Other·January 8, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a complaint conducted on 12/20/18. For Complaint CA00614100 regarding Admission/Transfer/Discharge Rights, federal deficiencies were identified (F 623 and F660 with s/s of "G"). Another Federal deficiency was identified for a violation unrelated to the complaint (F712). A CLASS B citation was also issued. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 32276, Health Facilities Evaluator Nurse.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 02/08/2019 §483.15(c)(3) Notice before transfer. 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: MKPW11 Facility ID: CA070000088 If continuation sheet 1 of 14 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 12/20/2018 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 Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 2 of 14 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 12/20/2018 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 this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 3 of 14 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 12/20/2018 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 is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, for one of three sampled residents (Resident 1) , the facility failed to issue a 30 day notice of discharge to the resident (or resident representative) and to the Office of the Ombudsman. This failure had the potential to result in the lack of coordination of support for Resident 1 during discharge planning or after discharge to the community. Findings: Review of Resident 1's current Admission Record indicated Resident 1 was admitted to the facility on 8/8/18. Review of Resident 1's Progress Notes dated 11/16/18 indicated "(medical doctor) gave order to discharge home..." The Notice of Transfer/Discharge was signed by Resident 1 on 11/16/18. Resident 1 was discharged home on 11/19/18 (three days after the Notice of Transfer/Discharge was signed). There was no documentation which indicated a plan for Resident 1 to be discharged. There was no documentation which indicated Resident 1, her son, or the Office of the Ombudsman were given a 30 day notice of the discharge. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 4 of 14 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 12/20/2018 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 During an interview with the Director of Rehabilitation B (DOR B), on 12/3/18, at 12:06 PM, she stated she had not been aware Resident 1 was going to be discharged, and was only notified the day after the discharge. During an interview with the Social Services Director A (SSD A) on 12/7/18, at 11:17 AM, she reviewed the clinical record for Resident 1 and verified the Notice of Transfer/Discharge was dated 11/16/18, three days before discharge. She verified there was no 30 day notice of discharge given to the resident or the Office of the Ombudsman. The facility policy and procedure titled "Discharge Plan/Post Discharge Plan of Care" dated 11/2017, did not address the requirement of a 30 day notice of discharge/transfer to the resident, representative, or Office of Ombudsman.

F660 SS=G Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 02/08/2019 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 5 of 14 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 12/20/2018 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. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 6 of 14 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 12/20/2018 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 the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to 1. Identify the discharge needs for one of three sampled residents (Resident 1) and develop an individualized discharge care plan 2. Regularly re-evaluate Resident 1's discharge needs and update the care plan as needed. 3. Consider Resident 1's capacity to care for herself and discuss with the resident. These failures resulted in Resident 1 admitted to the acute then re-admitted back to the facility for long term placement.Findings: During a review of the clinical record for Resident 1, the current Admission Record indicated Resident 1 was admitted to the facility on 8/8/18. The Progress Notes, dated 9/20/18, indicated Resident 1 had surgery to her left eye. On 10/9/18, Resident 1 had an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 7 of 14 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 12/20/2018 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 unwitnessed fall. On 10/15/18 the Progress Notes indicated "Alert and verbally responsive...with forgetfulness, (status post) fall...hard of seeing on[sic] left eye, bumps into things at times..." On 11/16/18, "(medical doctor) gave order to discharge home..." Resident 1 was discharged home on 11/19/18. Review of Resident 1's clinical record indicated no documentation of a discharge care plan. During an interview with the Social Services Director A (SSD A) on 12/7/18, at 10:35 AM, she stated Resident 1 was discharged to her home, where she lived alone. At 11:17 AM, when asked about the discharge plan, she stated Resident 1 had been admitted for rehabilitation; long term stay had been discussed, but the family was unable to afford the share of cost. SSD A reviewed the clinical record of Resident 1 and was unable to find documentation which indicated she had attempted to provide the family with financial assistance. She was unable to find documentation of the discharge care plan upon admission. "I don't have any notes, I thought she was going to be long term, so I did not do it." When asked if Resident 1's home had been inspected for safety, SSD stated "I don't do home inspections. I go by word of the family." She was unable to provide documentation of post-discharge needs (ex: nursing and therapy services, medical equipment or modifications to the home or ADL assistance). Review of Resident 1's Therapy Progress and Discharge Summary dated 10/31/18 indicated under the section for Long Term Goals, Safety: "Goal Not Met..."(Resident 1) is able to navigate to room (independently) with (walker) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 8 of 14 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 12/20/2018 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 using black contrast tape but requires supervision when ambulating in facility due to poor vision. Under the section Impact on Burden of Care/Daily Life, "Due to impaired vision acuity, (Resident 1) requires supervision with ambulation in facility and to prevent falls. (Resident 1) to remain on RNA (Restorative Nursing Assistant) program until expected return back home with caregivers. Continued nursing care required due to medical condition and co-morbidities." During an interview with Director of Rehabilitation B (DOR B), on 12/3/18, at 12:06 PM, she stated Resident 1 required assistance with activities of daily living (ADLs). DOR B stated Resident 1 was blind and would bump into things when walking. She had not been aware Resident 1 was going to be discharged, and was only notified the day after the discharge. "I would never expect her to be living by