Other·November 6, 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 standard abbreviated survey regarding investigation of an entity reported incident and a complaint conducted on 10/30/19. For Complaint CA00657285 regarding Quality of Care/Treatment, the Department did not substantiate a violation of federal or state regulations. However, a federal deficiency was identified for a violation unrelated to the complaint (see F684). A Class "B" Citation was issued. For Entity Reported Incident CA00656400 regarding Quality of Care/Treatment, Resident Safety, the Department did not substantiate a violation of federal or state regulations. Inspection was limited to the specific entity 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: 34432, Health Facilities Evaluator Nurse.

F684 SS=D Quality of Care CFR(s): 483.25

F684 11/16/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards 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: S4VW11 Facility ID: CA070000088 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: _______________ 055871 (X3) DATE SURVEY COMPLETED 10/30/2019 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 of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to provide treatment and care in accordance with professional standards of practice for one of three sampled residents (1) when: 1. Nursing staff did not immediately communicate a critically low laboratory value (panic value, laboratory test results that exceed established limits) to a physician. 2. Nursing staff failed to assess, monitor and report Resident 1's change of condition. 3. Nursing staff did not care plan for Resident 1's diagnosis of anemia. These failures had the potential to jeopardize Resident 1's health. Findings: 1. Review of Resident 1's clinical record on 10/4/19 indicated a diagnosis of anemia (low level of red blood cells or hemoglobin (Hgl, a red protein responsible for transporting oxygen in the blood) in chronic kidney disease (diseased kidneys do not make enough erythropoietin (EPO, a hormone produced in the kidneys, which stimulates the body to form red blood cells). Review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST) dated 10/25/17 indicated "Full Treatment" (Primary goal of prolonging life by all medically effective means) which was in effect on 9/17/19. Review of a "Physician Visit Notes" dated 9/17/19 at 10:04 a.m., written by Resident 1's cardiologist (MD A), indicated during a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S4VW11 Facility ID: CA070000088 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: _______________ 055871 (X3) DATE SURVEY COMPLETED 10/30/2019 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 scheduled office visit, Resident 1 presented to him with a Hgl level of 5.7 (normal levels 11.2 to 15.7) and lethargy (sluggish and slow behavior). The Physician Visit Notes indicated MD A directly admitted Resident 1 into the general acute care hospital (GACH) on 9/17/19 for "profound symptomatic anemia" and low heart rate. Review of MD A's GACH "History and Physical (H&P)", dictated on 9/17/19 at 1:38 p.m., indicated Resident 1 presented weak and lethargic and repeat Hgl at GACH on 9/17/19 was down to 5.2. H&P indicated MD A ordered a blood transfusion of three units of packed red blood cells. Review of the GACH's discharge summary dated 9/20/19 at 12:48 p.m., indicated Resident 1 was discharged from GACH on 9/20/19 with diagnosis of acute blood loss anemia. The discharge summary indicated Resident 1's lethargy was due in part to anemia. Review of Resident 1's "Lab Results Report (LRR)" of blood drawn on 9/15/19 at 7 p.m., indicated a Hgl of 5.7. The LRR indicated Resident 1's previous Hgl on 8/11/19 was 8.7 and Hgl on 8/9/19 was 9.0. The LRR indicated registered nurse B (RN B) was notified of the results of the critically low Hgl on 9/16/19 at 7:50 a.m. During a telephone interview with the clinical laboratory scientist (CLS) from the LRR laboratory on 10/29/19 at 9:45 a.m., she stated a Hgl below 7.5 was considered a critically low value and the result was immediately called to RN B. Review of the "Progress Notes" dated 9/16/19 at 12 p.m., indicated RN B reported Resident 1's critically low Hgl to the primary care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S4VW11 Facility ID: CA070000088 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: _______________ 055871 (X3) DATE SURVEY COMPLETED 10/30/2019 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 physician (PCP) per telephone and facsimile. However, there was no documentation RN B reported Resident 1's symptom of lethargy. During an interview with RN B on 10/4/19 at 1:30 p.m., she stated on 9/16/19 at around 8 a.m., the laboratory notified her of a critically low Hgl level. RN B stated she immediately called Resident 1's PCP to notify him of the critical low Hgl result. RN B stated she did not reach the PCP but left him a message to return her telephone call. RN B stated she did not attempt to notify another physician of Resident 1's abnormal laboratory results. RN B stated Resident 1's PCP telephoned four hours later at 12 p.m. when she notified him of the critically low Hgl result. RN B stated Resident 1 seemed weak; nurses had reported Resident 1 had been lethargic for the past few days. During an interview with licensed vocational nurse C (LVN C) on 10/23/19 at 12:07 p.m., she stated she was responsible for Resident 1's care during the morning of 9/17/19 when she sent Resident 1 out of the facility to her scheduled appointment with MD A. LVN C stated she and nurses from the previous shifts who cared for Resident 1 continued to call Resident 1's PCP but the PCP did not respond to their telephone calls. LVN C stated when she cared for Resident 1 on 9/14/19, Resident 1 was not her usual self; she was sleeping all the time and did not want to sit up in the wheel chair. During an interview with the director of staff development (DSD) on 10/4/19 at 2:15 p.m., she stated it was the facility's protocol to speak to the resident's PCP immediately to report critically low or high laboratory results. The DSD stated if the PCP is unavailable, the nurse should discuss the results immediately with the medical director (DM). