Monterey Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF607Apr 15, 2021

  Based on interview and record review, the facility failed to ensure a resident (Resident 1) was free from physical and mental abuse, and failed to ensure a staff (certified nursing assistant B, CNA B) who was a witness had immediately reported the incident for one of two sampled residents when: 1. Nurse Assistant A (NA A) pinned down Resident 1; and when 2. CNA B did not immediately report the incident to the charge nurse upon witnessing it. This failure resulted in emotional distress to the resident and the failure of late reporting delayed action to protect Resident 1 and other residents from the potential of further abuse. […]

• No harm, potential for more than minimal, widespreadF812Jun 30, 2023

  Based on observation, interview, and record review, the facility failed to: 1. Ensure the kitchen's two-compartment sink had an air gap (physical space or separation between the drain pipe and the floor); and 2. Properly label residents' food that was brought in from outside the facility and stored in the resident refrigerator/freezer. These failures had the potential to result in food borne illness for 67 out of 68 residents. Findings: 1. During an observation and subsequent interview with the dietary manager (DM) and cook 1 (CK G) on 6/26/23 at 7:47 a.m., an air gap under the two-compartment sink was not visible. A metal mesh band was wrapped around the drain pipe at floor level. The DM and CK G stated they were not sure where the drain pipe ended. […]

• No harm, potential for more than minimal, widespreadF908Jun 30, 2023

  Based on observation, interview, and record review the facility failed to ensure equipment was maintained in good repair when the water heater for the kitchen dishwasher had been broken for over one month. This failure had the potential to result in food borne illness for 67 out of 68 residents. Findings: During a kitchen observation and concurrent interview with the Dietary Manager (DM) on 6/26/23 at 9:31 a.m., the DM stated the dishwasher was not reaching the proper water temperature. […]

• No harm, potential for more than minimal, patternF804Feb 13, 2025

  Based on observation, interview and record review, the facility failed to serve food at an appetizing temperature for one item out of seven food items that were served during the lunch meal. This failure had the potential for causing food-borne illness due to the food item not being at the correct temperature. Findings: During an observation on 2/10/25 at 11:45 AM, the morning cook (MC) took the temperature of a tray of fried chicken, and got a reading of 168 degrees Fahrenheit with his thermometer. […]

• No harm, potential for more than minimal, patternF812Feb 13, 2025

  Based on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices when multiple food items did not have a opened on or use by date even after opening the item. This failure had the potential to spread food-borne illnesses to residents in the facility. Findings: During an observation on 2/9/25 at 9:18 AM, multiple food items were noted in the refrigerator with a date that say R 2-2-25, or R 1-28-25 but with no other dates. One carton of soy milk was noted to be half full, and the cap is open, but there is no date on it. One packet of parmesan cheese had no date written on the package. […]