Health 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 Page 1 of 2 555090 555090 02/05/2026 Pacific Coast Post Acute 720 East Romie Lane Salinas, CA 93901

F 0698 Renal Disease, Care of a Resident with, dated 2001, the P&P indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555090 Page 2 of 2