Inspection·November 14, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility reported incident review, and interviews, the facility failed to ensure residents remained free from staff to resident abuse and resident to resident altercations. This affected three residents (#144, #158, and #214) of 13 residents reviewed for abuse. The facility census was 118. Findings included: Record review revealed Resident #144 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, conversion disorder with seizures, anxiety disorder, sciatica, hypertension, major depression, post-traumatic stress disorder, nightmare disorder, and gastro-esophageal reflux disease. A minimum data set completed on 10/19/23 revealed Resident #144 had intact cognition and exhibited no behaviors. Interview on 10/13/23 at 10:10 A.M. with Resident #144 revealed Activity Director (AD) #257 would come up behind her to give her a hug, kiss the top of her head, and say inappropriate terms of endearment to her, such as you're fine as wine and you're sexy. Resident #144 stated she had given up activities for a brief period to avoid AD #257 until he was no longer employed at the facility. Interview on 10/13/23 at 2:34 P.M. with Resident #158 revealed she had reported AD #257 once he had exhibited inappropriate behaviors towards her, but after a brief suspension he came back and would give her smug looks. Resident #158 stated after his suspension, AD #257 did not exhibit inappropriate behaviors toward her. Interview on 10/13/23 at 2:46 P.M. with Resident #214 revealed she became uncomfortable around AD #257 when he would play with her hair even though she had repeatedly asked him to stop. Review of a facility reported incident (FRI), #239578 completed on 09/25/23, revealed the facility did investigate AD #257 for inappropriate behaviors and he was suspended pending the investigation. The facility investigation included interviewing staff, residents, and AD #257 as well as a skin check and a pain assessment for Resident #144. Among the interview residents included Resident #158 who stated AD #257 had hugged her and called her beautiful before who told AD #257 not to hug her anymore and Resident #214 who stated she was hugged by the AD #257 before but he did not do it again once she asked him not to. Review of personnel file for AD #257 revealed he was hired December 2022 with no evidence of an orientation being completed upon hire, including resident rights and abuse education. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365077 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Care Center 3929 Hoover Road Grove City, OH 43123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)