Monterey Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 1) was provided their scheduled pain medications. This failure resulted in Resident 1 increased pain and emotional distress. During an interview on 3/3/26 at 11:19 A.M. with Resident 1, Resident 1 states he did not receive his medications on 2/13/26 , his scheduled pain medications causing him to have increased pain on the weekend. During a review of Resident 1's medical record, dated February 2026, the medication administration record (MAR) indicated Resident 1 did not receive medications on 2/14/26 scheduled at 10 a.m. During a concurrent interview and record review on 3/3/26 at 1:56 p.m. with the Director of Staff Development (DSD), the MAR for February 2026 was reviewed. The MAR indicated Resident Resident 1 received medications on 2/13/26 but not on 2/14/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received adequate supervision and monitoring to prevent accidents when one resident (Resident 1) left the facility without staff awareness and/or supervision and resulted in Resident 1 wandering along the road unprotected and was missing from the facility from 6:30 am to around 1:47 pm. This failure put Resident 1 at risk for medical complications and being struck by a motor vehicle. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment was in good repair by ensuring the water temperature for the dishwasher consistently reached 120 degrees Fahrenheit for both the wash cycle and rinse cycle. This failure had the potential to cause or spread food-borne illnesses to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure privacy was maintained for one of 19 residents' (Resident 6) clinical records, when registered nurse (RN) E's computer screen was left open and unattended in the resident room during medication pass. These failures had the potential to result in unauthorized access to a resident's health information. Findings During a medication administration observation on 2/10/25, at 4: 20 p.m., the med cart A containing an open laptop computer was left unattended in the hallway outside of a resident's room [ROOM NUMBER]. The laptop computer was on, and the screen displayed information about multiple residents, when RN E left to do handwashing at the nurse station after taking the blood sugar of the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to provide proper oxygen (a colorless, odorless gas) care and treatment services for two of 19 sampled residents (Residents 25 and Resident 224) when: 1. Resident 25 had an oxygen concentrator (a portable device that provides oxygen) at the bedside, but there was no oxygen signage posted on the door. 2. Resident 224 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. This deficient practice had the potential for accidents and hazards that could pose harm to residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to routinely assess the arteriovenous fistula (AV fistula, a connection surgically made between an artery and a vein for dialysis access) for one resident (Resident 22) who received dialysis (a procedure in which a machine filters wastes and fluid from the blood). This failure had the potential to result in unidentified complications with Resident 22's AV fistula.

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty for 8 consecutive hours for 2 days during the months of October, and December of 2024. This failure had the potential to affect resident's care, health, and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the controlled medications (drugs with high potential for abuse or addiction) were fully accounted for on the medication administration record (MAR) to indicate they were given for three out of six residents (Residents 4, 58, and 67) for these medications that were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). This failure had the potential for access to medications and supplies by unauthorized persons such as residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to monitor for side effects and target behaviors (behaviors intended to be changed or eliminated by medications) for one of five residents (Resident 69) who received psychotropic medications (medications that cause changes in mood, feelings or behavior). This failure had the potential to compromise the facility's ability to determine if the psychotropic medications were effective. This failure also put Resident 69 at risk for experiencing harmful effects from the medications.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 11.9% when five medication errors occurred out of 42 opportunities during the medication administration observation for three of six residents (Residents 7, 63, and 75) when: 1. Resident 7 did not receive three medications, Amlodipine Besylate tablet, Acidophilus Xtra Oral Tablet, and Methenamine Hippurate Oral tablet as prescribed; 2. Resident 63 did not receive the medication Ferrous Gluconate as scheduled; 3. Resident 75 did not receive the medication ferrous sulfate as scheduled.; and 4. The nursing staff did not flush the resident's gastrostomy tube (G-tube; a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications) as ordered by the physician during medication administration for Resident 67. