Monterey Palms Health Care Center

Inspectors wroteBased 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. For Resident 2, the facility did not facilitate transportation to a scheduled chemotherapy (drug treatment that uses powerful medications to destroy cancer cells) appointment scheduled on June 22, 2026. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure communication with the physician was entered into the resident's chart for one of six residents reviewed (Resident 2) when nursing staff did not document communication with the physician regarding Resident 2's low hemoglobin (Hgb-red blood cells can't carry enough oxygen to your tissues) laboratory result. This failure had the potential for Resident 2 to have a delay in care due to information not being readily available in the resident's medical record.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident's diet as ordered by the doctor (Dr) and did not include the resident's preferences and dislikes for one of three residents (Resident 1). This failure resulted in the facility providing Resident 1 with a clear liquid diet (all food in liquid form), instead of a regular diet (solid foods) as ordered and did not include the residents' preferred foods.

Inspectors wroteBased 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. Storing two boxes of one medication requiring refrigeration, at room temperature in the drawer of one of two medication carts inspected. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. (Cross reference 805). These failures had the potential to negatively impact on the residents' nutritional status and further compromising residents' medical status.1. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' food preference were honored for seven out of 30 sampled residents (Resident 12, 41, 46, 66, 88, 101 and 104) during lunch on 5/11/2026 and 5/12/2026. This failure had the potential to result in decreased food intake, further compromising Resident 12, 41, 46, 66, 88, 101 and 104's nutritional and medical status. On May 11, 2026, at 12:13 p.m., a concurrent observation, interview and meal ticket (contains Resident name, room number, physician diet order, Allergies, food like and dislike) review were conducted with Resident 104 and Social Services Assistant (SSA) at dining room. Review Resident 104's meal ticket indicated, Preferences: Ice cream. Observed served food items, there was no ice cream. Resident 104 stated, I want ice cream for my lunch and dinner. [...]

Inspectors wroteBased on meal distribution observation, interview and record review, the facility failed to ensure physician ordered diets were followed when:1. Residents on Renal diet being served high sodium and potassium foods during lunch on 5/11/2026.2. Resident 104 on large portion did not receive large portion during lunch on 5/11/2026 and 5/12/2026.3. Resident 104 on No added salt diet being served with salt package during lunch on 5/12/2026.4. Resident 55 on high calories, high protein and high fiber diet did not receive high calories, high protein and high fiber during lunch on 5/11/2026. These failures had the potential negative impact on the residents' medical and nutrition status and in severe instances may result in hospitalization or death.1. [...]

Inspectors wroteBased on dietary observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:1. Ice machine in kitchen found grime buildup on ice maker.2. Dust found on several pieces of equipment and area.3. Grime buildup found on several pieces of equipment.4. [NAME] 1 had exposed facial hair during meal preparation. These failures had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) and foodborne illnesses (are illnesses that results from ingesting contaminated foods) for 85 out of 85 sampled residents who received foods from the kitchen.1. On May 12, 2026, at 11:08 a.m., a concurrent observation and interview were conducted with the RD in the kitchen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely maintenance of equipment when:1. The walk-in freezer was maintained in good working condition with ice condensation buildup.2. Rust found on several shelves in kitchen.3. Two worn out cooking pans with missing nonstick coating found in kitchen.4. Chipped paint found in several pieces of equipment in kitchen. These failures had the potential to cause food borne illnesses and poor quality of food served to a population 85 out of 86 sample residents who received food from the kitchen.1. On May 11, 2026, at 10:10 a.m., a concurrent observation and interview were conducted with the Registered Dietitian (RD) in the walk-in freezer. Ice condensation was observed on the ceiling, on the black pipe behind ventilator, on storage shelves below ventilator. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was documentation in the medical record the resident or the responsible party was fully informed with material information provided by the prescriber to be able to make informed decisions prior to starting a psychotropic medication for one of five residents reviewed (Resident 114). This failure had the potential for the residents to receive unnecessary medication. On May 12, 2026, the medical record of Resident 114 was reviewed and the following was noted: Resident 114 was [AGE] years old, admitted to the facility on [DATE], with diagnoses that included dementia with psychotic disturbance, major depressive disorder, and anxiety disorder; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a proper diagnosis and indication associated with the use of one psychotropic medication for one of five residents reviewed (Resident 114). This failure had the potential for the residents to receive unnecessary medication. On May 12, 2026, the medical record of Resident 114 was reviewed and the following was noted: Resident 114 was [AGE] years old, admitted to the facility on [DATE], with diagnoses that included dementia with psychotic disturbance, major depressive disorder, and anxiety disorder; Resident 114 had a physician order on May 4, 2026, for ramelteon 8 mg by mouth daily 30 minutes prior to bedtime without an indication or diagnosis, which was discontinued on May 7, 2026; Resident 114 had a physician order on May 7, 2026, for ramelteon 8 mg by mouth daily at bedtime for supplement; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and treatment for an injury/wound to prevent decline in skin integrity for a right second toe injury for one of 21 residents reviewed (Resident 3). This failure resulted in the wound going unmonitored, placing the resident at risk for infection and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one resident (Resident 85) reviewed for oxygen (O2) use when the nasal cannula (NC - a tube used to deliver oxygen through the nose) was not dated when it was last replaced. This failure had the potential to result in deterioration of the nasal cannula, which would allow infectious organisms to grow, causing an infection.

