Montesano Health-Rehab Center

In the surveyor’s words

From the most serious findings on record at Montesano Health-Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Jun 18, 2026

  Based on interview and record review, the facility failed to conduct real time analysis of their infection control program for 10 of 10 months (August 2025 to May 2026) reviewed for monthly line listings and monthly maps summaries for the facility's surveillance program. These failures placed the facility at risk for failing to identify infection trends and implementing interventions that would prevent residents from acquiring facility related infections. Finding included. Record review of the facility's policy titled, Infection Prevention and Control Program [IPCP], dated 09/18/2023, documented 4. […]

• No harm, potential for more than minimal, isolatedF812Jul 27, 2026

  . Based on observation, interview and record review, the facility failed to ensure beverage cups were thoroughly cleaned for 1 of 6 sampled residents (Resident 1) reviewed for dietary services. This failure placed residents at risk for exposure to unsanitary conditions that promote foodborne illness and a diminished quality of life.Findings included. Record review of the facility policy titled, Warewashing, dated 01/2024, showed All cookware, dishware, and serviceware that is not processed through the dish machine will be manually washed and sanitized. In an interview, and observation on 07/27/2026 at 4:17 PM, Resident 1 said that she had been served milk and other fluids in what appeared to be dirty cups. […]

• No harm, potential for more than minimal, isolatedF550Jun 18, 2026

  Based on observation, record review, and interview, the facility failed to provide care and services in a manner that maintained and promoted dignity when staff stood next to the resident while assisting with meals for 1 of 4 sampled residents (Resident 3) reviewed for resident rights. This failure placed residents at risk for diminished self-worth, self-esteem, and feelings of embarrassment.Finding included . Resident 3 was admitted to the facility on [DATE] with multiple diagnoses, to include paraplegia (medical condition characterized by the loss of motor and sensory function in the lower half of the body). […]

• No harm, potential for more than minimal, isolatedF657Jun 18, 2026

  Based on interview and record review, the facility failed to include resident's representative in the care planning conference for 1 of 6 residents (Resident 51) who was moderately cognitively impaired and reviewed for care conferences. This failure placed residents at risk of unmet care needs and a diminished quality of life.Findings included.Resident 51 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 04/28/2026, documented Resident 51 was moderately cognitively impaired.Record review of Resident 51's Brief Interview for Mental Status (BIMS, a 0-15 standardized cognitive screening tool to assess attention, orientation, and memory, with higher scores indicating better cognitive health) completed on 04/23/2026 documented Resident 51's BIMS… […]

• No harm, potential for more than minimal, isolatedF677Jun 18, 2026

  Based on interview and record review, the facility failed to provide care with activities of daily living (ADL) for dependent residents to include bed baths and/or showers for 1 of 3 residents (Resident 36), reviewed for ADLs. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings included.Resident 36 was admitted to the facility on [DATE]. The 5-day Minimum Data Set, and assessment tool, dated 05/31/2026, indicated Resident 36 was alert and oriented.Record review, on 06/17/2026, of Resident 36's bathing task, dated 05/21/2026 through 06/17/2026, documented Resident 36 had not had a bed bath and/or shower since 06/09/2026, eight days since the last bed bath and/or shower. […]