Other·July 18, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding an entity reported incident investigation conducted 6/30/17 and 7/06/17. For Entity Reported Incident CA00540799 regarding Quality of Care/Treatment, a level "G" deficiency was identified, F323, 483.25(d) (1)(2)(n)(1)-(3). In addition, a Class "B" Citation was identified. For Entity Reported Incident CA00540153 regarding Misappropriation of Property, the Department did not substantiate a violation of federal or state regulations. Inspection was limited to the specific entity report incidents investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 27007, Health Facilities Evaluator Nurse.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 07/22/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KQXF11 Facility ID: CA070000035 If continuation sheet 1 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555090 (X3) DATE SURVEY COMPLETED 07/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC COAST POST ACUTE 720 E Romie Ln Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and facility records, the facility failed to ensure Certified Nursing Assistant (CNA) E had a follow-up background screening when the background screening company identified a discrepancy with the employee's Social Security Number. In addition, the facility failed to ensure CNA E had proper documentation to continue working in the United States. This has the potential for allowing an employee to work illegally at the facility and places residents in risk of potential abuse. Findings: On 6/30/17 at 11:30 a.m. CNA E's employee file was reviewed. His background screening FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KQXF11 Facility ID: CA070000035 If continuation sheet 2 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555090 (X3) DATE SURVEY COMPLETED 07/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC COAST POST ACUTE 720 E Romie Ln Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE check dated 3/5/08, showed the facility was to reconfirm the CNA's Social Security Number. The background paperwork showed a note: "database records indicate this Social Security Number is not associated with your individual. Please verify this information with your applicant." In addition, CNA E's Permanent Resident Card (a card to show the employee was able to work in the United States legally) had expired on 5/19/14. No documentation was available to show the facility reconfirmed CNA E's Social Security Number, or obtained an updated Permanent Resident Card. During an interview on 6/30/17 at 11:30 a.m., the director of nurses and the director of saff development stated they were unaware CNA E's Resident Card had expired and of his background check requesting confirmation of CNA E's Social Security Card. They were unable to find documentation to show CNA E was notified of these findings. During an interview on 6/30/17 at 12:10 p.m., CNA E stated the facility never asked him for his Naturalization Papers.

F281 SS=D SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 07/22/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KQXF11 Facility ID: CA070000035 If continuation sheet 3 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555090 (X3) DATE SURVEY COMPLETED 07/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC COAST POST ACUTE 720 E Romie Ln Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the staff were knowledgeable in transferring a hemiparesis (weakness) resident (Resident 1) from the bed to a wheelchair. Failure to have proper training resulted in Resident 1 sustaining a right hip fracture during a transfer on 6/14/17. Findings: Clinical record review for Resident 1 was initiated on 6/30/17. Resident 1 was admitted to the facility on 12/16, with diagnoses including right hemiparesis (weakness), status post right below the knee amputation. Review of Resident 1's Minimum Data Set (MDS: an assessment tool) dated 3/23/17, indicated he had moderate cognitive impairment. In addition, Resident 1 was totally dependent for transfers from two staff members and had functional limitations to one arm and leg. Review of Resident 1's Weekly Progress Note dated 5/29/17 showed the resident was legally blind and required extensive assistance with his activities of daily living (ADL) care and total assistance with transfers. Review of Resident's 1 Investigation Report dated 6/23/17, showed during a transfer from the wheelchair to the bed, Resident 1 felt that his leg hit the bed frame, causing him pain. An interview with CNA E showed during the transfer, the resident's right prosthetic "leg did not fully turn with the rest of his body." On 6/30/17 at 10 a.m., an interview was conducted with RN A. He stated Resident 1 was alert, oriented and able to make his needs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KQXF11 Facility ID: CA070000035 If continuation sheet 4 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555090 (X3) DATE SURVEY COMPLETED 07/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC COAST POST ACUTE 720 E Romie Ln Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE known. He stated Resident 1 required total assistance from two staff members for transfers. During an interview on 6/30/17 at 10:15 a.m., Resident 1 was interviewed with CNA B as an interpreter. Resident 1 was alert to name and place. He stated he hurt his right leg during a transfer from the wheelchair to the bed. Resident 1 stated CNA E placed the wheelchair on the right side of the bed with his head facing the wall (weaker side against the bed). He stated during the