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications according to the facility's policy and procedures (P&P) and/or manufacturer's specifications when: 1. One insulin vial with no vial flip -off cap (type of closure used for packing and sealing pharmaceutical products) was found with no open date in the medication refrigerator; 2. One insulin pen expired in the medication cart; 3. Medications were not properly labeled and stored in two of three inspected medication carts; a. Seven insulin pens had no open dates; b. Five Artificial Tears eye drop were unlabeled; c. One bottle of Brimonidine 0.2% Eye drops had no open date; d. One Albuterol Sulfate HFA Inhalation Aerosol had no label and identifier; 4. No temperature monitoring for two days in [DATE] for the medication refrigerator; 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection prevention and control policy and procedures when an uncovered nebulizer (a machine that turns liquid medicine into mist that is inhaled into the lungs) mouthpiece was found on Resident 30's bedside table. This failure had the potential for the resident to acquire an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' environment was maintained safe and sanitary when Resident 17's bedside table was damaged. This failure had the potential for injury, decreased self-esteem and the potential to affect Resident 17's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was palatable when brown rice was served undercooked for 18 Residents. This failure had the potential to harm the digestive tract (pathway for food to travel to the body) of residents and cause further health issues.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of four sampled residents (Resident 1) when: 1. There were multiple days for which there was no documentation of treatment to Resident 1's right heel wound; and 2. There were multiple Weekly Summary Documentations (resident assessments done on a weekly basis) that were not accurately completed. Failure to provide treatments had the potential to result in worsening of Resident 1's right heel wound. Failure to accurately assess had the potential to compromise the facility's ability to plan care and provide interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) received a medication as ordered. This failure had the potential to compromise the resident's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of one of two residents (Resident 1) when the Certified Nursing Assistant A (CNA A) did not provide appropriate physical assistance/support in accordance with Resident 1's needs and did not make sure the shower chair was close enough to Resident 1 during transfer from bed to shower chair. This failure put Resident 1's safety at risk.

Inspectors wroteBased on interview and record review the facility failed to ensure a physician's decision to administer an antibiotic eye drop was ordered and carried out for one of two sampled residents (Resident 1). This failure had the potential to cause health complications to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one allegation of abuse was reported to the California Department of Public Health (CDPH) within 24 hours for one sampled resident (Resident 1) when Resident 1 filed a grievance of an allegation of abuse on 1/27/24 but the facility did not report to CDPH until 2/2/24. This failure resulted in the delay of the abuse allegation investigation and had the potential to result in further abuse. Review of Resident 1's Face Sheet (document that contains a summary of personal and demographic information), indicated Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of fracture (break in bone) of neck, unspecified, subsequent encounter. Face Sheet further indicated Resident 1 was self-responsible. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate social services support following an abuse allegation for one of one resident (Resident 1). This failure had the potential to place Resident 1 at risk for psychosocial distress.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. The call button (device used by a resident to signal his or her need for assistance from professional staff) was within reach for two of 17 sampled residents (Residents 4 and 14) and one non-sampled resident (Resident 29); and 2. The call light (visual signal indicating a resident needs assistance) was answered in a timely manner for one of 17 sampled residents (Resident 7). These failures had the potential to negatively affect the residents' health, safety, and overall well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and/or update the comprehensive person-centered care plan (a written plan that is a means of communicating and organizing the actions of a constantly changing nursing staff to provide direction for consistent care of the resident) for six of 17 sampled residents (Residents 7, 11, 50, 55, 57, and 68) when: 1. For Resident 7, the facility failed to create and implement a care plan for Enoxaparin Sodium injections (medication-a blood thinner) and a wound vac device (vacuum-assisted closure of a wound is a type of therapy to help wounds heal); 2. For Resident 11, the facility failed to create a baseline fall care plan and failed to update interventions on the fall care plan; 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when controlled medication use audit for 4 out of 4 sampled residents (Residents 8, 28, 48, and 328) did not reconcile. The medications were signed out of the Narcotic Record (an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were given to the residents. The failure resulted in inaccurate accountability and had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 17 sampled residents (Resident 11) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 11 received paliperidone (an antipsychotic medication) at the daily dose of 6 milligrams (mg, unit of measurement), twice the ordered dose of 3 mg, for about three months; and 2. Resident 11 also received bupropion (medication for depression) without adequate indication. The failures resulted in excessive and unnecessary medications for the resident, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 17 sampled residents (Resident 11) was free of a significant medication error when Resident 11 received daily dose of paliperidone (an antipsychotic medication) 6 milligrams (mg, unit of measurement), instead of 3 mg as ordered, for about three months. The failure posed a risk for adverse consequences related to the medication (such as sedation, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss) to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dignity of one of 68 residents (Resident 18) when a staff member was standing over the resident while helping her eat, instead of sitting down. This failure had the potential to have a negative effect on the resident's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to notify the local long-term care Ombudsman (LTC Ombudsman, organization that routinely visits the facility and advocates on behalf of the residents) about hospital transfers for two of three residents (Residents 230 and 14). This failure had the potential to compromise the residents' admission, transfer, and discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to notify one of three residents (Resident 14), or the resident representative, of the facility's bed hold policy duration when the resident was transferred to the hospital. This failure had the potential to result in Resident 14 not being able to return to the facility after a hospital stay.