Other·October 29, 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 a recertification survey conducted on 10/17/19. The facility was licensed for 99 beds. The census at the time of the survey was 82. The sample size was 18. A Class "B" Citation was also issued for F686. Representing the California Department of Public Health: 34383, Health Facilities Evaluator Nurse; 35790, Health Facilities Evaluator Nurse; 10918, Health Facilities Evaluator Nurse; 38087, Health Facilities Evaluator Nurse; and 38068, Health Facilities Evaluator Nurse.

F552 SS=D Right to be Informed/Make Treatment Decisions CFR(s): 483.10(c)(1)(4)(5)

F552 11/09/2019 §483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of 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: P4JY11 Facility ID: CA070000084 If continuation sheet 1 of 61 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 10/17/2019 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 proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to obtain informed consent (a written permission before implementing a healthcare intervention) for the use of psychotropic medication (drugs capable of affecting the mind, emotion, and behavior) for two residents (3and 49). These failures had the potential for Residents 3 and 49's responsible parties not being aware of the risks and benefits of taking psychotropic medication. Findings: 1. Review of Resident 3's clinical record indicated she had diagnoses that included anxiety (a feeling of uneasiness, worry and fear without cause). Her cognition was severely impaired. Her physician order dated 10/9/19 indicated Clonazepam (medication used for anxiety) 1 milligram (mg, unit of measurement) every 8 hours for anxiety. Further review of Resident 3's clinical record indicated there was no informed consent from the responsible party for the administration of Clonazepam. During an interview with the director of subacute (DOSA) on 10/17/19 at 3:02 p.m., she confirmed there was no evidence of documentation an informed consent was obtained from the responsible party prior to the administration of Clonazepam. The DOSA acknowledged an informed consent should have been obtained before the administration the Clonazepam for Resident 3. 2. Review of Resident 49's clinical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 2 of 61 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 10/17/2019 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 indicated he was admitted to the facility on 4/30/19 with diagnoses including anxiety disorder, major depressive disorder (mood disorder that causes persistent sadness and loss of interest), Down Syndrome (congenital disorder arising from a chromosome defect, causing intellectual impairment and physical abnormalities) and cognitive communication deficit (problems with communication that have an underlying cause with impairment in mental processes rather than a primary language or speech deficit). Review of Resident 49's physician order dated 4/30/19 indicated Lorazepam (psychotropic medication to treat anxiety) 0.5 milligrams (mg, unit of dose measurement) every 6 hours as needed related to anxiety disorder. Review of Resident 49's clinical record indicated no informed consent was obtained from the responsible party for the administration of Lorazepam until 9/29/19, five months after the medication was prescribed. Resident 49 was receiving Lorazepam for five months without the informed consent of the responsible party. During an interview with the director of nursing (DON) on 10/17/19 at 11:20 a.m., she confirmed there was no evidence of documentation an informed consent was obtained from the responsible party prior to the administration of Lorazepam. The DON acknowledged an informed consent should have been obtained before the administration of the Lorazepam. Review of the facility's policy and procedures dated 10/2017, "Psychotropic Medication Management", indicated informed consent for the use of psychotropic medication must be contained in the clinical record. This can be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 3 of 61 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 10/17/2019 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 located in the body of the order (following verbal verification from the physician), a statement from the physician documented in the progress note or on the physician's orders, or a signed consent form from the resident, family, or legal representative.

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 11/09/2019 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to accommodate needs for six of nine residents reviewed (Residents 20, 26, 32,36, 47 and 60), when: 1. Call light was not within reach for Resident 20. 2. Resident 32 had no working call light. 3. Call lights were not answered in a timely manner for Residents 26, 36, 47 and 60. These failures placed residents at risk for unmet needs and a diminished quality of life. Findings: 1. During concurrent observation and interview on 10/15/19 at 8:37 a.m., Resident 20's call light was dropped on floor and not within her reach. Resident 20 stated staff would put the call light away from her all the time. During interview with licensed vocational nurse B (LVN B) on 10/15/19 at 8:39 a.m., LVN B FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 4 of 61 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 10/17/2019 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 came in to place the call light within the resident's reach and stated the call light should be placed within reach at all times for the resident to access to call for the resident to access to call for assistance. The facility's policy and procedure, "Call light, Answering" revised, date 4/1/19, indicated "11. Place the call light within resident's reach." 2. During observation on 10/15/19 at 8:37 a.m., Resident 32's call light button on the wall was lighted. However, the call light bulb on the door outside was not turned on. There was no handbell in place on Resident 32's bedside table. Resident 32 stated she had finished breakfast and wanted to ask staff to remove her bedside table in front of her so she could rest comfortably. Resident 32 also stated it had been quite a long time since she was waiting. Review of Resident 32's minimum data set (MDS, assessment tool) dated 7/23/19, Resident 32 was cognitively intact. During interview with the maintenance director (MD) on 10/15/19 at 8:51 a.m., the MD stated he did not know when the bulb of the call light was not working. Review of the facility's policy and procedure titled "Call light, Answering," revised date 4/1/19, indicated "12. In the event of call light malfunction, notify maintenance and obtain alternate call bell device (i.e. hand-bell). Place in easy reach and explain use to resident." 3. During interview with Resident 26's responsible party (RP, person who makes medical decision for the resident) on 10/15/19 at 11:20 a.m., the RP stated that it took one to two hours for staff to answer the call light to do the secretion suction for Resident 26, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 5 of 61 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 10/17/2019 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 especially in the evenings and nights 4. During an interview with Resident 36 on 10/14/19 at 11:55 a.m., with Registered nurse C's (RN C) translation, Resident 36 stated it took a long time for staff to answer the call light and she had to wait for an hour especially in the day shift when she needed to be changed for the incontinent pad. During an observation on 10/16/19 at 4:30 p.m., Resident 36 made facial grimace while she had pressed the call light, which was pointing to her stomach tube. At 5 p.m., two certified nursing assistants (CNAs) came in to provide care for Resident 36. It took 30 minutes for staff to answer Resident 36's call light and address Resident 36's needs. During an interview with CNA D on 10/16/19 at 5:02 p.m., CNA D acknowledged it took 30 minutes for staff to respond to Resident 36's call light. CNA D stated Resident 36 used call light to request for reposition in bed and asking for her medications. 5. During an interview with Resident 47 on 10/15/19 at 9:14 a.m., Resident 47 stated it took staff a long time to answer the call lights. Resident 47 stated he waited 30 minutes for staff to come in to do his secretion suction and incontinent pad change. Review of Resident 47's MDS dated 9/3/19 indicated Resident 47 was cognitively intact. 6. During concurrent observation and interview with Resident 60 on 10/16/19 at 4:25 p.m., Resident 60's, call light was on and Resident 60's RP was at bedside. The respiratory therapy staff came in at 4:45 p.m. to respond the call light. It took 20 minutes for the staff to respond to Resident 60 call light and needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 6 of 61 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 10/17/2019 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 with Resident 60's RP on 10/16/19 at 4:25 p.m., Resident 60's RP stated it took one hour for staff to answer the call light. During an interview with director of subacute unit (DOSA) on 10/16/19 at 5:15 p.m., the DOSA stated the call light response time should be within as soon as possible to five minutes. The facility's policy and procedure, "Call light, Answering," revised date 4/1/19, indicated "3. All staff will promptly attend to residents requesting assistance. If the assigned nurse/aide is caring for another resident, another co-worker will answer the resident's light."

