Inspection·February 5, 2026

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 ensure one of two residents (Resident 1) who received dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment received care in accordance with professional standards of practice when:1. Staff did not follow fluid restriction order; and2. Staff did not notify the physician about the resident's excessive fluid intake.These failures had the potential to compromise the resident's health and well-being.Findings:A review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] and had diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD, irreversible kidney failure), and dependence on dialysis.A review of Resident 1' s physician's order, dated 12/19/25, indicated, fluid restriction (limiting liquids) 1000 cubic centimeters (cc, a unit of measurement) per day, Dietary provides: B (breakfast) 240 cc, L (lunch) 120 cc, D (dinner) 240 cc, Total 600 cc, Nursing provides: NOC (night) 100 cc, DAY 180 cc, EVE (evening) 120 cc, Total 400 cc.A review of Resident 1's daily intake record on 12/2025 MAR indicated, 1260 cc on 12/20/25; 1160 cc on 12/25/25;1240 cc on 12/26/25; 1110 cc on 12/27/25; 1460 cc on 12/28/25; 1240 cc on 12/29/25; 1250 cc on 12/30/25; 1100 cc on 1/1/26; 1740 cc on 1/2/26; 1310 cc on 1/6/26; 1400 cc on 1/7/26; 1160 cc on 1/14/26; 1290 cc on 1/20/26.A review of Resident 1's medical record indicated there was no documentation indicating the facility notified the physician about the resident's excessive fluid intake.During an observation and interview with Resident 1 on 1/21/26 at 12 p.m., he was sitting in his wheelchair in the hallway in front of his room. Resident 1 stated he was on fluid restriction and not getting any food and/or drink from outside. Resident 1 further stated he did not have any problem getting any drinks from the facility staff.During an interview with Licensed Vocational Nurse (LVN) A on 1/21/26 at 12:08 p.m., she stated Resident 1 was on fluid restriction but usually consume more than ordered for Day shift because of additional 240 cc of hot chocolate in the morning. LVN A acknowledged Resident 1's fluid restriction order should be followed, and the physician should be notified about the resident's excessive fluid intake.During an interview and record review with the Director of Staff Development (DSD) on 1/21/26 at 2 p.m., she confirmed the above record review. The DSD stated staff should follow the fluid restriction order and the physician should have been notified about the resident's excessive fluid intake.During a review of the facility's policy and procedure (P&P) titled Encouraging and Restricting fluids, dated 2001, the P&P indicated, The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. Notify the supervisor if the resident refuses the procedure.During a review of the facility's P&P titled Change in a Resident's Condition or Status, dated 2001, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.During a review of the facility's P&P titled End-Stage Residents Affected - Few (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 02/05/2026 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)