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. One of five sampled residents (Resident 4) had and was wearing his hearing aids (small devices placed in the ear to amplify sound); and 2. An ophthalmologist (eye doctor) order for eye drops and reading glasses was carried out in a timely manner for one of five residents (Resident 11). These failures had the potential to compromise the residents' health, ability to relate to others, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the wound vac (vacuum-assisted closure of a wound is a type of therapy to help wounds heal) was set up according to the physician orders for one of 17 sampled resident (Resident 7). This failure had the potential to result in delayed wound healing and worsening of Resident 7's stage 4 pressure ulcer (a deep wound reaching the muscles, ligaments, or bones).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for three of six sampled residents (Residents 8, 30, and 52) when: 1. For Resident 8, the facility did not provide restorative nursing assistant (RNA, an exercise program) treatments as ordered; 2. For Resident 30, the facility did not apply splints (device used to maintain the position of a body part) as ordered; and 3. For Resident 52, the facility did not provide RNA treatments as ordered. These failures had the potential to cause declines in the residents' functional abilities.

Inspectors wroteBased on interview and record review, the facility failed to use a Hoyer lift (a mechanical device used for resident transfers) when transferring one of 11 residents (Resident 230). This failure resulted in Resident 230's second fall in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen in accordance with their policy for one of 17 sampled residents (Resident 55) when: 1. Resident 55's nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen source) was outdated; and 2. There was no Oxygen in Use sign displayed at the entrance of Resident 55's room. These failures had the potential to compromise the resident's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessments related to the use of side rails (device attached to the sides of the bed to act as a barrier or to help with movement in bed) were completed and accurate for two of 17 sampled residents (Resident 11 and Resident 50). This failure had the potential to increase the risk for injury to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 55) was seen by a mental health professional when requested. This failure had the potential to compromise the resident's mental, emotional, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the Consultant Pharmacist (CP) failed to identify and report irregularities to the facility related to medication regimen review (MRR); and the facility failed to carry out the CP's recommendation, for two of 17 sampled residents (Residents 11 and 50) and for Resident 27. These failures resulted in medication interactions, inadequate indication for use, and inadequate monitoring for the residents which had the potential to compromise their health.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 8.11% when three medication errors occurred out of 37 opportunities during the medication administration observation for two out of nine residents (Resident 27 and 34). Resident 34 received the wrong strength of an eye drop medication; and Resident 27 received two medications not in accordance with the physician's order and/or accepted professional standards of practice. These failures had the potential for the residents not receiving the full therapeutic effect of medications, or adverse affects, compromising the residents' health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure insulin pens and other medications were properly labeled as in accordance with the facility policy and procedures (P&P) and/or accepted professional standards; expired medications were removed from active stock; and the medication refrigerator temperature was monitored every day. The failure had the potential for mix-up errors; or for residents given expired medications. Also, unmonitored temperature could lead to loss of stability and efficacy of medications, which could lead to ineffective medications for the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper pest control in the kitchen, when two flying insects were observed near freezer #2 and the coffee maker. This failure had the potential to result in the spread of food borne illness to 67 out of 68 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in food services when: 1. there was ice build-up in one of two freezers 2. two bananas with brown spots were found inside the refrigerator 3. two plate warmers had dark brown and black substances 4. there was no air gap in the two compartment sink 5. there was no air gap in the dishwasher 6. there was an undated bag of cookies 7. there was a dented can of pineapple and a dented can of tuna These failures had the potential to result in cross contamination and cause food borne illness (illness caused by food or water contaminated bacteria, viruses, parasite, or toxins).

