Inspection·July 9, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident records, staff interviews, and review of facility policy, the facility failed to provide documented evidence of good faith efforts to notify a former resident of an active urinary tract infection. This affected one former resident (Former Resident #115) out of four residents reviewed for urinary tract infections. The facility census was 113 residents. Findings include: Review of the medical record for Former Resident (FR) #115 revealed he was admitted to the facility on [DATE] with diagnoses including retention of urine and presence of urogenital implants. Review of FR #115's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed that he was cognitively intact and that he had an indwelling catheter. Review of FR #115's nursing progress notes dated 06/22/25 revealed that FR #115 was observed with intermittent confusion. The physician was called, and a new order was made to obtain a urinalysis and culture and sensitivity (UA C&S). Nursing progress notes dated 06/24/25 revealed that the urine was collected and picked up by the laboratory. Review of FR #115's social work progress notes dated 06/24/25 revealed that FR #115 desired to leave the facility Against Medical Advice (AMA). Review of nursing progress notes dated 06/25/25 revealed that FR #115 left the facility AMA. Review of FR #115's labs that resulted on 06/26/25 at 1:16 P.M. revealed that his urine growth was over 100,000 Escherichia coli (E. coli) bacteria, which was indicative of a urinary tract infection, and that it was susceptible to many options of antibiotics. Review of FR #115's medical progress notes and medical record revealed no documented evidence of facility notification to the resident or family regarding FR #115's UTI/laboratory results. Interview with the Administrator on 07/09/25 at 9:52 A.M. revealed that if a former resident decided to leave the facility AMA prior to receiving their laboratory (lab) results, if the facility received the labs back after the resident discharged , she would expect that the former resident would be notified of abnormal results. Interview with the Director of Nursing on 07/09/25 at 10:36 A.M. revealed that if a resident left the facility AMA, when they received lab results that resulted after the resident left the facility, the results would be sent to the physician for review. The DON indicated that it would be no different for a current resident that received abnormal lab results, than it would be for a former resident who had left the facility AMA and that they would be informed of the results. Interview with DON on 07/09/25 at 10:43 A.M. stated that FR #115 left AMA when he had a urinalysis pending. DON confirmed on 07/09/25 at 10:43 A.M. that FR #115's chart did not have documentation that FR #115 was informed of his lab results and that he had a urinary tract infection. Interview with Unit Manager #161 on 07/09/25 at 11:00 A.M. confirmed that she did not speak with FR #115 or FR #115's resident representative about the abnormal urinalysis report or urinary tract infection. Unit Manager #161 confirmed that she did not document that she attempted to contact FR #115 or FR #115's resident representative about his urinary tract infection. Review of a facility policy titled, Change in Condition, dated 08/09/23, revealed that a nurse will notify the resident and/or (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 2 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 07/09/2025 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)