Inspection visit

InspectionMay 26, 2023

Q: What happened during the May 26, 2023 survey of PACIFIC COAST POST ACUTE?

This was a inspection survey of PACIFIC COAST POST ACUTE on May 26, 2023. The surveyor cited 28 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Q: Were any deficiencies cited at PACIFIC COAST POST ACUTE on May 26, 2023?

Yes, 28 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

Q: What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

PACIFIC COAST POST ACUTECMS #55509028 citations on this visit

28 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 28 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to ensure the resident's right to dignity was provided for one of five residents (Resident 125) when her urinary drainage bag (catheter drainage bag [cath], container to catch the urine from an indwelling urinary catheter [tube into bladder]) was visible and not put into an outer bag to conceal the cath bag. This caused undo anxiety (feeling of worry)/embarrassment to Resident 125. Findings: Resident 125 was admitted to the facility with diagnoses including type 2 diabetes (a chronic condition that affects the way body processes blood sugar), muscle weakness, difficulty in walking, spina bifida (a condition that affects the spine and is usually apparent at birth), hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness) following cerebral infarction (disrupted blood flow to brain cells), and neuromuscular dysfunction of bladder (urinary condition in people who lack bladder control due to a brain, spinal cord or nerve problem). During an observation and concurrent interview with Resident 125 on 5/22/23 at 9:19 a.m., Resident 125 stated it was a little embarrassing to have the cath bag visible and not covered in an outer bag. During an observation and subsequent interview with certified nursing assistant B (CNA B) on 5/22/23 at 9:19 a.m., CNA B had emptied Resident 125's cath bag, then placed the cath bag into new blue bag she had brought into Resident 125's room. The cath bag was still in plastic wrap, which indicated a new blue bag. CNA B stated she was not sure how long Resident 125's cath bag had been without a cover bag. She stated the cath bag should be in a blue bag, for privacy. During an observation on 5/25/23 at 8:56 a.m., the cath bag was not in a blue bag. It was hanging on the right side of the bed (towards the door). During an observation on 5/26/23 at 9:06 AM the cath bag was not in a blue bag. It was hanging on the right side of the bed (towards the door). During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 02/2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. .12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 36 Event ID: 555090 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 expected to promote dignity and assist residents; for example: Level of Harm - Minimal harm or potential for actual harm a. helping the resident to keep urinary catheter bags covered; Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 2 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their policy regarding self-administration of medication for one of 27 sampled residents (Resident 22). This failure had the potential to compromise Resident 22's health, safety and well-being. Residents Affected - Few Findings: Review of Resident 22's medical record indicated she was readmitted on [DATE] and had the diagnoses of unspecified injury to the head and history of transient ischemic attack (TIA, neurological dysfunction resulting from interrupted blood supply to the brain). Review of Resident 22's Minimum Data Set (MDS, an assessment tool), dated 3/20/23, indicated she had a brief interview for mental status (BIMS) score of 10 (a score of 8 to 12 indicates moderate cognitive impairment). During an observation and concurrent interview on 5/23/23 at 9:02 a.m., Resident 22 was lying in bed awake. There was no facility staff in the room. On Resident 22's overbed table, there was an unlabeled medicine cup with a white substance inside. Resident 22 explained that the white substance was a cream that she would apply to her vaginal area. Resident 22 stated her nurse gave her the cream. During an observation and concurrent interview with the director of staff development (DSD) on 5/23/23 at 9:13 a.m., the unlabeled medicine cup with a white substance inside was still on Resident 22's overbed table. There was still no facility staff in the room with the resident. The DSD confirmed this observation. During the observation, Resident 22 told the DSD that the white substance was a cream that she would apply to her vaginal area. During an interview and concurrent record review with the DSD on 5/23/23 at approximately 9:15 a.m., the DSD reviewed Resident 22's medical record and confirmed the white substance on the overbed table was estrace vaginal cream (medication used to treat vaginal dryness, itching and irritation). The DSD explained that in order for the resident to self-administer medication, the facility must do an assessment to make sure she is safe to do so. The DSD stated the resident must also have a physician's order and a care plan indicating she can self-administer medication. The DSD reviewed Resident 22's medical record and confirmed there was no assessment, no physician's order, and no care plan indicating she could self-administer medication. The facility's undated policy and procedure (P&P) titled, Self-Administration of Medications indicated, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The P&P further indicated, If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 3 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to ensure an advance directive (legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf) and POLST (Physician Orders for Life-Sustaining Treatment) had been formulated and completed, for eight of 27 residents (Residents 1, 44, 68, 85, 117, 135, 241, and 242). These failures had the potential to result with inability to make medical decisions when residents cannot make for themselves and could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goal and wishes. Findings: During a review of electronic records (record) for residents 1, 44, 68, 85, 117, 135, 241, and 242, advance directive forms were not located. The residents POLST indicated an incomplete section regarding advance directive. During an interview on 5/24/23 at 12:06 p.m., with the social services director (SSD), who stated We understood that if we talked with the Resident, then we just stopped at section D, but if we discussed with the Legally Recognized Decisionmaker, then we would ask about advance directive. During a review of the facility's policy and Procedure (P&P) titled, Advance Directives, revised 09/2022, the P&P indicated, .Determining Existence of Advance Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. .If the Resident Does not have an Advance Directive 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. .b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance. 2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff. .If the Resident Has an Advance Directive 1. If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 4 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR-screening for residents with a mental disorder and residents with intellectual disability) screening document was accurately completed for one out of three resident (Resident 53). This failure had the potential for Resident 53 not to receive the required care and services. Residents Affected - Few Findings: Review of Resident 53's readmission record dated 3/7/23 indicated, she was readmitted to the facility with diagnoses including schizophrenia (a serious mental disorder that affects how a person thinks, feels, behaves, and reality orientation), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (a disorder that involves more than temporary worry or fear that can be mild or severe). Review of Resident 53's readmission physician's orders dated 3/7/23 indicated, she had an order of risperidone (a psychotropic medication used to treat mental/mood disorders) 1 milligram (mg- a metric unit of mass) every day at bedtime for schizophrenia. Review of Resident 53's readmission PASRR level 1 screening dated 3/7/23, did not indicate Resident 53's mental disorder diagnosis and the use of psychotropic medication. During a record review and interview with the director of nursing (DON) on 5/26/23 at 11:07 a.m., she reviewed Resident 53's clinical record and confirmed Resident 53's PASRR level 1 screening document was not completed accurately. The DON stated the PASSR should indicate Resident 53's mental diagnosis and the use of psychotropic medication. During a review of the facility's undated policy and procedure (P&P) titled, admission Criteria, the P&P indicated, All new admissions and readmissions are screed for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 5 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 294's clinical record indicated she was admitted to the facility with diagnoses including Type 2 diabetes mellitus (adult-onset diabetes, disease that impairs the body's ability to regulate blood sugar) and pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs). A review of Resident 294's medication orders included a maximum dose order for apixaban 5 milligrams (mg, unit of measurement) 2 tablets twice daily, dated 5/16/23. Resident 294 was also receiving two anti-diabetic medications, both dating 5/16/23: an insulin glargine injection inject 13 units subcutaneously in the morning and glipizide 2.5 mg every morning for diabetes mellitus. A review of Resident 294's clinical record indicated there was no comprehensive care plans developed to address goals, approaches, and interventions related to diabetes, nor was there one for the bleeding precautions related to the apixaban use, such as the monitoring for signs and symptoms of bleeding and neurological impairment. During a concurrent interview and record review with Nursing Supervisor H (NS H) on 5/25/23 at 1:55 p.m., she reviewed Resident 295's clinical record and confirmed there were no care plans developed for diabetes care and for anticoagulant use. She added, No care plan added yet. 4. A review of Resident 128's clinical record indicated he was admitted to the facility with diagnoses including hemiplegia (paralysis of one side of the body) and a stroke (loss of blood flow to part of the brain). He has been receiving apixaban 5 mg twice daily for history of stroke since 4/13/23 Further review of Resident 128's clinical record indicated there was no comprehensive care plan developed to address bleeding precautions related to the apixaban use, such as the monitoring for signs and symptoms of bleeding and neurological impairment. During a concurrent interview and record review with NS H on 5/24/23 at 4:55 p.m., she confirmed there should have been a care plan developed for anticoagulant use. Based on interview and record review, the