Inspectors wroteBased on observation, interview, and record and document review, the facility failed to ensure accurate and complete record of controlled substances (CSs), free of discrepancies when the remaining volume in the one pharmacy-labeled bottle containing hydromorphone (a federally scheduled II CS which has the highest potential for addiction and abuse) 5 mg/5 ml (5 milligram per 5 milliliter, unit of concentration of a liquid) oral solution did match the corresponding CS dispense log. This failure could lead to potential diversion of CS and residents not receiving medications needed for pain relief. On May 13. 2026, at 1:49 p.m., during a controlled substance (CS) audit in E Court Medication Cart 1 with Licensed Vocational Nurse (LVN) 1, the following was noted: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 57) was provided with special adaptive equipment as ordered by physician for eating with meals. This failure had the potential to result in a burn accident while Resident 57 drinking hot beverage. On May 11, 2026, at 12:28 p.m., a concurrent observation and meal ticket (contains Resident name, room number, physician diet order, allergies, adaptive equipment, food like and dislike) review were conducted with Resident 57 at Assisted Feeding dining room. Resident 57's meal ticket indicated, 2 Handled cup (sippy cup). Resident 57 was observed being used regular cup serving beverage. On May 12, 2026, at 12:42 p.m., an observation was conducted with Resident 57 at Assisted Feeding dining room. Resident 57 was observed both of her hands were shaking intensely. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash were found outside surrounding the dumpsters. And the lids of the dumpsters did not close properly due to overflowing. This failure had the potential to attract pests and rodents. On May 11, 2026, at 9:39 a.m., a concurrent observation and interview were conducted with the Dietary Supervisor (DS) outside back kitchen at dumpster area. There was three dumpsters, one for recycle and another two for trash. The lids of the two trash dumpsters were unable to fully close due to overflowing with trash. Trash was found on floor surrounding the trash dumpster area. One of the recycled dumpster's lid was widely opened. The DS stated surrounding dumpsters should not have trash and dumpsters' lids should close properly to prevent attract pests. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) was treated with dignity and respect when a staff member called the resident a liar after the resident alleged the staff member had purposely hit his elbow away while providing resident care. This failure resulted in Resident 1 becoming upset and angry.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of residents when two of four sampled residents' (Resident 3 and Resident 7) medications were not administered in accordance with the physician orders. This failure has the potential to negatively impact the effectiveness of the medication which could lead to worsening of Residents 3 and 7's health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained in accordance with the accepted professional standards and practices when three of four sampled residents' (Resident 3, Resident 5, and Resident 6) medication administrations were not accurately documented. This failure increased the risk for medication errors which could negatively impact Residents 3, 5, and 6's health condition.

Inspectors wroteBased on dietetic service observations, dietary staff interviews and dietary document reviews the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. Dietary Aide (DA) 2 did not follow manufacture's guideline time length for testing the Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces); 2. [NAME] 2 did not follow the proper steps to clean the Prep counter after preparing raw chicken on January 28, 2025, (Cross reference to 812); and 3. [NAME] 1 was unable to demonstrate proper Cooling Food (an essential process used in food production to prevent foodborne illness. Bacteria grow best in food in the temperature range 135°F (°F - a unit of measurement) to 41°F, also referred to as the temperature danger zone. Food must be cooled quickly to minimize bacterial growth. [...]

Inspectors wroteBased on dietary observation, dietary staff interview and record review, the facility failed to ensure the menus, recipes, Cooks spreadsheet were followed and resident nutritional needs were met when: 1. [NAME] 1 and [NAME] 2 did not follow the Cooks spreadsheet (the menu document used to guide dietary staff on food items, portions, texture of foods and therapeutic diet) to serve the portion size of pureed food items during the noon meal on 1/27/2025 and 1/28/2025; 2. [NAME] 1 did not follow recipe to make pureed cauliflower during the noon meal on January 27, 2025; 3. [NAME] 2 did not follow recipe to make Buttered corn during the noon meal on January 28, 2025 (Cross reference 804); 4. Dietary Aide 1 did not follow the Cooks spreadsheet served the right dessert for Low fat low cholesterol diet and Cardiac diet during the noon meal on January 28, 2025; and 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure to provide appetizing and palatable (refers to the taste and/or flavor of the food) food at appropriate temperatures according to residents' preferences, for seven out of 89 sample residents, Residents 23, 43, 47, 82, 84, 96 and 99. This failure placed residents at risk for decreased nutritional intake and had the potential to affect the resident's nutritional status.