F559 SS=D Choose/Be Notified of Room/Roommate Change CFR(s): 483.10(e)(4)-(6)

F559 11/09/2019 §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. §483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement. §483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 7 of 61 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 10/17/2019 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 This REQUIREMENT is not met as evidenced by: 2. During concurrent observation and interview with Resident 67 on 10/15/19 at 9:44 a.m., Resident 67 was capable to use her pad call light and asked for assistance. Resident 67 stated that she was a lighter sleeper and had trouble sleeping. Resident 67 stated staff woke her up when providing care, her roommates family talking and leaving late at night. Resident 67 stated she has no choice to share the room with her roommate, whose family members disturbed her sleep at night. During an interview with Resident 67's responsible party (RP) on 10/14/19 at 10:57 a.m., the RP stated she was furious since the day Resident 67 had roommate change and the facility did not incorporate their input regarding to roommate change. The RP stated the facility did not provide a written notice regarding Resident 67's roommate change. During an interview with licensed vocational nurse E (LVN) E on 10/15/19 at 11:25 a.m., LVN E stated Resident 67 did not want her roommate since 8/11/19 because of the noise of the roommate's family visitors in the evening. During an interview with the SSD on 10/17/19 10:13 a.m., the SSD confirmed there was no written notice of a roommate change provided to Resident 67 and the RP. Review of the facility's policy and procedure, "Room Change / Roommate Assignment", revised date 2/2014, indicated "3. The notice of a change in room or roommate assignment may be oral or in writing or both, and will include the reason(s) for such change. 4. When making a change in room or roommate assignment, the resident and his/her needs and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 8 of 61 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 10/17/2019 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 preferences will be considered, and in so far as practical.." Based on observation, interview, and record review the facility failed to ensure three of six residents reviewed (Residents 67, 71 and 130) shared room practicable with roommate of choice, when: 1. Staff did not accommodate a married couple's desire to reside in the same room (Residents 71 and 130); 2. There was no written notice of roommate change and staff did not incorporate Resident 67's input in roommate selection. These failures had the potential to cause emotional distress to the residents. Findings: 1. Review of Resident 71's Minimum Data Set (MDS, an assessment tool), dated 9/6/19, indicated the resident did not have any problems with memory and daily decision making skills. During an interview on 10/17/19 at 11:12 a.m., Residents 71 stated she wanted to reside in the same room with her husband (Resident 130) but they were separated after he returned to the facility from a hospital stay. Resident 71 also stated she asked staff and did not get any response about sharing the same room. During the same interview and observation as above, Resident 130, (Resident 71's spouse) was in Resident 71's room and stated he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 9 of 61 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 10/17/2019 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 wanted to live in the same room with his spouse. Review of Resident 130's 2019 Census List (record of where a resident resided), indicated he was residing with Resident 71 when he was admitted to the facility. When he returned from a hospital stay, Residents 130 and 71 resided in different rooms. During an interview on 10/17/19 at 11:18 a.m., the social services assistant (SSA) stated Residents 71 and 130 did not room in together because there was no room available and there was no rooming in policy for married couples. During an interview on 10/17/19 at 11:46 a.m., the social services director (SSD) reviewed the record stated there was no documentation showing staff were making arrangements for the couple to reside in the same room.

F625 SS=D Notice of Bed Hold Policy Before/Upon Trnsfr CFR(s): 483.15(d)(1)(2)

F625 11/09/2019 §483.15(d) Notice of bed-hold policy and return§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bedhold periods, which must be consistent with paragraph (e)(1) of this section, permitting a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 10 of 61 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 10/17/2019 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 resident to return; and (iv) The information specified in paragraph (e) (1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to provide a notice of bedhold (holding a resident's bed or room for 7 days during a hospital or therapeutic stay) to a resident or responsible party when two sampled residents were transferred to a hospital (Resident 4 and 130). This failure had the potential of the resident and/or responsible party not knowing their rights to return to the facility. Findings: 1. Review of Resident 4's record indicated he was transferred to a hospital for continued care on 8/17/19 and 10/5/19. There was no documentation indicating the facility provided a bedhold notice to the resident or responsible party when the resident was transferred. During an interview on 11/16/19 at 11:44 a.m., the nurse consultant (NC) and business office manager (BOM), who reviewed the record both stated they could not find a bedhold notice for Resident 4. 2. Review of Resident 130's record indicated he was transferred to a hospital on 9/27/19. The record lacked a bedhold notice. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 11 of 61 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 10/17/2019 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 with the BOM on 10/7/19 at 12:06 p.m., the BOM reviewed the record and stated Resident 130 was not placed on bedhold. Review of the facility's policy, "Bed-Hold & Readmission," dated October 2014, indicated a resident who was transferred to a general acute care hospital, or went on therapeutic leave, was to be afforded a bed-hold of seven days, which was to be exercised by the resident or the resident's representative. The policy applied to all residents, regardless of payment source.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 11/09/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 12 of 61 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 10/17/2019 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 rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: 3. Review of Resident 28's clinical record indicated she had a diagnoses of hemiplegia (paralysis of one side of the body), dementia (term for a disease that changes memory and/or thinking), cognitive communication deficit, and lack of coordination. Review of Resident 28's minimum data set (MDS, an assessment tool) dated 1/19/19 indicated she had a brief interview for mental status (BIMS, a structured cognitive test) a score of 11 (moderately impaired). Review of Resident 28's at risk for fall care plan related to confusion, unaware of safety needs, and history of purposefully pulling herself out of bed dated 4/13/18 indicated the intervention was to maintain the bed in low position. Review of Resident 28's fall scene investigation report dated 6/20/19 indicated Resident 28 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 13 of 61 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 10/17/2019 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 found on the floor and the intervention to prevent fall was to keep the bed in a low position. Review of Resident 28's fall scene investigation report dated 12/9/19 indicated Resident 28 was found on the floor and the intervention to prevent fall was to keep the bed in low position. During an observation on 10/15/19 at 1:20 p.m., 10/15/19 5:23 p.m., and 10/16/19 at 8:09 a.m., Resident was lying on bed and the bed was not in a low position. During an observation and concurrent interview with licensed vocational nursing B (LVN B) at 10/16/19 at 8:12 a.m., Resident 28 was lying on bed and the bed was in the high position. LVN B stated Resident 28's bed was too high and its should have been in a low position. During an interview with the director of nursing (DON) on 10/16/19 at 8:27 a.m., she stated Resident 28's bed should have been in a low position and the at risk for fall care plan should have been implemented. Review of the facility's policy, dated 11/2012 "Fall Management", indicated the policy of the facility that the physical environment remains free of accident hazard as possible. Resident will be assessed for fall risk and interventions would be implemented to reduce the risk for fall. Recent fall would be reviewed by a designated facility fall team to evaluate cause, determine additional strategies as needed to prevent recurrence for each resident and further revise care plan as needed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 14 of 61 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 10/17/2019 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 Based on observation, interview and record review the facility failed to ensure care plans were either initiated, fully developed or implemented for three of 18 sampled residents (Residents 4, 71, and 28) when, 1. Resident 71 was given Cymbalta (antidepressant medication) to treat for depression and there was no non-drug approaches developed to alleviate her depression, 2. Resident 4 developed aspiration pneumonia (lung infection that occurs when food, saliva, liquids, or vomit is breathed into the lungs) and urinary tract infection (UTI, infection of any part of the urinary system, such as bladder or kidney) and care plans to prevent and manage the infections were not developed and, 3. Resident 28 had repeated falls and the fall care plan intervention was implemented. Care plans identified resident problems and outlines the care and services needed to prevent health complications. Findings: 1. During an observations on 10/16/19, a male resident (in the same hallway as Resident 71) was heard in the hallway yelling in his room during the day. During an interview on 11/17/19 at 11:46 a.m., the director of social services stated had knowledge of Resident 71's statement of a noisy male resident bothering her. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 15 of 61 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 10/17/2019 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 Resident 71's record indicated she had a physician's order dated 9/9/19 to give Cymbalta 60 milligram (mg, a metric unit of measurement) capsule one a day to treat anxiety manifested by restlessness and irritability every shift (eight hours). Review of Resident 71's antidepressant use of Cymbalta care plan, dated 9/28/19, did not contain non-drug interventions to alleviate depression and anxiety, such having a quiet environment. During an interview on 11/17/19 at 11:38 a.m., the director of subacute (DOSA) reviewed the record and confirmed there was no documented of non-drug approaches for Resident 71's depression and anxiety. 2a. Review of Resident 4's record indicated he was admitted to the facility with diagnoses including dysphagia (difficulty swallowing from abnormal nerve or muscle control). He had a physician's order dated 10/16/19 to provide a regular diet with thin liquids consistency. Resident 4 had a care plan addressing a potential for developing aspiration pneumonia on 8/31/19 and the care plan was discontinued on 9/22/19. Review of Resident 4's record indicated he was transferred to the hospital on 10/5/19 and returned to the facility on 10/8/19 with a new diagnosis of aspiration pneumonia. There was no current care plan addressing the management of aspiration pneumonia. During an interview on 10/16/19 at 2:28 a.m., licensed vocational nurse I (LVN I) stated approaches to prevent aspiration was to elevate a resident's head 90 degrees, checking for cough and provide supervision when eating. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 16 of 61 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 10/17/2019 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 10/17/19 at 9:10 a.m., the occupational therapist stated Resident 4 was at risk for aspiration because of his progressive medical condition and from the effects of his pain medication. When he had aspiration pneumonia, it could signify food or liquid going into his airway (lung). During an interview on 10/17/19 at 11:45 a.m., the DOSA reviewed the record and stated there should have been and there was no care plan for aspiration pneumonia. 2b. During observations on 10/15/19 and 10/16/19, Resident 4 had an indwelling urinary catheter (flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) in place draining yellow colored urine. Review of Resident 4's record indicated he was transferred to a hospital on 8/7/19 and returned to the facility on 8/12/19 with a new diagnosis of urinary tract infection (UTI). There was no care plan addressing Resident 4's potential for developing and managing UTI. During the same interview on 10/17/19 at 11:45 a.m., the DOSA reviewed the record and stated there should have been and there was no care plan to prevent and later to manage UTI. Review of the facility's policy, "Baseline and Comprehensive Care Plan," dated 11/2017, indicated it was the policy of the facility to develop upon admission and following completion of the admission nursing assessment a comprehensive care plan for the resident. Review of the facility's policy, "Documentation," dated 11/2012, indicated to update the care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 17 of 61 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 10/17/2019 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 plan to reflect new problems.