herself...I didn't think it was realistic. She (Resident 1) was never a candidate to go home", and was unable to do things for herself beyond moving in her bed. DOR B reviewed the Physical Therapy Notes and Occupational Therapy Notes and verified both therapies indicated Resident 1 required assistance with ADLs. During an interview with Licensed Nurse D (LN D), on 12/3/18, at 1:05 PM, he stated Resident 1 needed supervision and assistance with ADLs. He stated he was unaware Resident 1 was to be discharged until about a week before she went home. Review of Resident 1's Physician's Progress Notes dated 8/14/18 indicated "The resident has the capacity to make his/her own health care decisions". During an interview with SSD A, on 12/7/18, at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 9 of 14 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 12/20/2018 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 10:35 AM, she stated Resident 1 had a neuropsychological evaluation. She stated the facility does an evaluation on everyone to establish a baseline. During a review of the clinical record for Resident 1, Neuropsychological Consultation, dated 10/31/18, indicated "Recommendations...Due to severity of her cognitive, medical/functional, and psychiatric difficulties, she will continue to require significant supervision and assistance with day to day affairs...The patient evidences diminished capacity to make independent healthcare decisions at this time given her major neurocognitive disorder (decline in mental ability severe enough to interfere with independence and daily life)...Conservatorship should be pursued given that the patient does not have capacity to make independent financial and healthcare decisions presently given her advanced dementia (long term loss of brain function)... During an interview with SSD A, on 12/7/18, at 10:35 AM, she reviewed the clinical record of Resident 1 and was unable to find documentation which indicated MD 1 was notified of the results of the Neuropsychological Consultation. During an interview with MD C, on 12/7/18, at 11:37 AM, he was unable to recall having been notified of the Neuropsychological Consultation. Review of Resident 1's Discharge Summary from the acute hospital dated 12/3/18 indicated Resident 1 was admitted to the hospital on 11/27/18 with diagnoses of altered mental status (change in behavior which ranges from slight confusion to total disorientation and increased sleepiness to coma.) and urinary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 10 of 14 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 12/20/2018 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 tract infection (an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney). Resident 1 was readmitted back to the facility on 12/3/18 for long term care placement. The facility policy and procedure titled "Discharge Plan/Post Discharge Plan of Care" dated 11/2017, indicated "The Discharge Planning Coordinator, with consultation with the interdisciplinary team (IDT), shall develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners to effectively transition them to post-discharge care, and to reduce factors leading to preventable readmissions. The resident and or resident representative shall be provided with sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility to allow their participation in the discharge planning process...The Discharge Planning Coordinator, with the (ID), shall complete an assessment and develop a planned program for discharge...if the resident does not have a discharge potential, the reason is to be stated...Information needed for the discharge planning process includes: a. Prior health status and care of resident. b. Resident's goals of care and treatment preferences. c. Current level of care needed. d. Caregiver/support person availability and resident's or caregiver/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. e. Projected time frame for moving resident to the next level of care. f. Rehabilitation and teaching/education that must be accomplished prior to discharge... g. Identification of post-discharge needs such FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 11 of 14 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 12/20/2018 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 as nursing and therapy services, medical equipment or modifications to the home or ADL assistance. ...The Discharge Planner shall...include regular re-evaluation of residents to identify changes that require modification of the discharge plan and the comprehensive care plan..."

F712 SS=D Physician Visits-Frequency/Timeliness/Alt NPP F712 CFR(s): 483.30(c)(1)-(4) 02/08/2019 §483.30(c) Frequency of physician visits §483.30(c)(1) The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. §483.30(c)(2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. §483.30(c)(3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally. §483.30(c)(4) At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist in accordance with paragraph (e) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 12 of 14 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 12/20/2018 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 facility failed to ensure one of three sampled residents (Resident 1) was seen by the medical doctor (MD) within 72 hours of admission, and every 30 days. This failure had the potential to result in unidentified medical conditions and/or insufficient provision of medical treatment. Findings: Review of Resident 1's current Admission Record indicated Resident 1 was admitted to the facility on 8/8/18 and was discharged home on 11/19/18. Review of Resident 1's Physician's Progress Note dated 8/28/18 (20 days after admission) indicated there were no other Physician's Progress Notes in the clinical record. During an interview with MD C, on 12/7/18, at 11:37 AM, he reviewed the clinical record for Resident 1 and was unable to find documentation of any notes he had written for this resident. During an interview with the Director of Nursing (DON) on 12/7/18, at 1:36 PM, she reviewed the clinical record and was unable to find documentation of monthly Physician's Progress Notes other than the one note dated 8/28/18. She verified Resident 1 was not seen by an MD within 72 hours of admission. During a review of the clinical record for Resident 1, there was no documentation the MD had assessed Resident 1 prior to discharge. During an interview with MD C, on 12/7/18, at 11:37 AM, he reviewed the clinical record for Resident 1 and was unable to find documentation of an assessment prior to discharge. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 13 of 14 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 12/20/2018 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 The facility policy and procedure titled "Physician Visits" dated 11/2012, indicated "Existing residents will be seen by their attending physician every 30 days. The Physician records resident progress every month in the physician progress notes." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKPW11 Facility ID: CA070000088 If continuation sheet 14 of 14