Inspectors wroteThe facility failed to maintain a sanitary environment, prepare, and serve food in accordance with the professional standards for food service and safety when: 1. Kitchen equipment was stored wet; 2. Dust was found on several locations in the kitchen; 3. Build-up on kitchen equipment: on storage shelves in walk in freezer, on the blender machine, ice machine and hot waterspout; 4. Two opened tortillas exposed to the air in walk in refrigerator; 5. Ground beef was placed in walk in refrigerator for defrosting without a label; 6. Strainer had brown spots on the sieve (mesh in the strainer frame); 7. Two cracked tiles and one broken tile found in dishwashing area; 8. Four jackets found on the rack in storage area number 2; 9. One cutting board was marred found in kitchen; and 10. Cook 2 did not follow proper steps to clean the prep counter after preparing raw chicken. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered care plan was developed and implemented for a resident with a new diagnosis of pulmonary emboli (a condition in which one or more arteries in the lungs become blocked by a blood clot) and on anticoagulant (medication used to prevent blood clots from forming or growing larger) treatment. This failure had the potential to delay the necessary care and services which could place Resident 24 at risk for another life-threatening blood clot or other complications that could develop related to the treatment with an anticoagulant.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain cleanliness and proper hygiene of resident's fingernails for one of 19 residents reviewed (Resident 29). This failure had the potential to negatively impact the physiological and psychological well being of Resident 29. In addition this failure had the potential to result in cross contamination of bacteria underneath the dirty fingernails to Resident 29's food during meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were properly stored when: 1. One of 36 residents reviewed (Resident 47) had a bottle of medication from an outside pharmacy by her bedside, readily available for use; 2. Three expired Daptomycin antibiotic (medications used to treat infections) intravenous piggyback (IVPB - a method of administering IV antibiotics by piggybacking it to a primary IV fluids) were stored in the F Court medication room refrigerator for Resident 68, readily available for use. These failures had the potential for the residents to self-administer a medication without licensed nurse monitoring and to receive expired or ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's food preference was honored for one of three sampled residents (Resident 50), when a turkey sandwich was on Resident 50's lunch plate and the meal ticket (lists resident's current diet, likes and dislikes for the current day and mealtime) indicated she disliked turkey and liked cottage cheese. This failure had the potential to result in decreased food intake, and could lead to unplanned weight loss, further compromising Resident 50's nutritional and medical status.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash was found outside on the floor surrounding the dumpsters, and the lids of the dumpsters did not close properly. This failure had the potential to attract pests and cause infection control issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control measures for one of 19 residents reviewed for infection (Resident 507) who required contact isolation precautions (method to prevent the spread of serious illnesses that can be transmitted by direct or indirect contact), when multiple staff members were observed entering and exiting the resident's room without following contact isolation precautions. This failure had the potential to result in spreading infection to a vulnerable resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure basic accommodations of needs were provided when one of three residents, (Resident 3)'s call light was not within reach. This failure resulted in Resident 3 to be unable to call for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call lights (devices that emit a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff), were answered timely, when two out of five residents (Residents 1 and 5), who required assistance from staff with activities of daily living (ADLs), verbalized their concerns of facility staff not answering their call lights and/or attending to their needs in a timely manner. This failure had the potential for delayed medical management and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of three trash dumpster lids were securely closed. This failure had the potential to attract pests, insects, and vermin (animals that are believed to carry diseases such as rodents [rats/mice]) which could create an unsanitary environment for the vulnerable residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from abuse when his arm was held down by a Certified Nurse Aide's (CNA) knee while attempting to dress him. This failure resulted in Resident 1 being subjected to physical abuse, which had the potential to result in physical injury, emotional and psychological distress.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess, and monitor neuro-checks (a neurologic function assessment tool used to assess and monitor a resident's level of consciousness) on one of four residents (Resident 1), after an unwitnessed fall. This failure had the potential to result in an unassessed altered level of consciousness (ALOC- state of decreased awareness and/or arousability), and delay of treatment for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to maintain a comfortable environment for residents residing in one of the facility's nursing stations (F court nursing station) when temperatures were measured greater than 81 degrees Fahrenheit. This failure had the potential to result in uncomfortable temperatures for residents residing in F court nursing station.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure stored medical supplies were current when expired intravenous (within the vein) medication tubing was found in the facility's medication storage room. This failure had the potential to cause all of the facility's four residents receiving intravenous therapy to be exposed to expired intravenous equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the over-the-counter (OTC) medication, hydrogen peroxide (an antiseptic solution) brought by the resident's family member was stored properly and was ordered by the physician for one of 20 residents reviewed (Resident 14). In addition, the facility failed to provide care and services in accordance to their policy and procedure and in accordance with professional standard of practice. This failure had the potential for the hydrogen peroxide to cause irritation of Resident 14's mouth and cause side effects to the resident's teeth and may cause breathing problems if not properly used.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter (a plastic flexible tube inserted into the bladder to collect urine) was monitored and assessed for the presence of sediment (particles or mucus) in the urine for one of two residents reviewed for catheters (Resident 16). This failure had the potential to delay the identification and treatment of a possible urinary tract infection for Resident 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary food preparation and storage practices were followed when: 1. One box of Tricolor Penne Pasta was left open to air; and 2. Gravy stored in a metal container was readily available for use after the use-by-date had already passed. These failures had the potential to expose residents to foodborne illness.