facility failed to develop care plans for four of 27 sampled residents (Residents 22, 294, 128 and 85) when: 1. For Resident 22, the facility did not develop a care plan to address risk for falls in a timely manner; 2. For Resident 294, the facility did not develop a care plan to address her use of antibiotics for a urinary tract infection (UTI-an infection in any part of the urinary system); 3. Also for Resident 294, the facility did not develop care plans to address diabetes care and interventions and the use of apixaban (an anticoagulant, or a blood thinner); 4. For Resident 128, the facility did not develop a care plan for the use of apixaban; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 6 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 5. For Resident 85, the facility did not develop care plans to address multiple diagnoses. Level of Harm - Minimal harm or potential for actual harm Failure to develop care plans had the potential to result in the residents not receiving interventions needed to maintain their health and safety at the highest practicable level. Residents Affected - Few Findings: 1. Review of Resident 22's medical record indicated she was originally admitted on [DATE] and had the diagnoses of difficulty in walking and muscle weakness. Review of Resident 22's Fall Risk Observation/Assessment, dated 1/31/23, indicated she was at moderate risk for falls. Review of Resident 22's Minimum Data Set (MDS, an assessment tool), dated 2/2/23, indicated she was unsteady while standing and walking. Review of Resident 22's SBAR [situation, background, assessment, recommendation] Communication Form, dated 3/4/23, indicated Resident 22 fell. Further review of Resident 22's medical record indicated she had a risk for falls care plan that was initiated on 3/4/23 (the same day she fell, and 32 days after she was assessed as a moderate risk for falls). There was no care plan to address Resident 22's risk for falls prior to 3/4/23. During an interview and concurrent record review with nursing supervisor M (NS M) on 5/24/23 at 9:27 a.m., she explained that when a resident is identified as being at risk for falls, the facility has 72 hours to develop the risk for falls care plan. NS M reviewed Resident 22's medical record and confirmed the facility did not develop a risk for falls care plan until 3/4/23 (the day the resident fell, and 32 days after she was assessed as a moderate risk for falls). 2. Review of Resident 294's medical record indicated she was admitted on [DATE] and had the diagnosis of UTI. Review of Resident 294's Order Summary Report indicated she had an Active physician's order, dated 5/16/23, for Bactrim DS (antibiotic used to treat bacterial infections) 800-160 milligrams (mg, unit dose measurement) one tablet by mouth every Monday, Wednesday and Friday for ten days for UTI. Review of Resident 294's medication administration record (MAR), dated 5/2023, indicated Resident 294 received the above medication as ordered and was scheduled to receive the last dose on 5/26/23. Further review of Resident 294's medical record indicated there was no care plan to address her use of antibiotic for UTI. During an interview and concurrent record review with licensed vocational nurse I (LVN I) on 5/25/23 at 3:34 p.m., she confirmed all the resident's conditions and treatments should be addressed in the care plan. LVN I reviewed Resident 294's medical record and confirmed the resident had an Active Bactrim DS order for UTI. LVN I confirmed Resident 294 did not have a care plan to address her use of antibiotic for UTI. 5. During a review of Resident 85's clinical record, indicated he was admitted on [DATE], and had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 7 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnoses including hemiplegia and hemiparesis (paralysis and/or weakness of one side of the body) following cerebral infarction (disrupted blood flow to the brain cells which can cause parts of the brain cells to die off) affecting right dominant side, type 2 diabetes mellitus (DM, high blood sugar), major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest), anxiety disorder (mental health disorder), and seizure (uncontrolled jerking movements of the arms and legs caused by abnormal brain activity). During a review of Resident 85's care plans, it was revealed that there was no care plan for the above diagnoses. During a concurrent interview and record review on 5/25/23 at 12:14 p.m., with the Director of Nursing (DON), she reviewed Resident 85's clinical record. The DON confirmed Resident 85 had the above diagnoses, and there were no care plans developed for the diagnoses. The DON acknowledged that a care plans for the diagnoses should have been developed. During a review of Resident 85's Minimum Data Set (MDS, an assessment tool), dated 3/06/23, the MDS indicated care areas were triggered for cognitive loss /dementia (a decline in mental capacity affecting daily functioning), communication, active daily living (ADL) functional /rehabilitation (care that can help a person get back, keep, or improve abilities), urinary incontinence (loss of bladder control) and indwelling catheter (a tube inserted to the bladder to drain urine), and falls. There were no care plans to address these triggered care areas. During a concurrent interview and record review on 5/25/23 at 12:50 p.m., with Minimum Data Set Coordinator O (MDSC O), she confirmed the above record review. MDSC O acknowledged that the care plan for the triggered care area should have been developed. During a review of Long -Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1 dated 10/2019, indicated, V0200: Care area assessments (CAAs) and Care Planning; 2. For each triggered care area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-centered, revised 12/2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. The P&P further indicated, The comprehensive, person-centered care plan will incorporate identified problem areas and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 8 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 294's clinical record indicated she had a physician's order, dated 5/17/23, for lidocaine patch (a medication applied topically to relieve pain) 4%, apply to affected area every morning. The facility scheduled it to be administered at 9:00 a.m. every morning. Residents Affected - Few A review of Resident 294's May 2023 medication administration record (MAR) indicated LVN D administered the lidocaine at 9:00 a.m. on 5/25/23. During an interview with LVN D on 5/25/23 at 1:24 p.m., when asked where he had applied the lidocaine on the resident's body, he responded, Why, did the patient ask you about the lidocaine patch? LVN D stated he had not given it yet and will give one right now. He acknowledged he should only document it only after he administered the medication. On 5/25/23 at 1:41 p.m., with the assistance of a nursing assistant, LVN D was observed applying the lidocaine 4% patch on Resident 294's right buttock. During a concurrent interview and record review on 5/25/23 at 4:39 p.m., Nursing Supervisor H (NS H) provided the Medication Admin Audit Report which indicated LVN D documented he administered the lidocaine patch on 5/25/23 at 10:02 a.m., more than 3 hours before he administered it. NS H stated LVN D should not have documented he administered it if the medication was not given. She stated the nursing staff should document right after we give it. A review of the facility's policy and procedure (P&P) titled, Documentation of Medication Administration, dated 11/2022, the P&P indicated, 1. A nurse . documents all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication is documented immediately after it is given. 4. Resident 51 was admitted to the facility with diagnoses including atrial fibrillation (irregular and often very rapid heart rhythm) and hypertension (high blood pressure). A review of Resident 51's clinical record indicated the following physician's orders: - Amiodarone (medication to treat abnormal heart rhythm) 200 milligram (mg-a unit of measurement of mass), give 1 tablet by mouth one time a day for atrial fibrillation- Hold for heart rate (HR; or pulse) less than (<) 60 (normal HR: 60 - 100 beats per minute), dated 1/30/23; and - Metoprolol (medication to treat high blood pressure) extended-release(slowly released into the body over a period of time, usually 12 or 24 hours) 50 mg, 1 tablet by mouth one time a day for hypertension - Hold for HR <60, dated 3/6/23. A review of Resident 51's history of HR readings indicated in the month of May, from 5/1 to 5/26/23, 24 out of 60 times (or 40% of the times) the resident had HR readings of less than 60 beats per minute. A concurrent interview and record review with NS H was conducted on 5/26/23 at 11:11 a.m. A review of the April and May 2023 MARs indicated the nursing staff obtained the resident's HR prior to the medication administration. However, the MARs indicated the nursing staff did not hold, but documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 9 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 they administered, amiodarone and metoprolol when the HR was below 60, as follows: Level of Harm - Minimal harm or potential for actual harm - Amiodarone: on 4/4/23, 4/23/23, 5/7/23, 5/17/23 - Metoprolol: on 4/4/23, 4/23/23, 5/7/23, 5/11/23, and 5/17/23 Residents Affected - Few During an interview on 5/26/23 at 11:20 a.m., NS H confirmed the above, and stated the nurses were supposed to hold the medications and document a code 4 or 5, which meant vital signs outside of parameter or hold/see nurse notes, respectively, on the MAR. She reviewed the nursing progress notes and could not find any documentation the above medications were held on those days. She acknowledged not holding them could cause the HR to go down further, which would be problematic, such as severely low HR, for the resident. During a review of the facility's undated P&P titled, Medication and Treatment Orders, the P&P indicated, Orders for medication and treatments will be consistent with principles of safe and effective order writing. 