Inspection·February 4, 2025

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** Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when: 1. The facility staff did not develop a care plan for Resident 1's antibiotic (ATB, used to treat bacterial infections) therapy, which was prescribed on 11/3/24 to treat burning urination (a possible sign of infection); and 2. The facility staff did not develop a care plan to address Resident1's change in condition on 11/11/24. These failures placed Resident 1 at risk of not receiving necessary care and services to maintain resident's health, safety and well-being. Findings: 1.Review of Resident 1's clinical record indicated she was admitted on [DATE] with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). Review of Resident 1's physician's order dated 11/3/24, indicated to give Cipro (an antibiotic used to treat bacterial infections) 500 milligrams (mg, unit of measurement) 1 tablet by mouth two times a day for 10 days for burning urination. During concurrent interview and record review with the Director of Staff Development (DSD) on 12/9/24, at 1:56 p.m., the DSD confirmed that Resident 1 did not have a care plan to address Resident 1's antibiotic treatment or monitor her response to therapy. The DSD also stated that Resident 1 should have a care plan in place. 2. Review of Resident 1's Health Status note, dated 11/11/24, indicated, Resident 1 had bradycardia (a slow heart rate) HR (heart rate or pulse, number of times the heart beats per minute [bpm]; normal HR is 60-100 bpm) 54, Oxygen Saturation (O2 Sat, the amount of oxygen in the blood; normal oxygen saturation is 95-100%) 90% on room air (RA, normal air we breathe) .Axillary (armpit, body temperature measured in the armpit) 95 degrees Fahrenheit [°F, measurement of temperature]. Resident's skin was dry and cold to touch . Review of Resident 1's Health Status Note, dated 11/14/24, indicated, Resident 1 had increased (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 2 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 02/04/2025 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)