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 11/09/2019 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the needs of one of three sampled residents (Resident 28). This failure had the potential of not providing the resident's quality of life. Findings: Review of Resident 28's clinical record indicated she had a diagnoses of hemiplegia (paralysis of one side of the body), dementia (term for a disease that changes memory and/or thinking), cognitive communication deficit, and lack of coordination. Review of Resident 28's minimum data set (MDS, an assessment tool) dated 1/19/19 indicated she had a brief interview for mental status (BIMS, a structured cognitive test) a score of 11 (moderately impaired). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 18 of 61 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 10/17/2019 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 Resident 28's activity participation review assessment dated 7/21/19 indicated Resident 28 preferred activities was independent and in room activities. During an observation on 10/15/19 at 8:17 a.m., on 10/16/19 at 9:18 a.m. and 12:43 p.m., Resident 28 observed lying on bed with eyes opened. During an interview and record review with activity director (AD) on 10/17/19, she stated Resident 28 had one to one in room visits for activities. The AD confirmed Resident 28 had two (2) one to one in room visits for the month of September 2019 and two (2) one to one in room visits for the month of August 2019. During an interview with the director of nursing on 10/17/19 at 10:34 a.m., she stated Resident 28 should have ongoing one-to-one in room visits for activities two to three times per week to promote quality of life of the resident. Review of the facility's policy, dated 8/2011, "Activity/Recreation Program", indicated the staff would provide for ongoing activity recreation program to meet the needs and interest of the residents.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 11/09/2019 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 19 of 61 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 10/17/2019 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 pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a treatment was provided after a coccyx (tail bone) pressure ulcer (skin injury caused by unrelieved pressure that results in damage to the underlying tissues) was identified and the facility failed to implement the wound doctor's recommendation to offload the buttocks when in the bed and when in the wheelchair for one of five sampled residents (Resident 19). The facility failed to apply Santyl ointment (a medication that removes dead tissue from wounds) ordered by the physician on the coccyx pressure ulcer for six (6) days and the wound doctor's recommendation to make sure the resident was repositioned every 2 hours when in the bed or in the wheelchair was not implemented. These failures resulted in Resident 19 developing an unstageable (covered with slough (dead tissue) coccyx pressure ulcer. Findings: Review of Resident 19's undated face sheet indicated she had diagnoses cerebral palsy (a problem that affects muscle tone, movement, and motor skills), muscle weakness, and stiffness on the left hip. Review of Resident 19's minimum data set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 20 of 61 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 10/17/2019 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 (MDS, an assessment tool) dated 7/8/19 indicated she had a brief interview of mental status (BIMS, a structured cognitive test) score of 00 (severely impaired) and was at risk for developing a pressure ulcer. It also indicated she was incontinent (uncontrolled) with urine and bowel movements. MDS also indicated Resident 19 had no pressure ulcer on her coccyx. Review of Resident 19's admission assessment dated 3/25/19 indicated she had a surgical incision on the left hip. There was no evidence Resident 19 had a pressure ulcer on the coccyx area upon admission. Review of Resident 19's Braden scale (risk assessment for developing pressure ulcers) on admission dated 3/25/19 indicated she had a score of 14 (a score of 13-14 represented a moderate risk for developing pressure ulcer). There was no evidence of a routinely Braden scale assessment was completed for the month of 6/2019 and 9/2019 to prevent skin breakdown. Review of Resident 19's high risk for pressure ulcer care plan revised on 10/16/19 indicated the intervention to prevent pressure ulcer was to provide proper skin care. Review of Resident 19's Interact Change in Condition Evaluation (a tool provides a simple, clear way to communicate changes in condition) dated 7/29/19 indicated Resident 19 had a pressure ulcer on the coccyx in the size of approximately 0.9 centimeter (cm, unit of measurement) length, 0.5 cm on width, no depth, and the physician order to apply a Santyl ointment (a medication that removes dead tissue from wounds) and cover it with a dressing on 7/29/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 21 of 61 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 10/17/2019 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 Resident 19's monthly treatment administration record (TAR) dated 7/2019 and 8/2019 indicated there was no treatment in placed on the coccyx pressure ulcer on 7/29/19, 7/30/19, 7/31/19, 8/1/19, 8/2/19, and 8/3/19. The treatment on the coccyx pressure ulcer was started after six (6) days after it was identified on 7/29/19. It indicated the Santyl ointment was applied on 8/4/19 to 8/6/19, and the treatment was changed to a zinc ointment and covered with a dressing from 8/8/19 to 8/20/19. There was no evidence in Resident 19's clinical record the pressure ulcer on the coccyx was measured on a weekly basis to prevent pressure ulcer from declining. Review of Resident 19's Interact Change in Condition Evaluation dated 9/14/19 indicated Resident 19's pressure ulcer on the coccyx reopened approximately by 2.8 cm length, 2 cm width, no depth, and the physician order to apply a hydro cellar dressing (a treatment provides an effective barrier for wound exudate) on 9/14/19. Review of Resident 19's monthly treatment administration record (TAR) dated 9/2019 indicated there was no treatment in placed for the pressure ulcer on the coccyx from 9/14/19, 9/15/19, 9/16/19, 9/17/19, and 9/18/19. The treatment on the coccyx pressure ulcer was initiated 5 days after it was identified on 9/14/19. There was no evidence in Resident 19's clinical record the pressure ulcer on the coccyx was assessed and measured on a weekly basis to prevent pressure ulcer from declining. During an interview with licensed vocational nurse B (LVN B) on 10/16/19 at 10:08 a.m., she stated she was the charge nurse on 7/29/19 when Resident 19 had coccyx pressure ulcer. LVN B stated she had an order to apply FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 22 of 61 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 10/17/2019 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 Santyl ointment on the coccyx pressure ulcer but it was not carried out on the TAR. However, she followed-up when she returned to work. She also stated on 9/14/19 the pressure ulcer on the coccyx reopened and the physician order was to apply a hydro cellar dressing but it was not on the TAR. Review of Resident 19's surgical consultation report dated 10/1/19 indicated Resident 19's had a coccyx pressure ulcer with a size of approximately about 3 cm in length, 2.5 cm width, and the depth was unstageable. The intervention was to emphasis offloading the buttocks, and turning the resident to prevent the pressure ulcer from worsening. Review of Resident 19's progress note dated 10/8/19 indicated the wound doctor (WD) assessed Resident 19's coccyx pressure ulcer, recommended to make sure Resident 19 was repositioned every two hours when in the bed and in the wheelchair and communicated to the licensed nurse A. There was no evidence in Resident 19's chart she was repositioned every two hours when in the bed and in the wheelchair. During an observation between 10/14/19 at 9:26 a.m. and 10/14/19 at 2:45 p.m., Resident 19 was sitting in her wheelchair, no signs of being offloaded and repositioned every two hours in the wheelchair for about five hours. During an interview with licensed vocational nurse A (LVN A) on 10/17/19 at 1:11 p.m., she stated the WD came to the facility and assessed Resident 19's coccyx wound and the WD communicated the intervention to heal the pressure ulcer was to offload the buttocks and make sure Resident 19 was repositioned every two hours when in the bed and in the wheelchair. