Inspection citations
11’19
21’23
7’24
15’25
1’26
55 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Mar 10, 2026 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Complaint |
| Dec 11, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 13, 2025 | D · potential | Keep residents' personal and medical records private and confidential. | Routine |
| Feb 13, 2025 | D · potential | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Routine |
| Feb 13, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Feb 13, 2025 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Feb 13, 2025 | D · potential | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Routine |
| Feb 13, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Feb 13, 2025 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Feb 13, 2025 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Feb 13, 2025 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Feb 13, 2025 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Feb 13, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 13, 2025 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Feb 13, 2025 | E · potential | Keep all essential equipment working safely. | Routine |
| Feb 13, 2025 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| Oct 9, 2024 | D · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Complaint |
| Sep 30, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Sep 30, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Sep 23, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Aug 14, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| May 29, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| May 3, 2024 | D · potential | Provide medically-related social services to help each resident achieve the highest possible quality of life. | Complaint |
| Jun 30, 2023 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jun 30, 2023 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Jun 30, 2023 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Routine |
| Jun 30, 2023 | D · potential | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | Routine |
| Jun 30, 2023 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jun 30, 2023 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Jun 30, 2023 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Jun 30, 2023 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Jun 30, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jun 30, 2023 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jun 30, 2023 | D · potential | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Routine |
| Jun 30, 2023 | D · potential | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Routine |
| Jun 30, 2023 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jun 30, 2023 | D · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Jun 30, 2023 | E · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Jun 30, 2023 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jun 30, 2023 | E · potential | Ensure that residents are free from significant medication errors. | Routine |
| Jun 30, 2023 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Jun 30, 2023 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 30, 2023 | F · potential | Keep all essential equipment working safely. | Routine |
| Jun 30, 2023 | D · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Routine |
| May 3, 2019 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| May 3, 2019 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| May 3, 2019 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| May 3, 2019 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| May 3, 2019 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| May 3, 2019 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| May 3, 2019 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| May 3, 2019 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| May 3, 2019 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| May 3, 2019 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| May 3, 2019 | D · potential | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Monterey Post Acute
1575 Skyline Drive, Monterey, CA 93940 · (831) 373-2731
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055962
- Certified beds
- 78
- Legal owner
- Windsor Monterey Care Center LLC
- Part of
- Windsor
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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