Other·February 26, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a complaint conducted on 2/12/2020. For Complaint CA00675548 regarding Quality of Care/Treatment, federal deficiencies were identified (see F770 and F773). A Class "B" citation was also issued. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the Department: 10918, Health Facilities Evaluator Nurse.

F770 SS=G Laboratory Services CFR(s): 483.50(a)(1)(i)

F770 03/06/2020 §483.50(a) Laboratory Services. §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the laboratory company urgently reported Resident 1's stat (immediate or urgent) test results. Resident 1 had a symptom of a urinary tract infection (UTI, an 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: YO5E11 Facility ID: CA070000084 If continuation sheet 1 of 7 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 02/12/2020 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 infection of the urinary system such as the kidneys and bladder, with symptoms including shakiness, confusion, and burning sensation or pain during urination) and the physician ordered stat laboratory tests. The laboratory reported one stat laboratory result a day later and the other test five days later. The failure of the late reporting resulted in a delay in notifying the physician, initiating treatment and had the potential of causing health complications to Resident 1. Findings: Review of Resident 1's Change in Condition (CIC) report, dated 1/25/2020 at 10:25 a.m., indicated Resident 1 was having pain when she went to the restroom, her pain started four days ago and the physician ordered urinalysis (UA, a urine test) with culture and sensitivity (CS, test to identify bacteria and which antibiotics the bacteria is sensitive to treatment) laboratory tests. Review of Resident 1's record indicated she had a physician's order dated 1/25/2020 to obtain stat UA with CS and complete blood count (CBC, a blood test used to evaluate overall health and detect a wide range of disorders including infection) tests related to painful urination. Review of Resident 1's UA and CS and CBC tests were all obtained on 1/25/2020 at 11:49 a.m. The CBC test was reported by the laboratory company on 1/26/2020 at 1:41 p.m. and there was an undated documentation indicating the physician was informed of the test result. Review of the UA form indicated the results was reported on 1/30/2020 at 9:15 p.m. and the form indicated a registered nurse on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5E11 Facility ID: CA070000084 If continuation sheet 2 of 7 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 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SALINAS VALLEY POST ACUTE 637 E Romie Ln Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2/5/2020 noted a physician's order was obtained to start an oral antibiotic medication. Review of Resident 1's record lacked documentation indicating licensed nurses were following up in obtaining and reporting laboratory results to the physician prior to 2/5/2020. During an interview on 2/12/2020 at 10:15 a.m., the director of nurse (DON) stated the facility changed laboratory company a few months ago and they were having "challenges," such as laboratory test results being reported late. During an interview on 2/12/2020 at 1:10 p.m., the licensed nurse (LN) stated, "when a physician ordered a stat laboratory test the results should be in by the same day. Since changing to a new laboratory company we have been having problems such as in obtaining stat and routine test results, having them timely pick up laboratory specimens and in phlebotomists being unable to obtain blood tests." The LN also stated, "we often had to call and remind the laboratory company to pick up and report laboratory tests." During a follow-up interview on 2/12/2020 at 4:50 p.m., the DON who reviewed the record stated Resident 1's 1/25/2020 laboratory tests were not reported by the laboratory company as stat. The DON stated she did not find any policy specifying the timeframe in obtaining stat laboratory results. Review of Resident 1's hospital History and Physical, dated 2/6/2020, indicated the resident was doing well until two weeks prior, when she was noted to have some weakness and a little confusion. A UA was ordered and the resident was found to have a UTI. However, it was not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5E11 Facility ID: CA070000084 If continuation sheet 3 of 7 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 02/12/2020 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 treated until yesterday and she was diagnosed with acute encephalopathy (recent brain disease, damage, or malfunction) and UTI. Review of the "CLINICAL LABORATORY AND RADIOLOGY SERVICES AGREEMENT" contract, dated 10/28/19, indicated for all stats ordered by the physician the providers was to dispatch services immediately and return results to the facility promptly, as required by law. Review of the "LAB WORK, ORDERING & REPORTING" policy, dated 11/2012, indicated if critical or stat labs were not received in a timely manner, the nurse was to call for them.