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 23 of 61 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 10/17/2019 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 a wound observation with Resident 19 and concurrent interview with the director of nursing (DON) on 10/16/19 at 2:26 p.m., Resident 19 was lying on her bed and observed with wound dressing. The DON stated Resident 19's coccyx pressure ulcer was unstageable and covered with 95 percent yellow slough on the wound bed. During an interview and concurrent clinical record review with the DON on 10/16/19 at 2:56 p.m., she stated the coccyx pressure ulcer was facility acquired and the treatment was not initiated until 6 days after the coccyx pressure ulcer was identified on 7/29/19. The DON stated there was no weekly measurement from 7/29/19 to 8/20/19 if the wound was increasing or decreasing. She also stated the coccyx pressure ulcer was reopened on 9/14/19 and the treatment was not initiated until five days after. There was no evidence of a weekly assessment after the pressure ulcer was reopened from 9/14/19 to 9/30/19. The DON also stated there was no evidence Resident 19 was repositioned every two hours when in the bed and in the wheelchair. She was unable to find the Braden scale assessment for 6/2019, and 9/2019 and she stated it should have been completed quarterly. The DON stated Resident 19's coccyx pressure ulcer should have been treated when the licensed nurse identified to prevent it from declining. She also stated Resident 19's reposition every two hours when in the bed and in the wheelchair should have been in placed. During an interview with the WD on 10/17/19 at 2:09 p.m., she confirmed Resident 19's pressure ulcer should have been treated right away after it was identified. She stated Resident 19's coccyx pressure ulcer was bigger in size when she returned to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 24 of 61 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 10/17/2019 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 10/8/19 compared to the 10/1/19 visit. She stated she communicated to the licensed nurse to make sure Resident 19 was repositioned every two hours when in the bed and in the wheelchair. The WD also stated Resident 19 had a special air mattress but the resident still needed to be repositioned every two hours when in the bed to offload the gravity on the coccyx area. The WD confirmed Resident 19's weekly assessment and measurement should have been done because it was very important to evaluate if the coccyx pressure ulcer was progressing or declining. Review of the facility's policy, dated 11/2012, "Pressure Ulcer Risk Assessment", indicated a pressure ulcer assessment should have been completed upon admission, quarterly, annually and with significant change. The licensed nurses would conduct skin assessments at least weekly to identify changes. Review of the facility's policy, dated 6/2018 "Pressure Ulcer Wound Guidelines", indicated the facility would ensure the resident's skin was assessed, appropriate interventions are developed and implemented to maintain skin integrity, promote healing and prevent avoidable skin breakdown.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/09/2019 §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 25 of 61 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 10/17/2019 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide two-person physical assist during bed mobility for Resident 36. This failure resulted in Resident 36 had fall on 4/6/19 and 6/23/19 with sustaining bruise and abrasion and was transferred to acute hospital. Findings: Review of Resident 36's clinical record, Resident 36 was admitted on 1/27/14 with diagnoses included chronic respiratory failure (a condition the blood doesn't have enough oxygen or has too much carbon dioxide), dependence on ventilator (breathing machine), and tracheostomy (surgical opening in the neck with a tube into the person's windpipe). Review of Resident 36's minimum data set (MDS, an assessment tool) dated 5/22/19, indicated Resident 36 was cognitively intact and required total dependence with two-person physical assist during transfer and bed mobility. Review of Resident 36 progress note dated 4/6/19, indicated at 11:00 a.m., Resident 36 was found on floor flat on her back and complained of pain at back of her neck. The Certified nursing assistant (CNA) stated she was about to do the resident care when the resident turned to other side and fell. Resident 36's trach was disconnected from the ventilator machine and was sent to hospital. Progress notes dated 4/6/19, Resident 36 returned to the facility at 3:40 p.m., noted with bruise to posterior right upper arm and verbalized minimal headache. Review of interdisciplinary team (IDT, group of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 26 of 61 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 10/17/2019 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 practitioners from various healthcare disciplines) fall investigation notes dated 6/26/19 indicated "On 6/23/19 at 9:58 p.m., CNA was changing Resident 36's brief pads and when she turned the resident to her left side, Resident 36 fell from the bed." Review of Resident 36's change of condition evaluation dated 6/23/19 indicated Resident 36 had abrasion on the right back and left leg pain. During an interview with CNA D on 10/16/19 at 5:02 p.m., CNA D stated there was no other CNA at the time in the subacute unit and she could not find any staff to help her move with the patient so she turned Resident 36 on the other side by herself and she fell on the floor. During an interview with licensed vocational nurse (LVN G) on 10/15/19 at 3:36 p.m., LVN G stated Resident 36 fell because there was only one CNA who assisted her during turning/repositioning. At the time she was using regular size of bed till the facility changed to bariatric (extra wide and heavy duty) bed. Review of Resident 36's hospital discharge summary dated 6/23/19, indicated "Patient experienced a ground level fall caregiver stated she was unsure of level of consciousness. Patient states she was sleeping and woke up on the floor complained of lower leg pain s/p fall." Review of Resident 36's care plans to address self-care deficit with activities of daily living (ADL) function and fall dated 12/06/15, indicated prior interventions did not include to provide two-person assist with ADLs, not until care plan was revised on 8/27/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 27 of 61 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 10/17/2019 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

