Other·April 3, 2018

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 investigation of a complaint conducted on 3/27/18. For Complaints CA00577402 and CA00577798 regarding Quality of Care, a federal deficiency was identified (see F689). A Class "B" citation was also issued for F689. Inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 38087, Health Facilities Evaluator Nurse.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide adequate supervision when Resident 1 eloped from the facility. This 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: OGTR11 Facility ID: CA070000035 If continuation sheet 1 of 3 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 03/27/2018 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 resulted in Resident 1's safety being compromised. Findings: Review of Resident 1's clinical record indicated she was admitted on 3/8/18 with diagnoses including dementia (decline in mental capacity affecting daily function). During an interview on 3/9/18 at 3:30 p.m., licensed vocational nurse A (LVN A) stated Resident 1 was admitted on 3/8/18 at 4:30 p.m. and oriented to the facility by LVN A. LVN A stated when she went to Resident 1's room after dinner to administer medication, Resident 1 was not in her room. LVN A stated she could not locate Resident 1 anywhere in the facility so she notified the evening supervisor. During an interview on 3/9/18 at 3:20 p.m., certified nursing assistant B (CNA B) stated she introduced herself to Resident 1 at 4:30 p.m. and oriented her to her room. CNA B stated Resident 1 refused to eat dinner and declined alternate food choices offered by CNA B. CNA B stated she saw Resident 1 in the lobby sitting in a wheelchair after dinner. During an interview on 3/9/18 at 3:00 p.m., LVN C stated she was informed by the charge nurse at 6:00 p.m. Resident 1 was not in the facility. LVN C stated she drove in the surrounding neighborhood to search for Resident 1 while other staff members searched the facility outside grounds. LVN C stated when she returned to the facility the social worker informed her Resident 1 had taken a taxi to her daughter's residence. During an interview on 3/9/18 at 4:10 p.m., the receptionist stated Resident 1 approached her at the front desk at 5:30 p.m. requesting a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OGTR11 Facility ID: CA070000035 If continuation sheet 2 of 3 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 03/27/2018 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 telephone. The receptionist stated Resident 1 wanted to call a taxi so the receptionist dialed the taxi company for Resident 1. The receptionist stated she believed Resident 1 was a visitor. During a telephone interview on 3/9/18 at 3:50 p.m., the social worker (SS) stated he had met and answered some questions for Resident 1 at 5:00 p.m. in her room. The SS stated after dinner he saw Resident 1 in the front lobby talking to the receptionist. The SS stated the receptionist acknowledged she called a taxi for Resident 1. The SS contacted the taxi company and learned Resident 1's destination had been the residence of Resident 1's daughter. The SS contacted Resident 1's daughter to notify her Resident 1 had left the facility and was now at her daughter's house. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OGTR11 Facility ID: CA070000035 If continuation sheet 3 of 3