transfer, he was wearing his prosthetic leg and his right leg hit the bed frame. Resident 1 stated he was "screaming in pain" during the transfer. An observation of Resident 1's right stump showed a hard cast/splint in place with an ace wrap. No prosthetic leg was in place. During an interview on 6/30/17 at 11:15 a.m., Physical Therapists (PT) C and D stated the proper procedure to transfer a resident with right sided weakness is to place the wheelchair on the left side (stronger side). They stated Resident 1 required a two person maximum assistance for transfers. PT C and D stated they were unaware of the reason Resident 1 was transferred from the bed to his wheelchair with the wheelchair positioned on his right side (weaker). During an interview on 6/30/17 at 11:30 a.m., the director of nurses (DON) stated if a resident has hemiplegia, two staff members should transfer the resident with the resident's dominant side closest to the bed/chair. She was unable to explain the reason CNA E did not use proper transfer techniques during the transfer. During an interview on 6/30/17 at 11:40 a.m., CNA E stated on 6/14/17 at approximately 4 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KQXF11 Facility ID: CA070000035 If continuation sheet 5 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555090 (X3) DATE SURVEY COMPLETED 07/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC COAST POST ACUTE 720 E Romie Ln Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE p.m., he was transferring Resident 1 from the wheelchair to bed. He stated he turned the wheelchair around so the resident was facing the wall and the resident's right side was against the bed. CNA E stated during the transfer the resident's prosthetic leg did not turn with him and the resident yelled out in pain. He stated he did not notify the nurse about Resident 1's pain because the pain subsided when the resident laid down in the bed. When CNA E was asked the reason he positioned Resident 1's weaker side against the bed, he stated because there was no room on the opposite side of the bed to position the wheelchair. Resident 1's right hip fracture was a direct result of one staff member performing an improper transfer of the resident from the wheelchair to the bed.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 07/22/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KQXF11 Facility ID: CA070000035 If continuation sheet 6 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555090 (X3) DATE SURVEY COMPLETED 07/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC COAST POST ACUTE 720 E Romie Ln Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was adequately assessed for proper transfer method to prevent injury. Certified Nursing Assistant (CNA) E failed to transfer Resident 1 safely from the wheelchair to the bed. Resident 1 was identified by the facility to require a two person transfer; however on 6/14/16 at approximately 4 p.m., CNA E attempted to transfer the resident by himself. He placed the wheelchair with Resident 1's weaker side against the bed. During the transfer Resident 1 yelled out in pain. CNA E noticed the prosthetic (artificial) leg did not pivot (turn) during the transfer. An X-ray was obtained on 6/17/17 that showed Resident 1 sustained a hip fracture. The failure of the facility to ensure staff were knowledgeable in proper transfer techniques was the direct cause of Resident 1's right hip fracture. Findings: Clinical record review for Resident 1 was initiated on 6/30/17. Resident 1 was admitted to the facility with diagnoses including right hemiparesis (weakness), and status post right below the knee amputation, requiring the use of a prosthetic leg. Review of Resident 1's Minimum Data Set (MDS: an assessment tool) dated 3/23/17, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KQXF11 Facility ID: CA070000035 If continuation sheet 7 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555090 (X3) DATE SURVEY COMPLETED 07/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC COAST POST ACUTE 720 E Romie Ln Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated he had moderate cognitive impairment (usually understands). In addition, Resident 1 was totally dependent for transfers with two staff members and had functional limitations to one arm and leg. Review of Resident 1's care plan with a revised date of 3/29/17, to address his self-care deficits related to his right side edweakness, indicated he was totally dependent on the staff for transfers. Review of Resident 1's Weekly Progress Note dated 5/29/17 showed the resident was legally blind and required extensive assistance with his activities of daily living (ADL) care and total assistance with transfers. Review of Resident 1's Physician's Order Note dated 6/15/17 at 3:17 p.m., showed the resident complained of increased pain to his right below the knee amputation and an X-ray was ordered of his right hip to knee. Review of Resident 1's hospital History and Physical report dated 6/18/17 showed his right knee/hip X-ray results showed he had an acute fracture to his right lower hip bone and a large right knee swelling. A hard cast splint was applied to his right stump (knee). Review of Resident's 1 Investigation Report dated 6/23/17, showed during a transfer from the wheelchair to the bed, Resident 1 felt that his leg hit on the bed frame, causing him pain. An interview with CNA E showed during the transfer, the resident's prosthetic leg "did not fully turn with the rest of his body." On 6/30/17 at 10 a.m., an interview was conducted with RN A. He stated Resident 1 