F697 Pain Management CFR(s): 483.25(k)

F697 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/09/2019 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide adequate pain management for one of four sampled residents (Resident 6) when pain medication was administered and the pain level was not appropriate as prescribed by the physician. This failure had the potential to result in ineffective pain management for the resident. Findings: Review of Resident 6's clinical record indicated she had diagnoses fracture on right ulna (forearm), pain in left knee, and hemiplegia (paralysis of one side of the body). Her minimum data set (MDS, assessment tool) dated 6/23/19, indicated she was cognitively intact and required assistance for dressing, toileting, and eating. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 28 of 61 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 10/17/2019 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 Resident 6's physician order pain monitoring scale dated 3/30/19, indicated pain 1 to 3 for mild pain, 4 to 5 for moderate pain, and 6 to 10 for severe pain. Review of Resident 6's physician order dated 8/27/19, Acetaminophen 650 mg every 4 hours as needed for mild pain and tramadol 100 milligrams every 12 hours as needed for severe pain. During an observation and interview with Resident 6 on 10/15/19 at 11:58 a.m., she was observed lying in bed and had pain. She stated the pain medication sometimes did not relieve her pain. During an interview and concurrent record review with the director of sub acute (DOSA) on 10/17/19 at 10:41a.m., she stated licensed nurses administered Acetaminophen 650 milligrams as needed for mild pain but Resident 6's pain level was 5. The DOSA also stated the tramadol 100 milligrams for severe pain was administered but Resident 6's pain level was 4 to 5. The DOSA confirmed the licensed nurses should have administered the medications appropriate to the pain level ordered by the physician to relieve Resident 6's pain. Review of the facility's policy, dated 11/28/17, "Pain Management", indicated appropriately trained staff determined competent to assess and treat pain using standardized pain rating scales.

F698 SS=D Dialysis CFR(s): 483.25(l) FORM CMS-2567(02-99) Previous Versions Obsolete

F698 Event ID: P4JY11 11/09/2019 Facility ID: CA070000084 If continuation sheet 29 of 61 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 10/17/2019 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 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide necessary care and services for one of one sampled residents (Resident 6) when licensed nurse did not followed-up the communication report from dialysis (a procedure by a trained professional to remove wastes and excess fluids from the body) center to discontinue Aspirin (antiplatelet medication) 81 milligrams (mg, unit of measurement) once daily. This failure had the potential to compromise the medical condition of the resident. Findings: Review of Resident 6's clinical record indicated she had diagnoses end stage renal failure (ESRD, a medical condition in which person's kidney stop functioning), renal dialysis, and hemiplegia (paralysis of one side of the body). Her minimum data set dated 6/23/19, indicated she was cognitively intact, required assistance for dressing, toileting, and eating. Review of Resident 6's physician order dated 8/27/19, indicated Aspirin 81 mg once daily. Review of Resident 6's nursing facility/dialysis center communication report dated 10/11/19, indicated Resident 19's special instruction was to discontinue the Aspirin. During an interview and concurrent record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 30 of 61 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 10/17/2019 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 with registered nurse K (RN K) on 10/15/19 at 4:45 p.m., she stated the licensed nurse should have discontinued the Aspirin 81 mg when she received the paper from the dialysis center on 10/11/19. RN K confirmed Aspirin 81 mg was not discontinued on the medication administration record (MAR) and Resident 6 continued to have the medication. During an interview with the director of nursing (DON) 10/17/19 at 12:26 p.m., she stated the facility licensed nurse received the dialysis center communication report. However, the licensed nurse did not discontinue the Aspirin. The DON acknowledged the licensed nurse should have notified the physician and discontinued the Aspirin 81 mg. Review of the facility's policy, dated 1/2018, "Dialysis, Coordination of Care & Assessment of Resident," indicated the policy of the facility that the dialysis treatment when provide for residents outside the center, shall take place with the benefit of a written agreement between the facility and the dialysis agency for the exchange of information useful and necessary for the care of the resident.

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 11/09/2019 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 31 of 61 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 10/17/2019 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 irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that medication drug regimens for 2 of 18 sampled residents (Residents 59 and 71), who received psychotropic medications (drugs capable of affecting the mind, emotion, and behavior), were reviewed for irregularities (medications used without adequate indication, without adequate monitoring, in excessive doses, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 32 of 61 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 10/17/2019 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 and/or in the presence of side effects). For Residents 59 and 71, there was no monitoring of specific behaviors for use of psychotropic medications; For Resident 59, there was no monitoring for side effects (S/E) for the use of psychotropic medication. This failure placed the residents at risk of receiving unnecessary medications. Findings: 1. Review of Resident 59's clinical records indicated he had diagnoses that included anxiety (a feeling of uneasiness and worry) and depression (persistent feeling of sadness and loss of interest). His physician order dated 9/26/19 indicated Sertraline hydrochloride (medication used for anxiety) 50 milligrams (mg, unit of measurement) tablet once a day and Clonazepam (medication used for anxiety) 0.5 mg tablet at bedtime both for anxiety. Review of Resident 59's medication administration records (MAR) dated 9/26/19 to 10/16/19 indicated there was no evidence of documentation of the monitoring the specific behavior manifestation for anxiety and side effects monitoring for the use of the above psychotropic medications. During a record review of the facility's PC medication regimen review (MRR, the process by which a Consultant Pharmacist reviews medication use for a patient) dated 10/3/19, there was no evidence of documentation by the CP regarding recommendation to monitor specific behavior manifestation and side effects for the use of Clonazepam and Sertraline hydrochoride for Resident 59. During an interview with the CP on 10/17/19 at 2:40 p.m., he confirmed he did not recommend to monitor specific behavior and side effects FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 33 of 61 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 10/17/2019 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 monitoring for the use of psychotropic medication on his MRR review for Resident 59 on 10/3/19. He acknowledged he should have recommended it to the facility. 2. Review of Resident 71's record indicated she had a physician's order dated 9/9/19 to give Cymbalta (antidepressant medication) 60 mg capsule one a day to treat anxiety manifested by restlessness and irritability every shift (eight hours). Review of Resident 71's MAR dated September 2019, indicated the resident's behavior of depression was manifested by difficulty accepting care and poor appetite and she had zero episode of those behaviors. During an interview on 11/17/19 at 11:38 a.m., the the director of subacute (DOSA) who reviewed the record stated the behaviors to support the use of Cymbalta was not clear. During an interview on 10/17/19 at 2:26 p.m., the CP stated he reviewed residents' records for drug irregularity on 10/1/19 and 10/3/19. The behaviors or irritability or restlessness was not specific. He stated he did not make any recommendation to clarify the behaviors, but should have. Review of facility's policy and procedure dated 4/2008, "Consultant Pharmacist Services Provider Requirements," indicated activities that the consultant pharmacist or off-site pharmacist performs includes, but is not limited to reviewing the medication regimen of each resident at least monthly, or more frequently under certain conditions, incorporating federally mandated standards of care in addition to the other applicable professional standards. The review will be documented in the resident medical record, a resident drug regimen must be free of unnecessary drugs. An unnecessary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 34 of 61 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 10/17/2019 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 drugs is any drug when used that includes without adequate monitoring, without adequate indication for its use and in the presence of adverse consequences which indicate the dose should be reduced or discontinued. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 35 of 61 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 10/17/2019 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)