2. Review of Resident 22's medical record indicated she was readmitted on [DATE] and had the diagnoses of unspecified injury to the head and history of transient ischemic attack (TIA, neurological dysfunction resulting from interrupted blood supply to the brain). Review of Resident 22's Minimum Data Set (MDS, an assessment tool), dated 3/20/23, indicated she had a brief interview for mental status (BIMS) score of 10 (a score of 8 to 12 indicates moderate cognitive impairment). Review of Resident 22's Order Summary Report indicated she had a physician's order, dated 4/12/23, for estrace vaginal cream (medication used to treat vaginal dryness, itching and irritation) 0.1 milligrams per gram (mg/gm, dose measurement) insert 2 gm vaginally one time a day every Monday, Wednesday and Friday. During an observation and concurrent interview on Tuesday, 5/23/23 at 9:02 a.m., Resident 22 was lying in bed awake. On Resident 22's overbed table, there was an unlabeled medicine cup with a white substance inside. Resident 22 explained that the white substance was a cream that she would apply to her vaginal area. Resident 22 stated her nurse gave her the cream. During an observation and concurrent interview with the director of staff development (DSD) on Tuesday, 5/23/23 at 9:13 a.m., the unlabeled medicine cup with a white substance inside was still on Resident 22's overbed table. The DSD confirmed this observation. During the observation, Resident 22 told the DSD that the white substance was a cream that she would apply to her vaginal area. During an interview and concurrent record review with the DSD on Tuesday, 5/23/23 at approximately 9:15 a.m., the DSD reviewed Resident 22's medical record and confirmed the white substance on the overbed table was estrace vaginal cream. The DSD confirmed the physician's order indicated Resident 22 was to receive estrace vaginal cream every Monday, Wednesday and Friday. The DSD confirmed Resident 22 was not supposed to receive estrace vaginal cream on Tuesday, 5/23/23. The DSD reviewed Resident 22's medication administration record (MAR) and confirmed the documentation indicated the resident received estrace vaginal cream the previous day, Monday, 5/22/23. Based on observation, interview, and record review, the facility failed to provide care and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 10 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm services in accordance with professional standards for four of 27 sampled residents (Residents 1, 22, 51, and 294) when: 1. For Resident 1, the facility did not follow a physician's order for the use of booties (boots worn to help prevent skin break down) to both feet and 4x4 gauze between each finger to left hand; Residents Affected - Few 2. For Resident 22, the facility did not follow the physician's order when giving a medication; 3. For Resident 294, a nursing staff documented he administered a medication to the resident when he did not; and 4. For Resident 51, the nursing staff failed to hold two medications as prescribed. These failures had the potential to negatively affect the residents' health, safety, and well-being. Findings: 1. During a review of Resident 1's physician order, dated 6/25/16, indicated, Apply booties to both feet for protection every shift. Review of Resident 1's physician order, dated 9/01/15, indicated, Apply 4x4 gauze in between each finger to left hand every day shift for skin protection. During an observation on 5/24/23 at 11:14 a.m., Resident 1 was lying in bed and was not wearing booties on both feet and left hand's second and third fingers only had a gauze. During a record review on 5/24/23 at 2:00 p.m., Resident 1's treatment administration record (TAR) indicated that booties to both feet and 4x4 gauze in between each finger to the left hand were applied. During an observation and concurrent interview on 5/24/23 at 2:05 p.m., with Licensed Vocational Nurse A (LVN A), Resident 1 was lying in bed and was not wearing booties, and there was no gauze between each finger on the left hand except between the 2nd and 3rd fingers. LVN A confirmed this observation. During an interview and concurrent record review with LVN A on 5/24/23 at 2:07 p.m., LVN A, reviewed Resident 1's physician's order and confirmed Resident 1 was supposed to wear booties on both feet and should have 4x4 gauze in between each finger on the left hand, not only on the second and third fingers. LVN A further stated she did not know where Resident 1's booties were. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 11 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was documented evidence that pressure ulcer (damage to the skin and underlying tissues as a result of prolonged pressure) treatments were provided for one of two sampled residents (Resident 51). This failure had the potential to result in worsening of Resident 51's pressure ulcer. Residents Affected - Few Findings: Review of Resident 51's medical record indicated he was admitted on [DATE] and had the diagnoses of kyphosis (excessive curvature of the spine that causes hunching) and peripheral vascular disease (disease that causes narrowing of blood vessels and decreased circulation). During an interview with Resident 51 on 5/22/23 at 9:52 a.m., he stated he had a wound on his back for which he was receiving daily treatments. Resident 51 stated he had this wound since he was admitted to the facility. During an interview with licensed vocational nurse N (LVN N) on 5/24/23 at 12:54 p.m., she stated Resident 51 had an unhealed pressure ulcer on his mid-back. LVN N stated Resident 51 had this pressure ulcer since admission. Review of Resident 51's treatment administration record (TAR) indicated he received daily pressure ulcer treatments to his spine (mid-back) until 5/10/23. There was no documentation of pressure ulcer treatments from 5/11/23 to 5/18/23. Further review of the TAR indicated Resident 51 started receiving daily pressure ulcer treatments to his mid-back again on 5/19/23. During a follow-up interview with LVN N on 5/24/23 at 1:57 p.m., she confirmed again that Resident 51's mid-back pressure ulcer was unhealed and had been present since admission. LVN N stated pressure ulcer treatments should be documented on the TAR. When asked to verify if there was treatment documentation for Resident 51's mid-back pressure ulcer from 5/11/23 to 5/18/23, LVN N stated she was not too familiar with the TAR and that she would ask a supervisor to help verify. During an interview with nursing supervisor M (NS M) on 5/24/23 at 3:35 p.m., she stated she reviewed Resident 51's medical record and confirmed there was no documentation that the pressure ulcer to his mid-back was treated from 5/11/23 to 5/18/23. NS M explained that the physician's order for Resident 51's pressure ulcer treatment ended on 5/10/23 and facility staff did not renew the order until 5/19/23. The facility's policy and procedure (P&P) titled, Wound Care, revised 10/2010, the P&P indicated, To verify that there is a physician's order for the wound care procedure. The P&P further indicated, To record the following information in the resident's medical record: 1.) The type of wound care given. 2.) The date and time the wound care was given. 3.) The position in which the resident was placed. 4.) The name and title of the individual performing the wound care. 5.) Any change in the resident's condition. 6.) All assessment data obtained when inspecting the wound. 7.) How the resident tolerated the procedure. 8.) Any problems or complaints made by the resident related to the procedure. 9.) If the resident refused the treatment and the reason(s) why. 10.) The signature and title of the person recording the data. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 12 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 80's clinical record indicated, Resident 80 was admitted on [DATE] with diagnoses including cardiomyopathy (chronic disease of the heart muscle), dementia (impairment of brain functions, such as memory loss and judgment), hypertension (high blood pressure), and glaucoma (eye disease). During a review of Resident 80's SBAR (situation, background, assessment, recommendation) Communication Form, dated 4/20/23, indicated she had a fall. During a review of Resident 80's fall risk observation/assessment, dated 4/20/23, indicated her fall risk score was 18 (high risk). During a review of Resident 80's care plan, Resident is at risk for falls or injury, indicated 4/20/23 unwitnessed fall. There were no new and/or updated interventions/tasks implemented after the fall. During a concurrent interview and record review on 5/24/23 at 9:31 a.m., with Minimum Data Set Coordinator O (MDSC O), she confirmed the above record review. MDSC O stated that there should have been a new and/or updated intervention implemented after the fall to prevent further falls. MDSC O further stated that the IDT would have a post-fall meeting after each fall and implement a new and/or updated intervention. During an interview on 5/24/23 at 1:10 p.m., with MDSC O, she stated that the IDT post- fall meeting did not occur after Resident 80's fall on 4/20/23 and there was no new and/or updated intervention to prevent further falls. During a review of the facility's P&P titled, Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recur despite initial interventions, staff will implement additional or different interventions. Based on observation, interview and record review, the facility failed to follow their fall and fall risk management policy and procedure (P&P) for two out of five residents (Resident 80 and 83) when no new interventions were implemented after a fall. This failure had the potential to result in further falls. Findings: Review of Resident 83's clinical record indicated she was admitted to facility with diagnoses including cerebral infarction (occurs when blood supply to part of the brain interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), heart failure (condition in which heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), dementia (loss of ability to think, remember, and reason to levels that affect daily life and activities), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), and atrial fibrillation (irregular heart beat). