Other·July 30, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a facility reported incident and a complaint conducted on 7/24/18. For Entity Reported Incident CA00593607 and Complaint CA00595157 regarding Quality of Care/Treatment, Resident Safety, a federal deficiency was identified (see F689). A Class "B" Citation was also issued. Inspection was limited to the specific facility reported incident and complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 37686, Health Facilities Evaluator Nurse.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 08/02/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide adequate supervision 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: HJCX11 Facility ID: CA070000088 If continuation sheet 1 of 5 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: _______________ 055871 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COASTAL POST ACUTE 348 Iris Dr Salinas, CA 93906 (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 separation following an incident of inappropriate sexual contact between two residents (1 and 2). These failures resulted in a repeat incident of inappropriate sexual contact between the same two residents five minutes later. Findings: Review of Resident 1's clinical record indicated he was admitted on 10/28/17 and had diagnoses of Alzheimer's disease (progressive mental deterioration), dementia (mental disorder caused by brain disease or injury), psychotic disorder (severe mental disorder that causes abnormal thinking and perceptions), and cerebrovascular disease (disease of the blood vessels that supply the brain). Resident 1's care plan revised on 7/2/18, indicated he exhibited sexually inappropriate behaviors toward staff and residents. The care plan indicated Resident 1 would attempt to grab staff on their private parts, expose his own private area, and masturbate when staff attempted to care for him. Review of Resident 2's clinical record indicated he was admitted on 5/25/18 and had diagnoses of transient alteration of awareness (short periods of impaired awareness), bipolar disorder (mental disorder marked by periods of elation and depression), cognitive communication deficit, and muscle weakness. The clinical record indicated Residents 1 and 2 were roommates during the incidents of inappropriate sexual contact. A nurse's note dated 7/1/18 indicated at 2:45 p.m., a certified nurse assistant (CNA) saw Resident 1 trying to insert his penis into the buttocks of Resident 2. The note indicated staff separated the residents and pulled the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HJCX11 Facility ID: CA070000088 If continuation sheet 2 of 5 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: _______________ 055871 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COASTAL POST ACUTE 348 Iris Dr Salinas, CA 93906 (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 privacy curtain. A nurse's note dated 7/1/18 indicated at 2:50 p.m., a CNA saw Resident 1 on top of Resident 2's bed. According to the note, Resident 1 had pulled Resident 2's pants down and was "thrusting" behind him. During an interview with CNA A on 7/10/18 at 11:10 a.m., she confirmed she was the CNA who witnessed the first incident between Residents 1 and 2 on 7/1/18, at 2:45 p.m. CNA A stated Resident 2 was in bed lying on his right side with his pants lowered and his upper buttocks exposed. Resident 1 was behind Resident 2 "rubbing" against his buttocks. CNA A stated she put Resident 1 back in his bed and left the room to inform other staff members about what happened. CNA A confirmed she left the residents in the room with no staff members to supervise them after the incident. CNA A explained Resident 1 had a history of touching other people's private areas. During an interview with Resident 2 on 7/10/18 at 11:25 a.m., he stated he recalled the incidents with Resident 1. Resident 2 stated Resident 1 "rubbed up on my behind." When asked how the incidents made him feel, Resident 2 stated he thought they were "creepy." During an interview with CNA B on 7/10/18 at 11:56 a.m., she confirmed she was the CNA who witnessed the second incident between Resident 1 and Resident 2 on 7/1/18 at 2:50 p.m. CNA B stated she saw Resident 2 in bed lying on his side with his pants down halfway. Resident 1 was kneeling behind Resident 2. CNA B stated Resident 1 was touching his own private area with one hand and touching Resident 2's hip with the other hand. CNA B stated Resident 1 attempted to "penetrate" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HJCX11 Facility ID: CA070000088 If continuation sheet 3 of 5 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: _______________ 055871 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COASTAL POST ACUTE 348 Iris Dr Salinas, CA 93906 (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 2's buttocks, but CNA B stopped him before he could do so. CNA B confirmed Residents 1 and 2 were alone in the room after the first incident and before the second incident. CNA B stated if a staff member remained present in the room after the first incident, the second incident could have been prevented. During an interview with the director of nursing (DON) on 7/10/18 at 12:25 p.m., she stated Residents 1 and 2 should not have been left alone in their room after the first incident. The DON explained CNA A should have either pushed the call light and waited for another staff member to arrive before leaving the room, or put Resident 1 in a wheelchair and removed out of the room. The DON stated CNA A was written up (a disciplinary action) after the incidents. During an interview with the director of staff development (DSD) on 7/12/18 at 11:08 a.m., she stated staff did not adequately separate Residents 1 and 2 after the first incident of inappropriate sexual contact. The DSD stated staff should have completely separated the residents by removing one resident out of the room. The DSD stated CNA A should not have left the residents alone in the room after the first incident. The DSD stated she conducted in-services (training sessions) regarding abuse in the past, and that she went over the facility's abuse policy during these in-services. Review of an "In-Service Training Class Attendance Record", indicated the DSD conducted an in-service on elder abuse on 4/24/18. The record indicated CNA A attended this in-service. The facility's policy, "Abuse Prevention and Prohibition Program", revised 4/2017, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HJCX11 Facility ID: CA070000088 If continuation sheet 4 of 5 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: _______________ 055871 (X3) DATE SURVEY COMPLETED 07/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COASTAL POST ACUTE 348 Iris Dr Salinas, CA 93906 (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 must not be subjected to abuse by anyone, including other residents. The policy further indicated if abuse is discovered or suspected, staff must provide a safe environment for the resident as indicated by the situation. If the suspected perpetrator is another resident, staff must "separate the residents immediately so they do no interact with each other until circumstances of the reported incident can be determined." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HJCX11 Facility ID: CA070000088 If continuation sheet 5 of 5