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S4VW11 Facility ID: CA070000088 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: _______________ 055871 (X3) DATE SURVEY COMPLETED 10/30/2019 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 nursing (DON) on 10/4/19 at 3:15 p.m., she stated when there were critically high or low laboratory results and the resident was symptomatic (negative signs in the presence of anemia), if the resident's PCP did not call back, the nurse should telephone the DM with the results. During an interview with Resident 1's PCP on 10/23/19 at 9:30 a.m., he stated he spoke to RN B on 9/16/19. The PCP stated he would send Resident 1 directly to the hospital, if she had a Hgl of 5.7 and was lethargic. The PCP stated he did not remember if RN A reported Resident 1 was lethargic. Review of the facility's 2012 policy, "Lab Work, Ordering and Reporting", indicated to report lab results to insure residents' health care needs are met and addressed timely ... Upon being notified of a critically abnormal lab result, the licensed nurse will phone the results immediatedly to the physician and obtain and implement the physician's orders given based on the abnormal lab result. Review of the facility's 2012 policy, "Physician Visits", indicated an alternate physician and contact number will be noted on the record to contact when the attending physician is unavailable. 2. During an interview with the DSD on 10/4/19 at 2:15 p.m., she stated a resident with a critical lab value is considered to have a change of condition (COC) which should have been initiated by RN B. Review of the "Progress Notes", dated from 10/16/19 to 10/17/19, indicated there was no documentation on Resident 1's assessment and monitoring for lethargy on 10/16/19 at 12 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S4VW11 Facility ID: CA070000088 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: _______________ 055871 (X3) DATE SURVEY COMPLETED 10/30/2019 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 p.m. or that this was reported to a physician. The progress notes indicated there were no notes written at all from 9/16/19 at 12 p.m. until 9/17/19 at 9:10 a.m. when the nurse documented Resident 1 went to her clinic appointment and MD A notified the facility Resident 1 was sent to the GACH for a blood transfusion. The progress note dated 9/17/19 at 9:10 a.m., did not include Resident 1's physical assessment. The above progress notes indicated there was no assessment done at any time on these dates for Resident 1's lethargy. During an interview with the DON on 10/4/19 at 3:15 p.m., she stated RN B should have initiated a COC which would have informed other licensed nurses to monitor, assess and document on a resident every shift for 72 hours. The DON stated endorsing to the nurse of the oncoming shift was not enough. The DON stated RN B and the nurses who followed her in the care of Resident 1 should have assessed Resident 1 for symptoms and documented the findings. Review of the facility's policy, "Change of Condition, Resident", indicated it is the policy of the facility to identify, inform the physician and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner ... document assessments and interventions on the clinical record at the time of the initiation of the COC and continue to monitor and document resident's condition at a minimum of every shift for 72 hours, until the resident is stable. 3. A review of Resident 1's clinical record indicated a diagnosis of anemia in chronic kidney disease, identified on 10/21/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S4VW11 Facility ID: CA070000088 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: _______________ 055871 (X3) DATE SURVEY COMPLETED 10/30/2019 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 and record review with the DON on 10/4/19 at 3:15 p.m., she stated she could not find a care plan including goals and interventions to care for Resident 1's diagnosis of anemia. The DON stated there should have been a care plan for Resident 1's anemia. Review of the facility's 2017 policy, "Care Plan, Baseline an Comprehensive", indicated a comprehensive person-centered care plan consistent with resident's rights will include measureable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified during the comprehensive assessment ... will describe services that are to be furnished to attain and maintain the resident's highest practicable physical, mental and psychosocial well-being. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S4VW11 Facility ID: CA070000088 If continuation sheet 7 of 7