Other·August 19, 2019

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 an abbreviated survey regarding investigation of complaints conducted on 8/15/19. For complaint CA00647579 regarding Quality of Care/Treatment, the Department did not substantiate a violation of federal or state regulations. However, a federal deficiency was identified for a violation unrelated to the complaint (see F755). A Class "B" citation was also issued. Representing the California Department of Public Health: 39949 Health Facilities Evaluator Nurse; 39588, Health Facilities Evaluator Nurse; and 39238, Health Facilities Evaluator Nurse

F755 SS=E Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 08/29/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. 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: MCKX11 Facility ID: CA070000084 If continuation sheet 1 of 6 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: _______________ 055739 (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SALINAS VALLEY POST ACUTE 637 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 §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure the availability of medications for 6 of 6 residents (Residents 1, 2, 3, 4, 5, and 6) when anti-convulsive/seizure (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders) medications were not administered as ordered by the physician and they were not available in the facility: 1) For Resident 1 - 10 doses - vimpat 2) For Resident 2 - 2 doses phenobarbital 3) For Resident 3 - 2 doses levetiracetam 4) For Resident 4 - 3 doses valporic acid 5) For Resident 5 - 1 dose dilantin, 1 dose keppra 6) For Resident 6 - 1 dose carbamazepine This failure resulted in residents not getting their medication and had the potential for adverse health effects. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MCKX11 Facility ID: CA070000084 If continuation sheet 2 of 6 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: _______________ 055739 (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SALINAS VALLEY POST ACUTE 637 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: 1. Review of Resident 1's clinical record indicated he was admitted to the facility with diagnoses including seizures (a sudden, uncontrolled electrical disturbance in the brain causing changes in behavior and body movements including loss of consciousness). Review of Resident 1's physician order indicated vimpat solution (anti-seizure medication) 10mg/ml (mg, milligrams, ml, milliliters, units of measurement), give 20 ml via g-tube (tube inserted through the belly that brings nutrition directly to the stomach) two times a day. Review of Resident 1's Medication Administration Record (MAR) and Progress Notes (PN) indicated vimpat solution 10mg/ml was not given to the resident due to unavailability of the medication on 9/26/18, 10/22/18, two doses on 3/14/19, 3/15/19, 4/23/19, 4/24/19, and two doses on 7/8/19 and 7/9/19. During an interview with registered nurse A (RN A) on 8/1/19 at 12:38 p.m., she stated vimpat medication was not given due to the pharmacy not delivering the medication and the medication had run out. During a concurrent interview with the director of nursing (DON), she stated the facility should not run out of medication. She further stated the facility has difficulty obtaining medications from the pharmacy because the pharmacy is about 3 to 4 hours away. Further review of the residents' MAR and PN revealed five other residents were not given their anti-convulsive/seizure medication due to unavailability of the medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MCKX11 Facility ID: CA070000084 If continuation sheet 3 of 6 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: _______________ 055739 (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SALINAS VALLEY POST ACUTE 637 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 of Resident 2's clinical record indicated she was admitted to the facility with diagnoses including seizure and chronic respiratory failure (long-term disease involving breathing). Review of Resident 2's physician order indicated, give phenobarbital solution (antiseizure medication) 20 mg/5 ml, 100 mg via peg tube (tube inserted through the belly that brings nutrition directly to the stomach). Review of Resident 2's MAR and PN indicated phenobarbital solution 20 mg/5 ml was not given to the resident due to unavailability of the medication on 12/12/18 and 3/5/19. 3. Review of Resident 3's clinical record indicated he was admitted to the facility with diagnoses including seizures and glaucoma (a group of eye conditions that can cause blindness) Review of Resident 3's physician orders indicated, give levetiracetam solution (antiseizure/epilepsy medication) 1000 mg via PEG-tube two times a day. Review of Resident 3's MAR and PN indicated levetiracetam 1000 mg was not given to the resident due to unavailability of the medication on 6/14/19 and 6/24/19. Review of the facility document submitted by the regional clinical director (RCD) dated 8/5/19 confirmed Resident 3 did not receive his levetiracetam 1000 mg medication due to pharmacy non-delivery. 4. Review of Resident 4's clinical record indicated she was admitted to the facility with diagnoses including thyrotoxicosis (excess of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MCKX11 Facility ID: CA070000084 If continuation sheet 4 of 6 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: _______________ 055739 (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SALINAS VALLEY POST ACUTE 637 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 thyroid hormone in the body) and convulsions. Review of Resident 4's physician orders indicated to give valporic acid solution (medication for convulsions) 500 mg via g-tube every 6 hours. Review of Resident 4's MAR and PN indicated the valporic acid solution 500 mg was not administered due to unavailability of the medication on 10/27/18 for three (3) doses. Review of the facility document submitted by the RCD dated 8/5/19, confirmed Resident 4 did not receive her valporic acid medication due to pharmacy non-delivery. 5. Review of Resident 5's clinical record indicated he was admitted to the facility with diagnoses including unspecified convulsions. Review of Resident 5's physician orders indicated give dilantin suspension (medication for convulsions) 400 mg via PEG-tube one time a day and give 15 ml of levetiracetam solution (medication for convulsions) 100 mg/ml via gtube every 12 hours. Review of Resident 5's MAR and PN indicated the following medications were not administered due to unavailability of the medication: a) dilantin suspension 400 mg on 8/1/19 b) levetiracetam solution 100 mg/ml on 11/7/18 During an interview with the DON on 8/2/19 at 3:22 p.m., she confirmed Resident 5's dilantin was not given on 8/1/19 due to non-delivery. 6. Review of Resident 6's clinical record indicated she was admitted to the facility with diagnoses including convulsions, deep vein thrombosis (DVT, blood clot in a deep vein, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MCKX11 Facility ID: CA070000084 If continuation sheet 5 of 6 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: _______________ 055739 (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SALINAS VALLEY POST ACUTE 637 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 usually in the legs) and hypothyroidism. Review of Resident 6's physician orders indicated give carbamazepine (medication for convulsions) tablet 200 mg via peg-tube two times a day. Review of Resident 6's MAR and PN indicated carbamazepine 200 mg was not administered due to unavailability of the medication on 7/5/19. During an interview with licensed vocational nurse B (LVN B) on 8/2/19 at 1:27 p.m., she stated they were having problems with the pharmacy services, "we have to follow-up a lot" on the delivery of the medications. She further stated the fax machine provided by the pharmacy would have problems with receiving refill requests and that issue happened every week. During an interview with LVN C on 8/2/19 at 1:32 p.m., he stated it was common that medications were unavailable because they would run out. Review of the facility's policy on Ordering and Receiving Medications from the dispensing Pharmacy dated 4/18 indicated medications and related products are received from the dispensing pharmacy on a timely basis. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MCKX11 Facility ID: CA070000084 If continuation sheet 6 of 6