Inspectors wroteBased on interview and record review, the facility failed to ensure need was accommodated for one of three sampled residents (Resident 66) when the certified nursing assistant (CNA) did not provide her shower as scheduled. This failure had the potential to negatively affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to re-evaluate the PASRR (pre-admission screening and resident review, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) for one of four residents (Resident 2) when Resident 2 had a qualifying diagnosis of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). This failure had the potential to put the resident at risk for not receiving appropriate care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement care plans for four of 17 sampled residents (Residents 35, 39, 66, and 271) when: 1. For Resident 35, the facility did not develop care plans to address the use of Duloxetine (medication used to treat depression), Zolpidem (medication used to treat sleeping difficulty) and Heparin (blood thinner); 2. For Resident 39, the facility did not develop a care plan to address the use of Buspar (medication used to treat depression); 3. For Resident 66, the facility did not develop a care plan to address the use of Trazodone Hydrochloride (medication used to treat depression); and 4. For Resident 271, the facility did not develop a care plan when the resident acquired a blister (a pocket of body fluid [serum, blood, or pus] within the upper layers of the skin) on his left heel. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance for one of 17 residents (Resident 26) with activities of daily living (ADLs, activities such as grooming, hand washing, bathing, eating) when nursing staff did not clean Resident 26's hands and fingernails. This failure had the potential to spread infection to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards of practice for four residents (Residents 15, 48, 67, and 72) when: 1. For Resident 15, the licensed nurse did not wait at least five minutes between eye drop administrations; 2. For Resident 48, the facility did not obtain a physician's order to transfer her to the acute hospital; 3. For Resident 67, the facility did not list all of his allergies in the clinical record; also for Resident 67, the facility administered oxygen without a physician's orde and 4. For Resident 72, the facility did not notify the physician when Resident 72 was transferred to the acute hospital. These failures had the potential to negatively affect the residents' health, safety, and well-being.

Inspectors wrote2. Review of Resident 32's clinical record indicated she was admitted on [DATE] with diagnoses including peripheral neuropathy (weakness, numbness and pain in the hands and feet caused by nerve damage), encephalopathy (disease that affects brain function), and difficulty in walking. Review of Resident 32's physician's order, dated 1/11/19, indicated she was to receive RNA treatments consisting of omnicycle, shoulder and elbow exercises, sitting on the edge of the bed and on the wheelchair, and standing with a walker. Review of Resident 32's document Rehabilitation and Restorative Nursing Program, dated 1/8/19, indicated she was to receive the above RNA treatments five times a week, Monday through Friday. Resident 32's RNA treatment record was reviewed on 5/3/19. Review of the record indicated from 1/11/19 to 5/2/19, the RNA documentation was left blank 20 times. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 61) when the facility failed to develop and implement care plan interventions to prevent falls. These failures had the potential to result to an injury to Resident 61 from falls.

Inspectors wroteBased on interview and record review, the facility failed to implement a bowel and bladder training program for two of five sampled residents (Residents 66 and 5) who were assessed to be a candidate for bowel and bladder training (programs to train the bowels and bladder to control incontinence). This failure had the potential to cause the resident to decline in bowel and bladder control.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 17 sampled residents (Residents 35, 2, and 66) were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when: 1. For Resident 35, gradual dose reduction (GDR, stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued) was not attempted by the facility for zolpidem (hypnotic medication); 2. For Resident 2, the side effects of anti-depressant medication (trazodone) were not accurately assessed and monitored; and 3. For Resident 66, the indication for use of trazodone did not include a specific target behavior. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Residents 9 and 52) were provided with appropriate care and/or services under hospice care (provides medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness) and ensuring coordination of care between the facility and the hospice agency when: 1. For Resident 9, the facility did not have hospice nursing visit notes readily available in the resident's medical record. Also, the facility did not involve the hospice nurse during their multidisciplinary care conference . 2. For Resident 52, the facility did not complete an individualized hospice care plan and the hospice nurse was not included in the multidisciplinary care conference.