F773 SS=D Lab Srvcs Physician Order/Notify of Results CFR(s): 483.50(a)(2)(i)(ii)

F773 03/06/2020 §483.50(a)(2) The facility must(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws. (ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure licensed nurses promptly obtained Resident 1's stat (immediate or urgent) laboratory test results and immediately notified the results to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5E11 Facility ID: CA070000084 If continuation sheet 4 of 7 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 02/12/2020 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. Resident 1 had a symptom of a urinary tract infection (UTI, an infection of the urinary system such as the kidneys and bladder, with symptoms including shakiness, confusion and burning sensation or pain during urination) and the physician ordered stat laboratory tests. When the physician reviewed the laboratory test results 16 days after the date they were ordered, an antibiotic drug was prescribed to treat the UTI and the resident was transferred to an acute care hospital the same day. The facility also failed to develop a care plan and did not monitor Resident 1 for the UTI. These failures resulted in a delay in treatment and had the potential of causing prolonged pain, discomfort and other health complications to Resident 1. Findings: Review of Resident 1's Change in Condition (CIC) report, dated 1/25/2020 at 10:25 a.m., indicated she was having pain when she went to the restroom, her pain started four days ago and the physician ordered laboratory tests of urinalysis (UA, a urine test) with culture and sensitivity (CS, test to identify bacteria and which antibiotics the bacteria is sensitive to treatment). The record lacked a care plan addressing Resident 1's problem of having UTI symptoms. Review of Resident 1's record indicated she had a physician's order dated 1/25/2020 to obtain stat UA with CS and complete blood count (CBC, a blood test used to evaluate overall health and detect a wide range of disorders including infection) related to painful urination. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5E11 Facility ID: CA070000084 If continuation sheet 5 of 7 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 02/12/2020 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 1's UA and CS and CBC laboratory, indicated the tests were all obtained on 1/25/2020 at 11:49 a.m. The CBC test result was reported to the facility on 1/26/2020 at 1:41 p.m. Review of the UA laboratory form indicated the results was reported to the facility on 1/30/2020 at 9:15 p.m. The same form indicated a registered nurse on 2/5/2020 obtained a physician's order to start an oral antibiotic medication. Review of Resident 1's Health Status Note, dated 2/5/2020 at 9:26 p.m., indicated the resident's hands were shaking. The physician then reviewed the 1/25/2020 UA and laboratory results and ordered an antibiotic medication to treat UTI. The note also indicated a family member arrived at the facility around 8:50 p.m., reported Resident 1 was having increased confusion, and the physician gave an order to send Resident 1 to an acute care hospital. Review of Resident 1's record lacked documentation indicating licensed nurses were following up to obtain and report laboratory test results to the physician prior to 2/5/2020 and the resident had been monitored for signs and symptoms of UTI. During an interview on 2/12/2020 at 1:10 p.m., the licensed nurse (LN) stated when a physician ordered a stat laboratory test the results should be in by the same day. During an interview on 2/12/2020 at 4:50 p.m., the director of nurses who reviewed the record, stated Resident 1's 1/25/2020 laboratory tests were not reported by the laboratory company as stat, the UTI care plan should have been developed after the 1/25/2020 CIC report, and the physician was not notified of the 1/25/2020 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5E11 Facility ID: CA070000084 If continuation sheet 6 of 7 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 02/12/2020 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 laboratory test results until days after tests were ordered. The documentation to support Resident 1's physician was notified of 1/25/2020 laboratory results before 2/5/2020 was requested and not provided. Review of Resident 1's hospital History and Physical, dated 2/6/2020, indicated the resident was doing well until two weeks prior, when she was noted to have some weakness and a little confusion. A UA was ordered and the resident was found to have a UTI but it was not treated until yesterday. The resident was diagnosed with acute encephalopathy (recent brain disease, damage, or malfunction) and UTI. Review of the "LAB WORK, ORDERING & REPORTING" policy, dated 11/2012, did not address the required timeframe in obtaining stat laboratory tests. However it indicated if critical or stat labs were not received in a timely manner the nurse was to call. Review of the "RESIDENT CHANGE OF CONDITION," policy, dated 11/2017, indicated when a resident had a change in condition to continue to monitor and document resident's condition at a minimum every shift (eight hours) for 72 hours and as needed, until the acute episode had subsided and resident was stable. Review of the "CARE PLAN GOALS AND OBJECTIVES" policy, dated 11/2012, indicated the goals and objectives of the care were reviewed when there was a significant change in the resident's condition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YO5E11 Facility ID: CA070000084 If continuation sheet 7 of 7