Other·September 3, 2019

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 three complaints on 8/27/19. For Complaints CA00650758, CA00650855, and CA00651120, regarding Quality of Care and Treatment, a federal deficiency was identified (see 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: 36623, Health Facilities Evaluator Nurse.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 09/16/2019 §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 for one of two residents when Resident 1 was unsupervised in the patio and under the sun. This failure resulted in Resident 1 suffering from heat stroke (serious illness of the body overheating; symptoms include high body 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: KRXY11 Facility ID: CA070000084 If continuation sheet 1 of 4 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 08/27/2019 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 temperature, difficulty breathing, and confusion) and second degree burns due to sun exposure. Findings: Review of Resident 1's record indicated he had diagnoses including muscle weakness, cognitive communication deficit, and dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 7/31/19 indicated his cognition was moderately impaired and he required limited assistance and one-person physical assistance while in his wheelchair. Review of Resident 1's Change in Condition Evaluation, dated 8/15/19 indicated he had increased confusion and was "unable to move without assistance, was drowsy, and unable to carry conversation." The Evaluation indicated he had labored breathing, increased temperature, and other abnormal vital signs. It also indicated he had a "cluster of blisters" on his left arm. It indicated there was a doctor's order to send the resident to the hospital. Review of Resident 1's History and Physical from the hospital indicated he had heat stroke with an initial temperature of 104.1 degrees Fahrenheit (F, scale of temperature, normal body temperature is 98.6 degrees F), encephalopathy (disease that affects brain function) "likely from heat stroke" and had blisters on his upper arms. Review of Resident 1's Discharge Summary indicated he had heat stroke and second degree burns from sun exposure. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KRXY11 Facility ID: CA070000084 If continuation sheet 2 of 4 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 08/27/2019 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 During an interview on 8/21/19 at 10 a.m., Resident 1 stated his arms hurt and he got the injury from sitting in the sun so long. During an interview on 8/21/19 at 10:32 a.m., licensed vocational nurse B (LVN B) stated she was assigned to take care of Resident 1 on 8/15/19 and did not see him outside on the patio. During an interview on 8/21/19 at 12 p.m., the lead respiratory therapist (RT) stated on 8/15/19 she saw the nurse and CNA A trying to wake up Resident 1. The RT stated Resident 1 was breathing fast, had an elevated heart rate, and was warm to the touch. The RT stated they put Resident 1 on oxygen. The RT stated she did not see Resident 1 outside on the patio. During an interview on 8/21/19 at 12:38 p.m., certified nursing assistant A (CNA A) stated another resident (Resident 3) called staff to help Resident 1 on the patio. CNA A stated Resident 1's feet got stuck in the dirt and plants and he could not move his wheelchair. CNA A stated Resident 1 was sweaty and looked exhausted. CNA A stated she pulled his wheelchair out and left the patio to inform the nurse about Resident 1. CNA A stated when she returned to the patio, Resident 1 was not responding. CNA A stated she did not see Resident 1 outside on the patio until Resident 3 called her. During an interview on 8/21/19 at 12:45 p.m., Resident 3 stated she saw Resident 1 on the patio and he looked like he was having trouble breathing. Resident 3 stated she told LVN C about Resident 1 and LVN C said he was OK. Resident 3 stated she saw Resident 1 wheel himself toward the plants in the dirt and get stuck. Resident 3 stated she turned on her call light to get staff to help Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KRXY11 Facility ID: CA070000084 If continuation sheet 3 of 4 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 08/27/2019 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 Review of the facility's 4/2017 policy, "Resident Supervision and Monitoring," indicated the residents are supervised under normal circumstances to ensure optimal safety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KRXY11 Facility ID: CA070000084 If continuation sheet 4 of 4