F758 Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/09/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 36 of 61 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 10/17/2019 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 provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: 4. Review of Resident 49's clinical record indicated he was admitted to the facility on 4/30/19 with diagnoses including anxiety disorder (chronic condition characterized by excessive and persistent worry and fear without cause), major depressive disorder (mood disorder that causes persistent sadness and loss of interest), Down Syndrome (congenital disorder arising from a chromosome defect, causing intellectual impairment and physical abnormalities) and cognitive communication deficit (problems with communication that have an underlying cause with impairment in mental processes rather than a primary language or speech deficit). Review of Resident 49's physician order dated 4/30/19, indicated Lorazepam 0.5 milligrams mg every 6 hours as needed (PRN) related to anxiety disorder. Review of the monthly MRR dated 5/15/19 and 7/8/19, indicated the consultant pharmacist (CP) made recommendations to set a duration for the as needed Lorazepam. Further notation in the MMR, indicated if a PRN psychotropic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 37 of 61 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 10/17/2019 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 order must be continued for longer than 14 days then a duration and specific rationale or reason must be obtained. Review of Resident 49's medication MAR was reviewed on 10/16/19. Review of the MAR indicated a physician order for PRN Lorazepam for Resident 49 from 4/30/19 until 8/26/19. A physician order dated 8/26/19, indicated Lorazepam 0.5 mg every 6 hours as needed for anxiety for 90 days. Review of Resident 49's clinical record did not indicate any specific rationale or reason for the PRN use of Lorazepam for the 90-day duration. During an interview with the DON on 10/17/19 at 11:20 a.m., she stated as needed psychotropic medications should be limited to 14 days. She confirmed Resident 49's physician order for PRN Lorazepam continued from 4/30/19 until 8/26/19 beyond 14 days without a specific duration identified. She confirmed the CP recommended the physician add a duration for the PRN Lorazepam order for Resident 49 on 5/15/19 and 7/8/19. She stated on 8/26/19 the PRN Lorazepam was ordered for 90 days and confirmed there was no physician documentation in Resident 49's clinical record indicating the rationale for continued Lorazepam use for 90 days. Review of the facility's policy, "Psychotropic Medication Use", dated October 2017, indicated PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's record and indicate the duration for the PRN order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 38 of 61 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 10/17/2019 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 3. Review of Resident 59's clinical records indicated he had diagnoses that included anxiety and depression. His physician order dated 9/261/9, indicated Sertraline hydrochloride 50 mg once a day and Clonazepam 0.5 mg at bedtime both for anxiety. Review of Resident 59's MAR dated 9/29/19 to 10/16/19, indicated there was no evidence of documentation of the monitoring of the targeted behaviors for anxiety and side effects for the use of the above psychotropic medications. During an interview with licensed vocational nurse H (LVN H) on 10/16/19 at 9:14 a.m., she confirmed there was no evidence of documentation in Resident 59's clinical record that targeted behaviors for anxiety and side effects monitoring were documented for the use of Sertraline HCL and Clonazepam for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 39 of 61 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 10/17/2019 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 above dates. During an interview with the director of sub acute (DOSA) on 10/16/19 at 2:43 p.m., she acknowledged the facility licensed staff should have monitored and documented the specific behavior manifestation and side effect for the use of psychotropic medications for Resident 59. Review of the facility's policy and procedures, dated 10/2017,"Psychotropic Medication Management," indicated medication effects will be monitored on the medication administration record, to include targeted behavior monitoring, and monitoring for adverse effects when medications are used. 2. Review of Resident 24's clinical record she had diagnoses muscle weakness, history of falling, cognitive communication deficit, unsteadiness on feet, and dementia (memory problem). Review of Resident 24's MDS dated 7/16/19 indicated the resident had impaired cognition, required assistance for bed mobility, transfer, eating, toileting, and personal hygiene. Review of Resident 24's physician order dated 9/18/19, indicated Lorazepam 0.5 mg every 6 hours as needed. Review of Resident 24's monthly medication review (MMR) dated 10/1/19, indicated the consultant pharmacy made a recommendation to review Lorazepam 0.5 mg every 6 hours as needed for anxiety. There was no evidence in Resident 24's clinical record the Lorazepam was reviewed by the physician. During an interview with the DON on 10/17/19 at 10:50 a.m., she stated as needed Lorazepam should have been reviewed by the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 40 of 61 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 10/17/2019 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 physician and provide specific rationale to extend the Lorazepam. Based on observation, interview and record review the facility failed to ensure four of 18 sampled residents (Residents 24, 49, 59, and 71) were free from unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior and used to treat challenging behaviors) when, 1. Resident 71's behavior for use of Cymbalta (anti-depressant medication) for depression was not specified and non-drug interventions were not identified and tried, 2. Resident 24's use of Lorazepam (an antianxiety medication) was used on an as needed basis and beyond 14 days and did not indicate a specific rationale or reason by the physician., 3. Resident 59's targeted behaviors for the use of Sertraline (anti-depressant medication) and Clonazepam (an anti-anxiety medication) were not specified and, 4. Resident 49's use of Lorazepam on an as needed basis extended beyond 14 days and did not indicate a specific rationale or reason by the physician. These failures had the potential for not treating the intended problem behavior, could result in the unnecessary use of the medications, could result in the residents receiving the medication for an excessive period of time and experiencing adverse side effects. Findings: 1. During an interview on 10/17/19 at 11:12 a.m., Residents 71 stated she wanted a room change, her room was very noisy, she could hear another resident yelling and she wanted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 41 of 61 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 10/17/2019 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 reside in the same room with her husband. Resident 71 also stated she was taking Cymbalta for pain and the medication was not working. During observations on 10/16/19, a male resident (in the same hallway as Resident 71) was heard in the hallway yelling in his room during the day. Review of Resident 71's record indicated she had diagnoses including depression and anxiety. Her Minimum Data Set (MDS, an assessment tool), dated 9/6/19, indicated the resident did not have any problems with memory and daily decision making skills. Review of Resident 71's record indicated she had a physician's order dated 9/9/19 to give Cymbalta 60 milligram (mg, a metric unit of measurement) capsule one a day to treat anxiety manifested by restlessness and irritability every shift (eight hours). Review of Resident 71's Interdisciplinary Team (IDT, team members from different departments involved in a resident's care) notes dated 9/23/19 at 6:35 p.m., indicated the resident was taking Cymbalta for depression as evidenced by her having difficulty accepting care. It indicated the medication was reviewed by the psychologist who was to send recommendations to the physician. On 10/17/19, a copy of the psychologist evaluation was requested and the facility did not provide such evaluation. Review of Resident 71's Medication Administration Records (MAR) dated September 2019, indicated the resident's behavior of depression was manifested by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 42 of 61 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 10/17/2019 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 difficulty accepting care and poor appetite and she had zero episode. Review of Resident 71's Social Services Progress notes, dated 10/15/19 indicated Resident 71 was not able to sleep last night due to noise. Review of Resident 71's antidepressant use of Cymbalta care plan, dated 9/28/19 did not contain non-drug interventions to alleviate depression and anxiety, such having a quiet environment. During an interview on 11/17/19 at 11:46 a.m., the director of social services stated having knowledge of Resident 71's statement of a noisy male resident bothered her. During an interview on 11/17/19 at 11:38 a.m., the director of subacute (DOSA) who reviewed the record stated the behavior of irritability and restlessness was not clear and there was no documentation of non-drug interventions being tried to help the resident cope with depression and anxiety. Review of the undated policy, "Psychotropic Medication Management," indicated when a resident presented with symptoms or behavior that caused impairment in function, alteration in emotional well-being, or a danger to self or to others, it was the responsibility of the IDT to determine if the symptoms could be cause by the transient medical condition or reversible environmental and/or psychological stressor.