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 13 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 83's SBAR (situation, background, assessment, recommendation) Communication Form, dated 5/10/23 indicated, Resident 83 had unwitnessed fall, sustained abrasion on her forehead and had facial discolorations. Review of Resident 83's fall risk observation/assessments, dated 3/6/23 indicated her fall risk score was 20 (indicates high risk for fall), and dated 5/10/23, score was 26 (indicates high risk for fall). During a review of Resident 83's care plan, Resident at risk for falls or injury, dated 5/10/23 indicated, unwitnessed fall. There were no new and /or updated interventions/tasks implemented after the fall. During a concurrent interview and record review with nursing supervisor M (NS M) on 5/25/23 at 1:18 p.m., NS M reviewed and confirmed above record review. NS M stated interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) met on 5/11/23, discussed Resident 83's fall and new interventions to prevent her further falls. NS M stated, I forgot to document IDT post fall meeting's notes after I attended the meeting. NS M acknowledged the new fall interventions for Resident 83 were not implemented and the risk for fall care plan was not updated. During an interview with the director of nursing on 5/25/23 at 1:25 p.m., the DON stated the IDT post fall meeting notes should have been documented. The DON further stated Resident 83's new fall interventions should have been implemented, and risk for fall care plan should have been updated after the fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 14 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate treatment was rendered for one of two sampled residents (Resident 1) to prevent complications of enteral feeding (refers to the intake of liquid food into the stomach, duodenum, or jejunum). This failure could result in health complications. Findings: During a review of Resident 1's clinical record, indicated she was admitted on [DATE] and had the diagnoses including disorder of brain (different problems with the brain can have various causes such as illness, genetics, or injury), gastrostomy (a surgical opening into the stomach for the introduction of food) status, and quadriplegia (paralysis that affects all four limbs). During a review of Resident 1's physician order, dated 10/21/18, the order indicated Enteral feed order: elevated head of bed (HOB) 30-45 degrees at all times during feeding and at least 30-60 minutes after feeding is stopped, every shift. During a review of Resident 1's care plan, Resident requires enteral feeding,, the care plan included keep head of bed elevated at least 30-45 degrees during and for 30 minutes after tube feeding. During an observation on 5/22/23 at 9:39 a.m., Resident 1 was lying in bed with an ongoing enteral tube feeding, and the HOB was elevated. Certified Nursing Assistant C (CNA C) lowered the HOB to flat and left the room. During a concurrent observation and interview on 5/22/23 at 9:41 a.m., with Licensed Vocational Nurse D (LVN D), Resident 1 was lying flat in the bed with an ongoing enteral tube feeding. LVN D stated Resident 1's HOB should be elevated at least 45 degrees during enteral feedings to prevent aspiration. LVN D raised Resident 1's HOB to about 45 degrees. During an interview on 5/23/23 at 7:41 a.m., with the Director of Staff Development (DSD), she stated that the HOB should be elevated to at least 45 degrees during enteral feedings to prevent aspiration. During a review of the facility's undated policy and procedure (P&P) titled, Enteral Tube Feeding Via Continuous pump, the P&P indicated, Position the head of the bed at 30 - 45 degrees (semi-Fowler's position) for feeding, unless medically contraindicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 15 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. 3.Record review of Residents 11,53, 57, 75, 83, and 87's Bed Rail Observation/Assessment indicated the section of the assessment designated for documenting the risks and benefits were explained, and informed consent was obtained were left blank. During an observation on 5/22/23 at 8:43 a.m., Resident 11 had 1/4 bed rails up bilaterally. During an observation on 5/22/23 at 9:57 a.m., Resident 53 had 1/4 bed rails up bilaterally. During an observation on 5/23/23 at 9:22 a.m., Resident 57 had 1/4 bed rails up bilaterally. During an observation on 5/22/23 at 11:01 a.m., Resident 75 had 1/4 bed rails up bilaterally. During an observation on 5/22/23 at 10:03 a.m., Resident 83 had 1/4 bed rails up bilaterally. During an observation on 5/22/23 at 9:22 a.m., Resident 87 had 1/4 bed rails up bilaterally. During a concurrent interview and record review with minimum data set coordinator O (MDSC O) on 5/24/23 at 1:10 p.m., she reviewed above resident's medical records and confirmed there was no documentation that the facility explained the risks and benefits and obtained informed consent for the use of bed rails. MDSC O stated facility should have discussed risks and benefits for the use of bed rails and obtained informed consent prior to using bed rails. During an interview with the DON on 5/25/23 at 3:46 p.m., she stated staff should have followed facility's policy and procedure of explaining risks and benefits and obtaining informed consent before using bed rails for residents. 4. A review of Residents 1, 44, 47, 68, 80, 85, and 86's Bed Rail Observation/Assessment indicated the section of the assessment designated for documenting that risks and benefits were explained and informed consent was obtained was left blank. During an observation on 5/24/23 at 9:38 a.m., Resident 44 had 1/4 bars up bilaterally. During an observation on 5/24/23 at 9:40 a.m., Resident 85 had 1/4 bars up bilaterally. During an observation on 5/24/23 at 9:42 a.m., Resident 86 had 1/4 bars up bilaterally. During an observation on 5/24/23 at 9:45 a.m., Resident 68 had 1/4 bars up bilaterally. During an observation on 5/24/23 at 9:48 a.m., Resident 1 was lying in bed and had 1/4 bars up bilaterally. During an observation on 5/24/23 at 9:53 a.m., Resident 47 had 1/4 bars up bilaterally. During an observation on 5/24/23 at 1:45 p.m., Resident 80 was sitting up in her wheelchair and had grab bars up bilaterally. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 16 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 5/24/23 at 1:30 p.m., with Minimum Data Set Coordinator O (MDSC O), she reviewed these residents' medical records and confirmed there was no documentation that the facility explained the risks and benefits and obtained informed consent for the use of bed rails. MDSC O stated that the facility should have discussed the risks and benefits of the use of bed rails and obtained informed consent prior to applying the bed rails. Residents Affected - Some The facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, revised 8/2022, the P&P indicated, For the purpose of this policy bed rails include: a. side rails; b. safety rails; and c. grab/assist bars. The P&P further indicated, Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. Based on observation, interview and record review, the facility failed to ensure there was documented evidence that risks and benefits were explained and informed consent was obtained for the use of bed rails (side rails, safety rails and grab/assist bars) for 23 of 27 sampled residents (Residents 292, 67 123, 135, 241, 117, 242, 125, 128, 11, 53, 57, 75, 83, 87, 93, 1, 44, 47, 68, 80, 85 and 86). These failures had the potential to compromise the residents' rights to be fully informed and make decisions regarding their care and treatment. Findings: 1. During an observation on 5/25/23 at 7:32 a.m., Resident 292 was lying in bed and had grab bars (short rails attached to the sides of the bed to help the resident move around in bed) up bilaterally (on both sides). Resident 292's Bed Rail Observation/Assessment, dated 4/12/23 was reviewed. The section of the assessment designated for documenting that risks and benefits were explained and informed consent was obtained was left blank. During an observation on 5/25/23 at 8:05 a.m., Resident 67 was sitting up in bed and had grab bars up bilaterally. Resident 67's Bed Rail Observation/Assessment, dated 4/19/23 was reviewed. The section of the assessment designated for documenting that risks and benefits were explained and informed consent was obtained was left blank. During an interview and concurrent record review with the director of staff development (DSD) on 5/25/23 at 8:18 a.m., the DSD confirmed that Residents 292 and 67 had grab bars on their beds bilaterally. The DSD reviewed these residents' medical records and confirmed there was no documentation that the facility explained the risks and benefits and obtained informed consent for the use of grab bars. 2. During a review of residents electronic records (records) the side rail assessments/consents did not contain a signature or check mark on the consents for discussing the risk vs. benefits of having the side rails in the up position. During an interview on 5/24/23 at 11:56 AM with the DON, she stated We do not have residents sign the side rail assessments, because it is not considered a side rail, because they can still get out of bed. Nor do they limit their capability of getting out of bed. They are not full side rails, they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 17 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 are quarter rails. Level of Harm - Minimal harm or potential for actual harm During an observation on 5/25/23 at 9:49 AM, Resident 123 had grab bars. During an observation on 5/25/23 at 9:49 AM, Resident 135 had 1/4 bars. Residents Affected - Some During an observation on 5/25/23 at 9:52 AM, Resident 241 had 1/4 bars. During an observation on 5/25/23 at 9:53 AM, Resident 117 had grab bars. During an observation on 5/25/23 at 9:53 AM, Resident 242 had grab bars. During an observation on 5/25/23 at 9:54 AM, Resident 125 had grab bars. During an observation on 5/25/23 at 9:54 AM, Resident 128 had grab bars. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 18 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when random review of medication use for one of five sampled residents (Resident 295) did not reconcile. Five (5) Norco (hydrocodone with acetaminophen, a potent controlled medication for moderate to severe pain) tablets were removed from the the automated dispensing unit (ADU, where medications are stored and electronically tracked) without being documented as administered to the resident. This failure resulted in inaccurate accountability and potential for abuse or diversion of controlled medications. Findings: During a visit to one of the medication rooms in Nursing Station 2 on 5/22/23 at 3:10 p.m., the facility's ADU was observed in the presence of Registered Nurse K (RN K). She stated the facility had the ADU for a few months; it contained medications for routine as well as PRN (or as-needed) medication use. She explained, for PRN medications, the nursing staff would sign in, remove the desired medication under the resident's name, administer it to the resident based on the physician's order, and document the administration on the medication administration record (MAR). A 7-day PRN controlled medication removals was requested during this visit. A review of Resident 295's clinical record indicated she had a physician's order, dated 5/11/23, for Norco (hydrocodone-acetaminophen) 10-325 milligrams (mg, unit of measurement), 1 tablet every 6 hours as needed for moderate pain, and 2 tablets every 6 hours as needed for severe pain. She had diagnoses including migraine headache(a headache of varying intensity, often accompanied ny nausea and sensitivity to light and sound), lesion of unspecified level of lumbar spinal cord (an abnormal change caused by a disease or injury that affects tissues of the spinal cord), and encounter for other orthopedic (related to bones and muscles) aftercare. A review of the provided Control PRN Dispenses for a seven day period, from 5/14/23 to 5/22/23, indicated the nursing staff removed 2 tablets of Norco 10/325 mg for Resident 295: on 5/16/23 at 4:48 a.m.; on 5/18/23 at 1:54 p.m.; and on 5/22/23 at 2:10 a.m., without documenting the corresponding administration on the MAR to show they were administered to the resident. During a concurrent interview and record review with Nursing Supervisor H (NS H) on 5/34/23 at 11:33 a.m., she reviewed the Control PRN Dispenses record