was alert, oriented and able to make his needs known. He stated Resident 1 required total FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KQXF11 Facility ID: CA070000035 If continuation sheet 8 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555090 (X3) DATE SURVEY COMPLETED 07/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC COAST POST ACUTE 720 E Romie Ln Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assistance from two staff members for transfers since admission. During an interview on 6/30/17 at 10:15 a.m., Resident 1 was interviewed with CNA B as an interpreter. Resident 1 was alert to name and place. He stated he hurt his right leg during a transfer from the wheelchair to the bed. Resident 1 stated CNA E placed the wheelchair on the right side of the bed with his head facing the wall (weaker side against the bed). He stated during the transfer, he was wearing his prosthetic leg and his right leg hit the bed frame. Resident 1 stated he was "screaming in pain" during the transfer. A concurrent observation of Resident 1's right stump showed a hard cast/splint in place with an ace wrap. He was not able to wear his right prosthetic leg. During an interview on 6/30/17 at 11:15 a.m., Physical Therapists (PT) C and D stated the proper procedure to transfer a resident with right sided weakness is to place the wheelchair on the left side (stronger side). They stated Resident 1 required a two person maximum assistance for transfers. PT C and D stated they were unaware of the reason Resident 1 was transferred from the bed to his wheelchair with the wheelchair positioned on his right side (weaker). During an interview on 6/30/17 at 11:30 a.m., the director of nurses (DON) stated if a resident has hemiplegia, two staff members should transfer the resident with the resident's dominant side closest to the bed/chair. During an interview on 6/30/17 at 11:40 a.m., CNA E stated on 6/14/17 at approximately 4 p.m., he was transferring Resident 1 from the wheelchair to bed. He stated he turned the wheelchair around so the resident was facing the wall and the resident's right side was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KQXF11 Facility ID: CA070000035 If continuation sheet 9 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555090 (X3) DATE SURVEY COMPLETED 07/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC COAST POST ACUTE 720 E Romie Ln Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE against the bed. CNA E stated during the transfer the resident's prosthetic leg did not turn with him and the resident yelled out in pain. He stated he did not notify the nurse about Resident 1's pain because the pain subsided when the resident laid down in the bed. When CNA E was asked the reason he positioned Resident 1's weaker side against the bed, he stated because there was no room on the opposite side of the bed. He was unable to answer the reason he was unable to answer. Review of the National Institute for Occupational Safety and Health Website (www.cdc.gov/niosh/docs) documented for safe resident handling from the bed to the chair when the resident has impaired upper extremity strength, use a full-body sling (lift) and two caregivers should be used. If the resident has partial weight-bearing capacity, transfer toward the stronger side.

F508 SS=D PROVIDE/OBTAIN RADIOLOGY/DIAGNOSTIC SVCS CFR(s): 483.50(b)(1)

F508 07/22/2017 (b) Radiology and other diagnostic services. (1) The facility must provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. This REQUIREMENT is not met as evidenced by: Based on interview and clinical record review, the facility failed to ensure a physician's order for Resident 1's hip X-ray was obtained timely. In addition, Resident 1's physician was not notified in the delay of the X-ray. Failure to provide a timely X-ray has the potential for a delay in treatment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KQXF11 Facility ID: CA070000035 If continuation sheet 10 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555090 (X3) DATE SURVEY COMPLETED 07/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFIC COAST POST ACUTE 720 E Romie Ln Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Clinical record review for Resident 1 was initiated on 6/30/17. Resident 1 was admitted to the facility with diagnoses including status post right below the knee amputation and right sided hemiplegia (weakness). Review of Resident 1's late entry Health Status Change note dated 6/15/17 at 2:31 p.m., showed the resident complained of his right leg hurting. The licensed nurse documented Resident 1 stated a staff member bumped his leg onto the bed frame during a transfer the previous day. Resident 1's physician was notified and ordered an X-ray of the resident's right leg. Review of Resident 1's Physician's Order Note dated 6/15/17 at 3:17 p.m., showed the resident complained of increased pain to his right below the knee amputation and an X-ray was ordered of his right hip to knee. Review of Resident 1's right hip X-ray report showed the X-ray was obtained on 6/17/17 (two days after the order was obtained). The results showed Resident 1 had an acute right hip fracture and was transferred to the hospital for an evaluation. During an interview on 6/30/17 at 11:30 a.m., the director of nurses (DON) stated she was aware of Resident 1's delay in obtaining his right leg X-ray. She was unable to find documentation to show Resident 1's physician was aware of the delay. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KQXF11 Facility ID: CA070000035 If continuation sheet 11 of 11