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 11/09/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 43 of 61 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 10/17/2019 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 the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored and labeled appropriately when inspections of two medication rooms and randomly selected medication carts found: 1. Medication Room #1 with one opened and undated multi-dose vial (contains more than one dose of medication) of Tuberculin Purified Protein Derivative solution (PPD - used for tuberculosis screening) and one opened and undated multi-dose vial of Flucelevax 2019/2020 solution (used for Influenza vaccination) 2. Medication Room #2 with one opened and undated multi-dose vial of Flucelevax FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 44 of 61 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 10/17/2019 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 2019/2020 solution 3. Medication cart #4 with expired eye drops. 4. Medication cart #1 with an opened and undated insulin pen 5. Resident 41's metered dose inhaler was left on bedside table. These failures had the potential for residents to receive expired, contaminated, or deteriorated medications and biologicals. Findings: During an observation and concurrent interview with licensed vocational nurse I (LVN I) on 10/14/19 at 2:45 p.m., medication room #1 contained one opened multi-dose vial of PPD and one opened multi-dose vial of Flucelevax. Both vials did not have an open date or discard date on the label. LVN I confirmed the vials should be dated when opened. Review of Lexicomp online (www.lexicomp.com, a nationally recognized drug information resource) indicated the vial of tuberculin PPD which has been entered and in use for 30 days should be discarded because oxidation (the combination of a substance with oxygen) and degradation (decline to a lower condition) may have reduced the potency (a measure of the activity of a drug in a biological system). According to Flucelevax's manufacturer's guideline, discard multiple dose vials 28 days after initial entry. 2. During an observation and concurrent interview with licensed vocational nurse B (LVN B) on 10/14/19 at 3:15 p.m., medication room #2 contained one opened multi-dose vial of Flucelevax. The vial did not have an open date or discard date on the label. LVN B confirmed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 45 of 61 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 10/17/2019 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 the vial should be dated when opened. 3. During an observation and concurrent interview with licensed vocational nurse E (LVN E) on 10/15/19 at 9:12 a.m., medication cart #4 contained a bottle of Atropine Sulfate opthalimic solution (eye drops) with an expiration date of 9/5/19. LVN E confirmed the eye drops were expired and should be discarded. A review of the facility's policy, "Medication Storage in the Facility," dated 04/2008, indicated outdated medications are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 4. During an observation and concurrent interview with licensed vocational nurse A (LVN A) on 10/17/19 at 10:15 a. m., medication cart #1 contained a Lantus Pen (long acting insulin to control sugar in the blood). The pen had no open or discard date on the label. LVN A confirmed the pen should be dated when opened and discarded after 28 days. According to the Lexicomp website, regarding Lantus, indicated a lantus pre-filled pen could be used for up to 28 days at room temperature storage. 5. During concurrent observation and interview on 10/15/19 at 10:13 a.m. , there was a metered dose inhaler on Resident 41 's bedside table. Resident 41 stated the nurse forgot to keep it back to her medication cart. In an interview with RN L on 10/15/19 at 10:30 a.m., RN L stated she should have returned it to her medication cart. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 46 of 61 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 10/17/2019 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

F812 Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/09/2019 §483.60(i) Food safety requirements. The facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 47 of 61 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 10/17/2019 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 §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility document review, the facility failed to follow proper sanitation and food handling practices when: 1. Pans were stacked and stored wet, 2. Personal items were stored in the kitchen, and 3. Juice containers were stored without proper coverings. These failures had the potential to cause food contamination and foodborne illness to residents who received their food from the kitchen Findings: 1. During the initial kitchen tour on 10/14/19 at 8:35 a.m., with the registered dietician (RD), three metal pans of various sizes were observed stacked and stored on a wire rack and were wet on the inside surfaces. The RD confirmed the pans were wet and stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 48 of 61 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 10/17/2019 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 pans should not be stacked and stored wet and should be air-dried. A review of the facility's diet manual, Section C titled "Sanitary Conditions in Dishwashing Area" indicated all items air dried before being stored. 2. During the initial kitchen tour on 10/14/19 at 8:45 a.m., with the RD, a small pink radio was observed on the window sill in a food preparation area. The RD confirmed the radio was on the window sill in the kitchen. The 2017 Federal Food Code Section 6501.110 states that street clothing and personal belongings can contaminate food, food equipment, and food preparation surfaces and consequently must be stored in properly designated areas or rooms. 3. During the initial kitchen tour on 10/14/19 at 8:55 a.m., with the dietary manager (DM), Three plastic pitchers containing a yellow, red and orange liquid were observed in a food preparation area. A paper towel was observed laying on top of the openings of each pitcher. The container with the red liquid was observed to have a paper towel floating on the surface, touching the liquid and the red color was absorbing onto paper towel. The DM confirmed the observations and stated the plastic pitchers contained cranberry juice, orange juice, and lemonade. He stated that the lids to the pitchers "seem to be getting lost" and further stated the liquids should be covered more securely. A review of the facility's diet manual, Section A titled "Sanitary Conditions in Storage of Food" indicated all containers are seamless or plastic containers with tight fitting lids. All containers are clean, tightly covered, labeled and dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 49 of 61 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 10/17/2019 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 with date product was placed into container.

F849 SS=D Hospice Services CFR(s): 483.70(o)(1)-(4)