and Resident 295's May 2023 MAR and confirmed the above finding. She also reviewed the nursing progress notes and could not find documented evidence these tablets were administered to the resident. During an interview with Licensed Vocational Nurse (LVN) E on 5/23/23 at 12:28 p.m., she stated she had asked another nurse to remove two Norco tablets on 5/18/23 at 1:54 p.m. to administer to Resident 295, but she documented she administered only one tablet by mistake. During a follow-up interview and record review with NS H on 5/23/23 at 2:05 p.m., she provided the following explanation: a. For the two Norco tablets pulled on 5/16/23 at 4:48 a.m., LVN D removed them for Resident 295 to take with her to an ortho appointment but failed to document on the MAR and the progress notes indicating so. She stated the resident confirmed by interview today (5/23/23) that she recalled taking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 19 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 the two Norco tablets with her to the appointment on 5/16/23; Level of Harm - Minimal harm or potential for actual harm b. For the two Norco tablets pulled on 5/18/23 at 1:54 p.m., LVN E administered two tablets to the resident but documented she gave only one tablet on the MAR (as per the interview above); Residents Affected - Few c. Regarding two Norco tablets removed on 5/22/23 at 2:10 a.m., LVN D removed them from the ADU and administered them to the resident but could not document on the MAR because the Norco order required a renewal. When LVN D renewed the order, it became pending and needed the signature from the physician. When the physician signed the order on 12:49 p.m. on that day, LVN D forgot to go back in to document on the MAR. He did not document in the nursing progress notes while waiting for the physician's signature. During the interview and record review above, NS H acknowledged the accountability issue related to five Norco 10-325 mg tablets not being reconciled. During an interview with LVN D on 5/24/23 at 7:55 a.m., he confirmed he had prepared two Norco tablets along with three other routine medications for Resident 295 to take with her to the ortho appointment on 5/16/23, but failed to document on the MAR and/or the progress notes that he had done so. Regarding two tablets removed from the ADU on 5/22/23 at 2:10 a.m., LVN D explained, he had to modify the order because there were only two tablets left from the previous order. When he modified the order, it became pending, waiting for the signature from the physician. He gave the two Norco at about 5:30 a.m. that morning but could not document because of the pending order. He forgot to document the administration after it was signed. He stated he should have documented in the progress notes. A review of the facility's policy and procedure (P&P) titled, Documentation of Medication Administration, dated 11/2022, the P&P indicated, 1. A nurse . documents all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication is documented immediately after it is given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 20 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on observation, interview, and record review, the facility failed to ensure the physician provided the clinical rationale when declining the consultant pharmacist's (CP) recommendations for one of 27 sampled residents (Resident 57). Also, the CP failed to identify Resident 57's seizures as a potential side effect and made recommendation to the facility for the reduction or discontinuance of the medications that may be causing the seizures. These failures resulted in unnecessary medications and potential for unrecognized and prolonged side effects related to psychotropic medications. Findings: A review of Resident 57's clinical record indicated she was an elderly resident admitted to the facility with diagnoses including anxiety, unspecified dementia [impaired ability to remember, think, or make decisions that interferes with doing everyday activities], unspecified severity with other behavioral disturbance, and other seizures [sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness]. Resident 57's clinical record indicated she had been receiving Seroquel (an antipsychotic medication) 25 milligrams (mg, unit of measurement) every morning and 50 mg at bedtime (total: 75 mg/day; a moderate dose; maximum dose is 150 mg/day) related to OTHER PSYCHOTIC DISORDER NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION since 2/18/2020 (or more than 3 years ago). The facility monitored the behaviors of agitation and verbally aggressive for its use. Resident 57's clinical record also indicated she had been receiving trazodone (an anti-depressant) 50 mg at each bedtime (a moderate dose) related to insomnia since 11/22/18 (more than 4 years ago). The facility monitored for the hours of sleep for the effectiveness of this medication. During the survey, Resident 57 was observed on multiple occasions: on 5/24/23 at 9:55 a.m.; on 5/24/23 at 10:01 a.m.; on 5/24/23 at 10:17 a.m.; on 5/24/23 at 11:30 a.m.; on 5/24/23 at 12:48 p.m.; on 5/24/23 at 4:47 p.m.; and on 5/26/23 at 10:28 a.m. During these observations, the resident was observed to be pleasant and quietly talking (or mumbling) to herself in an almost inaudible voice. There was no agitation, distress, or verbal aggressiveness observed. During an interview with Certified Nursing Assistant Q (CNA Q) on 5/24/23 at 10:05 a.m., she stated the facility staff had been monitoring Resident 57 for seizures because she had multiple episodes in the past. She stated she never witnessed the resident having any behaviors including agitation or aggressive behaviors. During an interview on 5/24/23 at 10:09 a.m., with CNA R, she stated Resident 57 did not have any behaviors except she was always mumbling in very low voice. During an interview with the Activity Staff (AS) on 5/24/23 at 10:17 a.m., the AS stated Resident 57 had been brought to the activity room every day, and never had any behaviors while in activity. During an interview with facility Staff G on 5/24/23 at 10:19 a.m., she stated the staff had been monitoring Resident 57 for seizure activity. She stated, [Resident 57] has been good, doesn't speak. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 21 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Sometimes she mumbles. Staff G stated the resident had no agitation or any aggressiveness. Level of Harm - Minimal harm or potential for actual harm A review of the Minimum Data Set (as assessment tool, conducted at least quarterly), dated 10/21/22, 1/12/23, and 4/10/23, indicated the resident had severe cognitive impairment, and had no behaviors exhibited during these assessment periods. Residents Affected - Few A review of the quarterly Anti-psychotic Medication Care Plan Evaluation, dated 8/24/21, 1/16/23, and 4/11/23, indicated Resident 57 had zero (0) behaviors of agitation and verbal aggressiveness during the previous three months prior to the evaluation. A review of the April and May 2023 MARs (where nursing staff documented the behavior monitoring) indicated zero episodes of the monitored behaviors. In other words, the quarterly evaluation and the MARs indicated the resident had no episodes of the monitored behaviors for at least 8 months, from October 2022 to May 2023. A review of the quarterly Psychotropic Meetings for Antidepressant, dated 9/2/21 and 4/11/23, indicated the resident had good sleep of about 6-8 hours per day all three months prior to the meeting. A review of the care plan for seizure-like movements, initiated 11/12/19, indicated the resident had seven (7) episodes of seizure or seizure-like activity: on 4/11/2020, 4/24/2020, 8/25/21, 9/14/21, 4/11/22, 8/5/22, and on 11/30/22. A review of the nursing progress notes, documented on 8/5/22 at 10:29 p.m., indicated, Staff heard a scream coming from her room, staff . went to check resident. Resident note[d] with seizure like movement lasting 30 secs. Noted resident twitching and stiff. Eyes wide open, noted clenching mouth, labored breathing, and non-verbal when talk to. No noted injury . A review of another nursing progress notes, documented on 11/30/22 at 12:35 p.m., indicated, Seizure . Resident sitting upright during breakfast when she was noted with seizure like movement. Movement approx 15-20 seconds. Resident became non-responsive to verbal and tactile stimuli. Eyes open . Assisted back to bed by staff . A review of Lexi-comp, a nationally recognized drug information resource, indicated the side effects of Seroquel included seizures. Under Disease-related concerns, it indicated, Seizures: Use with caution in patients at risk of seizures, including those with a history of seizures . or concurrent therapy with medications which may lower seizure threshold. Elderly patients may be at increased risk of seizures due to an increased prevalence of predisposing factors. Regarding the use of trazodone, Lexi-comp also indicated one of its potential side effects was seizures, and Use with caution in patients at risk of seizures, including those with a history of seizures concurrent therapy with medications that may lower seizure threshold. Lexi-comp indicated to monitor for seizure activity in patients receiving trazodone. A review of the consultant pharmacist (CP)'s recommendations, called the monthly medication regimen review or MRR, indicated the CP recommended for the gradual dose reduction (GDR) of Seroquel and trazodone on 10/29/20, 3/23/21, 4/17/22, 4/14/23, and 4/30/23. The physician declined these recommendations. A concurrent interview and record review was conducted with Nursing Supervisor H (NS H) on 5/24/23 at 11:37 a.m. A review of CP's recommendations for GDRs (as stated above) with NS H indicated the physician just checked the CP's pre-printed template of Resident with good response, maintain current (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 22 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dose as a response. Specifically, on 4/14/23, the CP made a recommendation for changing Seroquel to another medication, Depakote; and again on 4/30/23, the CP asked for consideration for Seroquel and/or trazodone reduction. The physician placed a check mark on the DISAGREE without providing the clinical rationale explaining why she declined the recommendations. NS H stated, The doctor usually just signs the MRRs and doesn't write the verbiage. She acknowledged the physician should document her rationale why she declined. During a telephone interview with Resident 57's attending physician on 5/25/23 at 8:30 a.m., she stated Resident 57's seizures had not been verified; that the resident had jerkiness, and the nursing staff may have mistaken it for seizure activity. The physician stated the resident looks uncomfortable as she mumbles to herself and bounces her legs, as the reason why she did not want to make changes to the medications. When asked the reason why she did not document the