026.3. [NAME] 3 used the right scoop served Beef Stroganoff for Residents on Regular diet, Easy to chew, Soft and Bite Sized, and Minced and moist during lunch on 5/12/2026.4. [NAME] 3 followed recipe preparing pureed cauliflower during lunch on 5/12/2026. Failure to follow recipe resulted in pureed cauliflower unable hold its shape (running) on plate and which compromise swallowing safety and increase the risk of choking and/or aspiration. […]

• No harm, potential for more than minimal, patternF805May 14, 2026

  Based on observation, interviews, and record review, the facility failed to ensure the appropriate food textures was provided when1. Residents on pureed diet received grainy pureed beef, lumpy bread and running pureed cauliflower during lunch on 5/12/2026. (Cross reference 802, and 803)2. Residents on Minced and Moist received wrong texture for beef, noodle and cauliflower during lunch on 5/12/2026.3. Residents on Soft and Bite Sized received wrong texture for noodle during lunch on 5/12/2026.4. Resident 88 and 20 received wrong broccoli texture during lunch on 5/11/2026.5. Resident 20 received wrong dessert texture during lunch on 5/11/2026.These failures had the potential to place the residents at risk of aspiration (when food is breathed into the lungs) and choking.1. […]