F849 11/09/2019 §483.70(o) Hospice services. §483.70(o)(1) A long-term care (LTC) facility may do either of the following: (i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices. (ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. §483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following: (A) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 50 of 61 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 10/17/2019 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 chapter. (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. (H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (I) A provision that when the LTC facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 51 of 61 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 10/17/2019 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 personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. (K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. §483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 52 of 61 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 10/17/2019 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 terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient. (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. (E) Instructions on how to access the hospice's 24-hour on-call system. (F) Hospice medication information specific to each patient. (G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. §483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 53 of 61 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 10/17/2019 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 by: Based on interview and record review, the facility failed to ensure good communication occurred between the facility and the hospice (end of life care) provider for one of three sampled residents (Resident 19) when Vitamin C (supplement) 500 milligrams twice daily (mg, unit of measurement) and Zinc (supplement) 220 mg to aid for wound healing was discontinued by the hospice provider. This failure had the potential not to address the appropriate needs of the resident. Findings: Review of Resident 19's undated face sheet indicated she had diagnoses cerebral palsy (a problem that affects muscle tone, movement, and motor skills), muscle weakness, and stiffness on the left hip. Review of Resident 19's minimum data set (MDS, an assessment tool) dated 7/8/19 indicated she had a brief interview of mental status (BIMS, a structured cognitive test) score of 00 (severely impaired), required assistance for bed mobility, transfer, dressing, eating, toileting, and personal hygiene. Review of Resident 19's interdisciplinary (IDT, a coordinated group of experts from several different fields who work together for residents' care) progress note for weight variance & nutritional condition dated 10/9/19 indicated the IDT agreed with the registered dietician (RD) recommendation for Vitamin C 500 mg twice daily for 14 days and Zinc 220 mg x 14 days for wound healing. Review of Resident 19's hospice diagnoses and orders dated 10/10/19 indicated Resident 19 was admitted to hospice on 10/10/19 and order was to discontinue Vitamin C and Zinc. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 54 of 61 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 10/17/2019 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 with the director of sub acute (DOSA) on 10/16/19 at 11:04 a.m., she stated Resident 19's Vitamin C and Zinc was discontinued and the hospice did not communicate the reason why it was discontinued. During an interview with the RD on 10/17/19 at 9:01 a.m., she stated she recommended Vitamin C and Zinc for Resident 19 and she was not aware it was discontinued. During an interview with the director of nursing (DON) on 10/17/19 at 11:01 a.m., she stated the hospice provider should have communicated to the facility the Vitamin C and Zinc was discontinued. Review of the facility's 4/2007, "Nursing Home Facility Agreement", indicated hospice shall supervise, control, coordinate, evaluate the provision of all services by Facility with at least the same stringency as it supervise, control, coordinates and evaluates the provision of its own services.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 11/09/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 55 of 61 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 10/17/2019 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 §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 56 of 61 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 10/17/2019 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 corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: 5. During an observation on 10/14/19 at 11:28 a.m., LVN A cleansed the glucometer after checking Resident 66's blood sugar. LVN A used an alcohol prep pad containing 70% isopropyl alcohol to cleanse the glucometer. She confirmed the glucometer was used for multiple residents. LVN A stated she only used alcohol to cleanse the glucometer after use. During an observation on 10/14/19 at 11:45 a.m., LVN B cleansed the glucometer after checking Resident 56's blood sugar. LVN B used an alcohol prep pad containing 70% isopropyl alcohol to cleanse the glucometer. She confirmed the glucometer was used for multiple residents. LVN B stated she only used alcohol to cleanse the glucometer after use. During an interview with the director of staff development (DSD) on 10/17/19 at 8:45 a.m., she stated glucometers should be cleansed and sanitized after each use with micro-kill bleach wipes. Review of the facility's policy titled "Cleaning and Disinfection of Glucometer" dated 11/2017, indicated to disinfect after each use with an EPA (Environmental Protection Agency)registered detergent/germicide with a tuberculocidal and HBV/HIV label claim. It FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 57 of 61 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 10/17/2019 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 further stated Alcohol should not be used unless indicated by manufacturer's label and instructions. The manufacturer's guidelines titled "Cleaning and Disinfecting Your Assure Platinum Blood Glucose Meter" dated 12/2014, indicated the meter should be cleaned and disinfected after each patient use. "Disinfecting can be accomplished with an EPA-registered disinfectant detergent or germicide that is approved for healthcare settings or a solution of 1:10 concentration of sodium hypochlorite (bleach)." Based on observations, interview and record review, the facility failed to maintain effective infection control program for seven of 21 residents (Resident 16,26,40,50,59,60, and 67), when: 1. There was lack of resident risk assessment for seven of seven residents reviewed (Residents 16, 26, 40, 50, 59, 60, and 67) requiring enhanced standard precautions (ESP, implementation of personal protective equipment in nursing homes to prevent spread of targeted multidrug resistant organisms [MDROs, one of the worst germs]); 2. No appropriate signages were posted for seven resident rooms on ESP and all gowns and masks were stored in the resident closets; 3. No designated thermometer, stethoscope or blood pressure (BP) cuff (inflatable rubber applied to person's arm) was provided solely to Residents 26 and 67's rooms; 4. Two family visitors did not wear gowns and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 58 of 61 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 10/17/2019 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 masks while providing direct contact care for Resident 26; and 5. The glucometer devices (machine that checks blood sugar) were not sanitized according to manufacturer specifications. These failures had the potential to result to spread transmission of MDROs and placed residents at increased risk of healthcare associated infections. Findings: 1. Review of clinical records for Residents 16, 26, 40, 50, 59, 60, and 67 with presence of indwelling devices in subacute unit, revealed the lack of resident risk assessment. During interview with the director of subacute (DOSA) on 10/17/19 at 2:45 p.m., DOSA confirmed that there were no resident risk assessments initiated for seven residents on ESP and there should have been one for each of them in order to determine the need for staff to use gowns and gloves during specific care activities for high-risk residents. The facility policy and procedure titled "14. Enhanced Standard Precautions" revised date 1/10/19, indicated "1. Risk assessment will address behaviors, hygiene, underlying health conditions of both residents. 14. The documentation needed for colonizing a resident with an MDRO following antimicrobial therapy is the assessment (and documentation in the chart) of the licensed nurse as to the absence of clinical signs and symptoms ..." According to California Department of Public Health (CDPH) Enhanced Standard Precautions for Skilled Nursing Facilities (SNF) 2019, indicated "SNF Health Care Personnel should conduct the risk assessment for all FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 59 of 61 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 10/17/2019 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 residents prior to or upon admission and periodically thereafter to determine the need for HCP use of gowns and gloves during specific care activities for high-risk residents. A checklist (Appendix A) can assist with risk assessments." 2. During observation on 10/14, 10/15, 10/16 and 10/17 at 9:30 a.m., there were no appropriate precaution signages in the front door or in the room of residents on ESP to remind people coming in what kind of precautions to follow. Also, all gowns and masks were stored in the resident closets. During an interview with Resident 67's responsible party (RP, person who made the medical decision for the resident) on 10/14/19 at 10:57 a.m., RP stated Resident 26 and 67 were in the same room because they both had colonized MDRO. Resident 26's family members did not follow ESP rules when they do high contact care with the resident. Children who had been coughing also comes in the room. During an interview with Resident 60's RP on 10/16/19 at 4:25 p.m., Resident 60's RP stated the ESP were not clear to the family visitors. The facility policy and procedure titled "Enhanced Standard Precautions" revised date 1/10/19, indicated "3. A sign will be posted outside the resident's room to indicate special precautions are in place and needed when coming within 3 feet of the isolated resident's environment. 4. Personal Protective Equipment will be stocked on or in a covered cart (to avoid contamination before use) outside the isolated resident's room for easy access before caring for resident. Cart for PPE should not block egress from resident room." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 60 of 61 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 10/17/2019 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 3. During observation on 10/15/19, at 9:30 AM, there was no thermometer, stethoscope and BP cuff was intended solely to Resident 26 and 67's room. During interview with LVN M on 10/15/19 at 9:17 p.m., LVN M stated there were no designated stethoscope, thermometer or BP cuff for Resident 26 and 67's room use. The facility policy and procedure titled "Enhanced Standard Precautions" revised date 1/10/19, indicated "11. When possible, dedicate non-critical care equipment such as stethoscope and sphygmomanometer (an instrument for measuring blood pressure) to a single resident or cohorted (a group of people who share a characteristic) residents.." 4. During observation on 10/15/19 at 9:05 p.m., two family members of Resident 26 were changing incontinent pads, providing hygiene, turning, and repositioning for Resident 26. The family members changed Resident 26's bed linens. They did not wear gowns and masks. During an interview with LVN M, on 10/15/19 at 9:17 p.m., LVN M stated the family members should have worn gowns and masks when they did direct contact resident care activities. Review of Resident 26's care plan on enhanced precaution dated 10/14/19, indicated "Resident's family members will be educated regarding enhanced precautions." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: P4JY11 Facility ID: CA070000084 If continuation sheet 61 of 61