rationale, as required, for no GDR of the medications, she stated, It's cumbersome. I'll write rationale from here on. During a telephone interview with the CP on 5/26/23 at 11:41 a.m., he stated, The doctors sometimes give me a 'benefits outweigh the risk,' that's all they give me. The CP stated the facility staff write the rationale in the resident's care plan, but he acknowledged the regulations required the physician to document the clinical rationale when declining his recommendations. When asked whether he identified the resident's multiple episodes of seizures as the potential side effect from Seroquel and/or trazodone and made the recommendation to the facility, the CP stated he was not aware the resident had seizures. He acknowledged Seroquel and trazodone could lower seizure threshold and cause seizures. He stated, Normally seizure is the red flag for me. He stated again that he was not aware the resident had seizures. A review of the facility's undated policy and procedure (P&P) titled, Tapering Medications and Gradual Dose Reduction, the P&P indicated, Residents who use antipsychotic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs . and Attempted tapering of psychopharmacologic [those that control behavior or to treat thought disorder processes] medications . shall be considered as a way to demonstrate whether the resident is benefiting from a medication or might benefit from a lower or less frequent dose. The P&P further indicated the facility shall attempt a GDR at least annually, unless contraindicated after the first year of the resident receiving antipsychotic or psychotherapeutic medications. A review of the facility's April 2018 P&P titled, Medication Utilization and Prescribing - Clinical Protocol, the P&P indicated, The Physician will provide and/or document a rationale when the .duration . of a prescribed medication is greater than commonly accepted practice . A review of the facility's undated P&P titled, Medication Regimen Reviews, the P&P indicated, The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication . The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication . The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems . and other irregularities, for example . potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 23 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and record review, the facility failed to ensure two of 27 sampled residents (Residents 57 and 128) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 57 received Seroquel (an antipsychotic medication) and trazodone (an anti-depressant) without gradual dose reduction (GDR) in the presence of having had episodes of seizures (a potential side effect from both medications) and in the absence of target behaviors; and 2. Resident 128 received trazodone without staff identified and monitoring for target symptoms/behaviors in order to assess the effectiveness of the medication. The failures resulted in inadequate monitoring for effectiveness and unnecessary medications, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: 1. A review of Resident 57's clinical record indicated she was an elderly resident admitted to the facility with diagnoses including anxiety, unspecified dementia [impaired ability to remember, think, or make decisions that interferes with doing everyday activities], unspecified severity with other behavioral disturbance, and other seizures [sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness]. Resident 57's clinical record indicated she had been receiving Seroquel 25 milligrams (mg, unit of measurement) every morning and 50 mg at bedtime (total: 75 mg/day; a moderate dose; maximum dose is 150 mg/day) related to OTHER PSYCHOTIC DISORDER NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION since 2/18/2020 (or more than 3 years ago). The facility monitored the behaviors of agitation and verbally aggressive for its use. Resident 57's clinical record also indicated she had been receiving trazodone 50 mg at each bedtime (a moderate dose) related to insomnia since 11/22/18 (more than 4 years ago). The facility monitored for the hours of sleep for the effectiveness of this medication. During the survey, Resident 57 was observed on multiple occasions: on 5/24/23 at 9:55 a.m.; on 5/24/23 at 10:01 a.m.; on 5/24/23 at 10:17 a.m.; on 5/24/23 at 11:30 a.m.; on 5/24/23 at 12:48 p.m.; on 5/24/23 at 4:47 p.m.; and on 5/26/23 at 10:28 a.m. During these observations, the resident was observed to be pleasant and quietly talking (or mumbling) to herself in an almost inaudible voice. There was no agitation, distress, or verbal aggressiveness observed. During an interview with Certified Nursing Assistant (CNA) Q on 5/24/23 at 10:05 a.m., she stated the facility staff had been monitoring Resident 57 for seizures because she had multiple episodes in the past. She stated she never witnessed the resident having any behaviors including agitation or aggressive behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 24 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm During an interview on 5/24/23 at 10:09 a.m., with CNA R, she stated Resident 57 did not have any behaviors except she was always mumbling in very low voice. During an interview with the Activity Staff (AS) on 5/24/23 at 10:17 a.m., the AS stated Resident 57 had been brought to the activity room every day, and never had any behaviors while in activity. Residents Affected - Few During an interview with facility Staff G on 5/24/23 at 10:19 a.m., she stated the staff had been monitoring Resident 57 for seizure activity. She stated, [Resident 57] has been good, doesn't speak. Sometimes she mumbles. Staff G stated the resident had no agitation or any aggressiveness. A review of the Minimum Data Set (as assessment tool, conducted at least quarterly), dated 10/21/22, 1/12/23, and 4/10/23, indicated the resident had severe cognitive impairment, and had no behaviors exhibited during these assessment periods. A review of the quarterly Anti-psychotic Medication Care Plan Evaluation, dated 8/24/21, 1/16/23, and 4/11/23, indicated Resident 57 had zero (0) behaviors of agitation and verbal aggressiveness during the previous three months prior to the evaluation. A review of the April and May 2023 MARs (where nursing staff documented the behavior monitoring) indicated zero episodes of the monitored behaviors. In other words, the quarterly evaluation and the MARs indicated the resident had no episodes of the monitored behaviors for at least 8 months, from October 2022 to May 2023. A review of the quarterly Psychotropic Meetings for Antidepressant, dated 9/2/21 and 4/11/23, indicated the resident had good sleep of about 6-8 hours per day all three months prior to the meeting. A review of the care plan for seizure-like movements, initiated 11/12/19, indicated the resident had seven (7) episodes of seizure or seizure-like activity: on 4/11/2020, 4/24/2020, 8/25/21, 9/14/21, 4/11/22, 8/5/22, and on 11/30/22. A review of Lexi-comp, a nationally recognized drug information resource, indicated the side effects of Seroquel included seizures. Under Disease-related concerns, it indicated, Seizures: Use with caution in patients at risk of seizures, including those with a history of seizures . or concurrent therapy with medications which may lower seizure threshold. Elderly patients may be at increased risk of seizures due to an increased prevalence of predisposing factors. Lexi-comp also indicated abnormal involuntary movements of the body or extremities as the potential side effects of Seroquel. Regarding the use of trazodone, Lexi-comp also indicated one of its potential side effects was seizures, and Use with caution in patients at risk of seizures, including those with a history of seizures concurrent therapy with medications that may lower seizure threshold. Lexi-comp indicated to monitor for seizure activity in patients receiving trazodone. Despite the presence of multiple episodes of seizures and in absence of target behaviors, there was no evidence the facility conducted the GDR for Seroquel since 2/18/2020 (more than 3 years); or for trazodone since 11/22/18 (more than 4 years) A review of the consultant pharmacist (CP)'s recommendations, called the monthly medication regimen review or MRR, indicated the CP recommended for the GDR of Seroquel and trazodone on 10/29/20, 3/23/21, 4/17/22, 4/14/23, and 4/30/23. The physician declined these recommendations. During a concurrent interview and record review with Nursing Supervisor H (NS H) on 5/24/23 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 25 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11:37 a.m., she reviewed Resident 57's clinical record and stated there had been no agitation or aggressive behaviors documented, and acknowledged there had been no GDR for the Seroquel since 2/2020; and trazodone since 11/2018. A review of the CP's recommendations for GDRs (as stated above) with NS H indicated the physician just checked the CP's pre-printed template of Resident with good response, maintain current dose or placed a check mark by the DISAGREE without documenting the clinical rationale or explanation for declining the recommendations. She stated, The doctor usually just signs the MRRs and doesn't write the verbiage. During a telephone interview with Resident 57's attending physician on 5/25/23 at 8:30 a.m., she stated Resident 57's seizures had not been verified; that the resident had jerkiness, and the nursing staff may have mistaken it for seizure activity. The physician stated the resident looks uncomfortable as she mumbles to herself and bounces her legs, as the reason why she did not want to make changes to the medications. She acknowledged mumbling to oneself did not cause harm or significant distress to the resident; and the bouncing of her legs (involuntary movement) could be a side effect of Seroquel. When asked the reason why she did not document the rationale, as required, for no GDR of the medications, she stated, It's cumbersome. I'll write rationale from here on. A review of the facility's undated policy and procedure (P&P) titled, Tapering Medications and Gradual Dose Reduction, the P&P indicated: Residents who use antipsychotic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs . and Attempted tapering of psychopharmacologic [those that control behavior or to treat thought disorder processes] medications . shall be considered as a way to demonstrate whether the resident is benefiting from a medication or might benefit from a lower or less frequent dose. The P&P further indicated the facility shall attempt a GDR at least annually, unless contraindicated after the first year of the resident receiving antipsychotic or psychotherapeutic medications. 