Pacific Coast Post Acute

Inspectors wroteBased on interview and record review the facility failed to ensure follow-up of surgeon and oncology (study of cancer) referrals dated 12/17/24 and 1/31/25 for one of three sample residents (Resident 1). This failure resulted in a delay in evaluation and treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision and implement fall prevention interventions for one of three sampled residents (Resident 1) when Resident 1 had repeated attempts to stand on 1/17/26 and staff did not provide extra activity to keep Resident 1 occupied during attempts of standing up unassisted. This failure resulted in Resident 1 sustaining a 5-centimeter (cm, unit of measurement) x 2 cm head laceration (wound on the skin, typically caused by blunt trauma) that required hospitalization and 13 staples (specialized metal or plastic used in medical procedure to close deep wound).

Inspectors wroteBased on interview and record review, the facility failed to ensure the result of the investigation of an alleged resident-to-resident altercation that occurred 2/2/26 was reported to the State Survey Agency (SSA) within the required timeframe for two of three sampled residents (Residents 2 and 3). This failure had the potential to delay the State Survey Agency's review of the investigation results.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to complete the discharge planning for one of three sampled residents (Resident 1) when there was no final discharge date and no documented place of discharge for Resident 1. These failures resulted in incomplete discharge planning and had the potential for Resident 1's needs to be unmet after leaving the facility on 6/7/25.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of two residents (Resident 1) when: 1. The facility did not follow their own policy for diabetes (blood sugar higher than normal) management; and 2. The facility did not follow the physician's order. These failures had the potential to compromise residents' care and well-being.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. Undated food items, food past their use by date, expired food, and rotten vegetables were found in the refrigerator, the freezer, and on the shelves in the kitchen; 2. Dietary Aid E (DA E) and the maintenance director (MD) did not wash their hands when entering the kitchen; and 3. Juice temperature was higher than acceptable delivery temperature. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 144 residents receiving food at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meals with food items according to preferences for four of 144 residents (34, 36, 58, and 117). This failure had the potential to result in meal dissatisfaction, decreased intake, and leading to compromised nutritional and medical status for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. A nurse did not perform hand hygiene after removing gloves during Resident 61's wound dressing change; 2. The tips of the feeding tubing was left uncovered for two residents (Residents 137 and 128); 3. Oxygen tubing was undated, touching, and lying on the floor for Resident 41, Resident 71, and Resident 134; and 4. Certified nursing assistant H (CNA H) and certified nursing assistant I (CNA I) walked out of Resident 106's room and Resident 107's room with gloves on. These failures had the potential to result in transmission and spread of infection in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident's care needs were accommodated for one of four sampled residents (Resident 99) when Resident 99's call light button (a cord with a button used by residents to request assistance) was not within reach to use. This failure had the potential to result in the delay of care and treatments for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure service provided met professional standards when: 1. Resident 64 received ferrous sulfate (an iron supplement used to treat or prevent low blood levels of iron) and calcium-vitamin D (a medication used to prevent or treat low blood calcium levels) at the same time; and 2. A medication was not administered correctly for Resident 98. This failure resulted in Resident 64 and Resident 98 not getting the full dose and desired effect of the prescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (86) was served with the appropriate diet texture. This failure had the potential to result in choking for the resident.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure for one of three residents (Resident 1) when an allegation of abuse was not reported to proper authorities. This failure had the potential for residents being at risk of abuse/harm.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote3. 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and 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; 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure that two of three sampled residents (Residents 127 and 293) discharged from Medicare Part A services (or their representatives) received mailed copies of the Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying them that Part A coverage is being terminated and providing information on how to file an appeal of that decision). This failure had the potential to result in an inability of the resident's representative to file a timely appeal due to not having the contact information for the Quality Improvement Organization (QIO, an independent reviewer authorized by Medicare to review the decision to end services).

Inspectors wroteBased on interview and record review, the facility failed to notify one of 29 sampled residents (Resident 22) and/or Resident 22's representative of the facility's bed hold policy when Resident 22 was transferred to a general acute care hospital (GACH). This failure had the potential for Resident 22 not to be able to come back to the facility after being discharged from the GACH.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal hygiene and grooming services for one of 29 sampled residents (Resident 9) when his fingernails were long and he had dirt underneath his fingernails. This failure could potentially affect the resident's heath and safety.

Inspectors wroteBased on observation, interview,and record review, the facility failed to administer oxygen (O2) according to professional standards of practice for one of 29 sampled residents (Resident 54), when the facility did not administer O2 according to the physician's order. This failure could potentially affect the resident's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 29 sampled residents were free from unnecessary psychotropic medications (alters mood and behavior) when: (1) possible side-effects from Aripiprazole (medication used to treat mental health disorder) or Depakote (mood stabilizer medication) were not properly assessed and documented for Resident 88, and (2) behavioral approaches were not consistently implemented for Residents 35 and 125. These failures had the potential to place residents at risk for adverse consequences related to prolonged use of psychotropic.