2. A review of Resident 128's clinical record indicated he was admitted to the facility with diagnoses including anxiety and depression. A review of his physician's orders included an order for trazodone 50 mg, half tablet (or 25 mg) at bedtime for depression/anxiety, dated 5/4/23. Resident 128's clinical record showed no evidence of identification and monitoring for target symptoms/behaviors or the manifestation of depression/anxiety such as inability to sleep, social isolation, crying, etc. During an interview with Registered Nurse K (RN K) on 5/24/23 at 4:43 p.m., she stated she did not know and could not locate any target behaviors for Resident 128's depression/anxiety. During a concurrent interview and record review with NS H on 5/24/23 at 4:55 p.m., she stated the trazodone was for treating depression but she did not know what specific symptoms of depression the resident had. She confirmed the facility would not be able to assess the effectiveness of the medication without knowing and monitoring for the specific behavioral symptoms. A review of the facility's P&P titled, Psychotropic Medication Use, dated 12/2016, the P&P indicated 1. Residents will only receive psychotropic medications when necessary to treat specific conditions which they are indicated and effective as documented in the clinical record. 2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood . specific symptoms, and risks to the resident and others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 26 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a medication error rate of 6.45% when two medication errors occurred out of 31 opportunities during the medication administration for one of six residents (Resident 22). Resident 22 did not receive two medications with meals, as prescribed. The failure had the potential for the resident to suffer side effects from the medications such as stomach upset or pain. Residents Affected - Few Findings: During a medication pass observation with Licensed Vocational Nurse E (LVN E) on 5/22/23 at 10:16 a.m., she was observed preparing eight medications for Resident 22. Included in the medications was one tablet of metformin (medication used to treat diabetes [high levels of blood sugar]) 500 milligrams (mg-unit of measurement). On 5/22/23 at 10:34 a.m., at Resident 22's bedside, LVN E administered the medications to Resident 22 with a small cup of water. There was no breakfast tray or food observed on the over-bed table. Resident 22 complained of a sore throat while taking her medications. During an interview on 5/22/23 at 10:40 a.m., Resident 22 stated she did not eat breakfast because of her sore throat. On 5/22/23 at 10:42 a.m., LVN E was observed removing two tablets of ibuprofen (a non-steroidal anti-inflammatory drug [NSAID], to treat minor pain) 200 mg (total 400 mg) from the medication cart and returned to the resident's room. Resident 22 took them with a small amount of water. LVN E did not offer to give ibuprofen with food or a snack. During an interview on 5/22/23 at 10:52 a.m., LVN E stated breakfast trays were brought out around 8 a.m. (more than 2 hours ago). She acknowledged the metformin should be given with a meal. Regarding the ibuprofen, LVN E acknowledged an NSAID should be administered with food to avoid stomach upset. She added, I forgot. During an interview with Resident 22's assigned certified nursing assistant (CNA B) on 5/22/23 at 10:57 a.m., he stated Resident 22 ate just a bit of breakfast and a small sip of a nutrition drink at around 8:20 a.m. that morning. A review of Resident 22's clinical record indicated the following physician's orders: a. Metformin 500 mg Give 1 tablet by mouth two times a day for DMII [diabetes Type 2] (Give with meals), dated 4/19/23; b. Ibuprofen 400 mg, Give 400 mg by mouth every 6 hours as needed for generalized pain management (Give with food), dated 3/3/23. A review of Lexi-comp, a nationally recognized drug information resource, indicated the following for metformin administration: Administer with a meal (to decrease GI [gastrointestinal] upset). For ibuprofen, it indicated, Administer with food or milk. During a follow-up interview on 5/22/23 at 1:42 p.m., LVN E acknowledged the metformin was supposed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 27 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to be given with meals as per the physician's order. She stated the administration time was way over breakfast time as she was running late this morning. A review of the facility's policy and procedure (P&P) titled, Administering Oral Medications, dated October 2010, the P&P indicated that it provided guidelines for safe administration of medications; however, the P&P did not delineate the 5-rights of medication administration, such as the right time, and the requirement to follow the physician's order or manufacturer's specifications. Event ID: Facility ID: 555090 If continuation sheet Page 28 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure insulin pens and other medications were safely labeled; and an expired medication was removed from active stock, to avoid mix-up errors or medication given beyond its effective date. Findings: During a visit to the Station 3 Medication Room on [DATE] at 11:20 a.m. with Facility Staff G (Staff G), the medication refrigerator was identified. It contained eight insulin pens (pre-filled pen containing medication to lower blood sugar); two of the pens had the pharmacy label (one containing information such as patient name, medication name, direction for use, prescription number) on the cap (instead of the body) of the pens. Staff G stated sometimes the pharmacy would send the pens with the label on the cap; and the staff would usually re-label it by moving the label from the cap to the body. She confirmed the patient's label should not be on the cap to avoid mix-up errors. The inspection of the medication refrigerator also identified an opened, multi-dose tuberculin vial (a protein extract used in a skin test to help diagnose tuberculosis infection), which had an open date of [DATE] (more than 3 months ago). Staff G verified this finding. During an interview with Nursing Supervisor H (NS H) on [DATE] at 11:24 a.m., she stated opened multi-dose vials, such as tuberculin, were good for a month; she confirmed it was past its expiration date. During an inspection of Medication Cart 1C with Licensed Vocational Nurse J (LVN J) on [DATE] at 3:49 p.m., three (3) insulin pens were identified in the cart. One of three pens had the pharmacy label on the cap, and another pen had no pharmacy label. LVN J stated the pharmacy label should be on the body of the pen, and she did not know whom the unlabeled pen belonged to. The unlabeled pen had a small yellow sticker indicating it was opened on [DATE]. LVN J acknowledged she could not use the pen because it was not labeled, and had the potential for error due to being used on the wrong resident. The medication cart inspection with LVN J also identified a fluticasone/vilanterol Ellipta Inhaler (a hand-held inhaler for breathing conditions) which was opened without an open date. A review of the manufacturer's labeling with LVN J indicated, Discard the inhaler 6 weeks after opening the moisture-protective foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. LVN J confirmed it should have an open date to prevent it being used past the 6-week expiration date. A review of the 2017 Institute for Safe Medication Practices' (ISMP, a nonprofit patient safety organization with recognized national expertise in medication error prevention) Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults, indicated, A patient-specific label is affixed on the body of the insulin pen (not on the removable cap), without obscuring important information on manufacturer labeling or the dose counter/dose window . Insulin pen mix-ups between patients have been reported to ISMP when patient-specific labels were stuck to (or placed on) the pen caps rather than to the barrel of the pen and the caps of two different pens were inadvertently switched. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 29 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023, the P&P indicated, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices, Multi-dose vials that have been opened or accessed . are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial, If medication containers having missing . labels, contact the dispensing pharmacy for instructions . and Only the dispensing pharmacy may label or alter the label on a medication container or package. Event ID: Facility ID: 555090 If continuation sheet Page 30 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide milk for dry cereal during breakfast meal for one out of seven resident (Resident 11). This failure had the potential to compromise Resident 11 nutritional needs. Findings: Review of Resident 11's clinical record indicated, she was admitted on [DATE] with diagnoses including anemia (a condition in which lower than normal amount of red blood cells in blood), anxiety (a feeling of worry or fear that can be mild or severe),depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (loss of ability to think, remember and reason to levels that affect daily life and activities). Review of Resident 11's minimum data set (MDS- clinical and functional assessment tool) dated 1/14/2023, indicated her brief interview for mental status (BIMS) score was 14 (a score of 13 to 15 indicates intact cognition). During an observation and concurrent interview with Resident 11 on 5/23/23 at 8:40 a.m., there was a bowl of dry cereal with no milk in her breakfast tray. Resident 11 stated Kitchen staff sending me bowl of dry cereal every day with no milk, how can I eat dry cereal without milk? Review of Resident 11's breakfast tray card, indicated Resident 11 had no known food allergies or dislikes to milk. During an interview with certified nursing assistant P (CNA P) on 5/23/23 at 8:41 a.m., CNA P confirmed the above observation. CNA P stated kitchen staff should have provided milk for dry cereal to eat with. During concurrent record review and interview with the dietary supervisor (DS) on 3/24/23 at 8:40 a.m., the DS reviewed Resident 11's breakfast tray card and confirmed Resident 11 had no known allergies or dislikes to milk. The DS stated dietary staff should have sent milk along with the dry cereal. During an interview with registered dietitian on 5/24/23 at 9:23 a.m., the RD stated dietary staff should provide Resident 11 with milk along with the dry cereal. Review of facility's policy and procedure (P&P) titled, Food and Nutrition Services, revised October 2017, the P&P indicated, Each resident is provided with nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into considerations the preferences of each resident. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 31 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the diet order for one of 27 sampled residents (Resident 292). This failure had the potential to compromise Resident 292's health and safety. Findings: Review of Resident 292's medical record indicated she was admitted on [DATE] and had the diagnosis of dysphagia (difficulty or discomfort in swallowing). Review of Resident 292's care plan, dated 4/18/23, indicated she was at risk for aspiration (food or liquids accidentally entering into the lungs) due to dysphagia. The care plan further indicated, Provide appropriate food/fluid consistency. Review of Resident 292's Order Summary Report indicated she had a physician's order, dated 5/22/23, for a fortified diet (food with increased nutrients) with mechanical soft texture (diet that restricts foods that are difficult to chew or swallow). During an observation on 5/26/23 at 8:42 a.m., Resident 292 was sitting in bed eating breakfast. There were two slices of toast on her plate. The toast was medium to dark brown and did not appear to be soft. During an observation and concurrent interview with the director of staff development director/infection preventionist (DSD/IP) on 5/26/23 at 8:52 a.m., Resident 292 was still in her room eating breakfast. The DSD/IP confirmed there was toast on Resident 292's plate. The DSD/IP stated she did not think there should be toast on Resident 292's plate because the toast was not soft. During an interview with the registered dietitian (RD) on 5/26/23 at 9:31 a.m., she explained that a diet with mechanical soft texture was considered a Level 3: Advanced diet. The RD confirmed that under this diet, Resident 292 was not supposed to have toast. The facility's undated document titled National Dysphagia Diet (NDD) Level 3: Advanced was reviewed. Toast was listed in the column titled Foods to Avoid. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 32 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide a sippy cup (a cup with a lid and a spout) during lunch for one of 27 sampled residents (Resident 80). This failure had the potential to affect the resident's ability to complete self-feeding task. Residents Affected - Few Findings: During a dining room observation on 5/22/23, Resident 80 had regular cups for milk, juice, and coffee. There was no sippy cup during the lunch meal. Resident 80's meal card on the dining table indicated, Adaptive equip: Built up fork, built up spoon, sippy cup. During a review of Resident 80's physician order, dated 4/20/23, the order indicated, Fortified diet: mechanical soft ground texture, thin liquids consistency, built up/non-weighted spoon/fork and sippy cup with meals. During a concurrent observation and interview on 5/22/23 at 12:52 p.m., with Restorative Nursing Assistant L (RNA L), Resident 80 was using regular cups for her drinks. When asked where was the sippy cup for Resident 80, RNA L stated the sippy cup was not provided from the kitchen. RNA L further stated that the sippy cup should have been provided to Resident 80. During an interview on 5/22/23 at 12:55 p.m., with the Dietary Supervisor (DS), he reviewed the meal card and stated the sippy cup should have been provided to Resident 80. During a review of the facility's policy and procedure (P&P) titled, Assistive devices and equipment, revised 1/2020, the P&P indicated, Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include specialized eating utensils and equipment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 33 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored and labeled in accordance with professional standards for food service safety for 133 of 136 residents who received food from the kitchen when: 1. Undated milk was stored in the kitchen refrigerator; 2. Outdated milk was stored in the kitchen refrigerator; and 3. Undated food was stored in the resident food refrigerator. These failures had the potential to cause foodborne illness for 133 residents who received food from the kitchen. Findings: 1. During the initial kitchen tour on 5/22/23 at 8:04 a.m. with the Dietary Supervisor (DS), three 236-millimeter (ml, a type of unit measurement) cartons of milk without a use-by date were stored in the kitchen refrigerator. The DS confirmed the observation and removed the three milk cartons from the refrigerator. The DS stated he did not know its use-by date and/or why it didn't have a use-by date. The DS stated those milks should not be stored in the refrigerator. 2. During the initial kitchen tour on 5/22/23 at 8:06 a.m. with the DS, one 236-ml carton of milk with a use-by date of 5/07/23 was stored in the kitchen refrigerator. The DS confirmed the observation and removed the milk carton from the refrigerator. The DS acknowledged that the milk was outdated and should have been used by 5/07/23. The DS stated the milk should not be stored in the refrigerator. 3. During a refrigerator inspection on 5/23/23 at 4:31 p.m., with the Director of Staff Development/infection preventionist (DSD/IP), station 2's resident food refrigerator had an unlabeled plastic container filled with beans, sauce and two pieces of cheese. The DSD/IP confirmed the observation and removed the plastic container from the resident food refrigerator. The DSD/IP stated that staff should have labeled the plastic and the food container with the resident's name and the date the food was brought into the facility before storing them in the refrigerator. The DSD/IP further stated that perishable food was safe for three days in the refrigerator. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage revised 11/22, the P&P indicated, All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. During a review of the facility's P&P tilted, Foods Brought by Family/Visitors revised 3/22, the P&P indicated, Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. Containers are labeled with the resident's name, the item, and the date the food was brought into the facility Perishable food is safe in the refrigerator for up to 3 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 34 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation of starting of a tube feeding (feeding tube inserted into stomach to provide nutrition when cannot eat or drink safely by mouth) on 5/25/23 at 1:59 p.m., licensed vocational nurse I (LVN I), had brought needed items into Resident 128's room (new set-up), and set them on overbed table. LVN I had washed her hands, told Resident 128 what she was doing. Put on (donned) gloves. Raised bed, brought the head of the bed up. Set the feeding tube pump. Without changing her gloves, LVN I checked for patency of the feeding tube and checked for residual (any remaining fluid from previous feeding), then hooked the new tubing for feeding. Residents Affected - Few During an interview with LVN I, she stated she should have changed gloves before going to the patient (after touching the bed remote and feeding pump). During a review of the Center for Disease Control and Prevention (CDC) website, hand hygiene, indicated .2. Remember, your hands can spread germs too! You and your visitors should clean hands at these important times: .After touching bed rails, bedside tables, remote controls, or the phone. Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infection when one of 16 bathrooms had: 1a. Unlabeled emesis basin (a plastic kidney-shaped emesis basin used to collect body fluids and for oral hygiene) was placed on top of paper towel holder and 1b. Three wet wash cloths hanging on a grab bar (a metal bar fixed on wall, helps resident to keep balance while standing, moving around, or getting in and out) next to commode; and charge nurse did not change gloves in between tasks for one of three opportunities during preparation of enteral feeding. These failures had the potential for disease transmission among residents. Findings: 1a.During a concurrent observation and interview with certified nursing assistant F (CNA F) on 5/22/23 at 11:35 a.m., there was an unlabeled emesis basin contained toothbrush and toothpaste placed on top of the paper towel holder in residents' room [ROOM NUMBER] bathroom. CNA F acknowledged emesis basin was in use, and not labeled with resident's name. CNA F stated emesis basin should have labeled with resident's name. 1b .During an observation and interview with CNA F on 5/22/23 at 11:35 a.m., there were three wet wash clothes hanging on grab bar next to commode in resident's room [ROOM NUMBER] bathroom. The CNA F acknowledged they were wet and used wash cloths. The CNA F stated wash cloths should not have left on grab bar and they should have sent for laundry. During an interview with the director of staff development /infection preventionist (DSD/IP) on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555090 If continuation sheet Page 35 of 36 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 5/25/23 at 10:49 a.m., the DSD/IP stated staff should have labeled emesis basin with resident's name. She further stated wet wash cloths should not hanging on grab bar after use, staff should have sent those for laundry to follow standard infection control practices to prevent transmission of infections among residents. Review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfecting Non-Critical Resident-Care items, dated June 2011, the P&P indicated, Single resident use items such as bed pans, wash basins, urinals etc . are for single resident use only. [NAME] with resident's name and /or room number and discard upon transfer or discharge. Reusable items are cleaned and disinfected or sterilized between residents. Event ID: Facility ID: 555090 If continuation sheet Page 36 of 36

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Citations

28 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0554GeneralS&S Dpotential for harm
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
0645GeneralS&S Dpotential for harm
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
0658GeneralS&S Dpotential for harm
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0700GeneralS&S Epotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0800GeneralS&S Dpotential for harm
F800 - Food and nutrition services
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
0805GeneralS&S Dpotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0810GeneralS&S Dpotential for harm
F810 - Assistive devices
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0578GeneralS&S Epotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
0500GeneralS&S Dpotential for harm
Meet other general requirements that are deficient.
0712GeneralS&S Dpotential for harm
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
0918GeneralS&S Dpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0919GeneralS&S Epotential for harm
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
0920GeneralS&S Dpotential for harm
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.

FAQ · About this visit

Common questions about this visit

What happened during the May 26, 2023 survey of PACIFIC COAST POST ACUTE?

This was a inspection survey of PACIFIC COAST POST ACUTE on May 26, 2023. The surveyor cited 28 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at PACIFIC COAST POST ACUTE on May 26, 2023?

Yes, 28 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·May 26, 2023