Salinas Valley Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention practices when:1. Staff did not wear appropriate personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments, e.g., gloves, mask, gown) when caring for a resident on enhanced-barrier precautions (an infection control practice used to reduce transmission of multidrug-resistant organisms); 2. Licensed Vocational Nurse (LVN) M used the same paper tissue to wipe excess liquid from both eyes during the administration of eye medications for Resident 74; 3. Staff did not perform hand hygiene between contaminated (exposed to body fluids or potentially infectious material) and clean tasks during wound treatment;4. Unlabeled resident's care items;5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assessments and services which meet professional standards of quality for 11 of 21 sampled residents (Residents 92, 52, 83, 1, 72, 73, 7, 8, 91, 47, and 9) when the following were observed: 1. Inaccurate bed rail (metal or rigid plastic and adjustable safety bars attached to the sides of the bed) and entrapment risk observation/assessments for Resident 72, 52, 1, and 83; 2. Inaccurate bed rail and entrapment risk observation/assessments for Resident 73, 7, 8, 91, 47, and 9; 3. Treatment nurse C (TN C) applied zinc oxide (topical skin barrier) to wound without a physician's order for Resident 92. These failures had the potential to compromise the health and safety of above sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff covered facial hair while working over exposed food in the kitchen. This deficient practice placed 95 residents at risk for receiving contaminated food in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure free from loss of personal property for one (Resident 6) of three sampled residents. This failure had the potential to affect the health and emotional well-being of sampled Resident 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of four residents (Resident 9) is free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication when: Resident 9's Seroquel (an antipsychotic medication that helps treat several kinds of mental health conditions) ordered as needed with no stop date. This failure had the potential for increased risks associated with use of psychotropic medication that could negatively affect the resident's physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure to code minimum data set (MDS, resident assessment tool) assessment accurately to reflect status of the residents for three of six sampled residents (Resident 6, 49, and 1) when; 1. Resident 6's dental status was coded inaccurately;2. Resident 6's weight loss status was coded inaccurately;3. Resident 49's dental status was coded inaccurately;4. Resident 1's orders for insulin (medication used to treat and regulate blood sugar) was coded inaccurately. These failures can lead to inappropriate care and interventions for sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR, a screening for mental illness and treatment to ensure the facility coordinates with the appropriate State-designated authority to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs) screening form for one of eight sampled residents (Resident 84). This failure had the potential to result in the resident not receiving specialized care and services appropriate to the condition.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement person centered comprehensive care plans that included target symptoms, measurable objectives, and interventions for four out of 21 sampled residents (Resident 47, Resident 6, Resident 49, and Resident 72) when: 1. Resident 47, the facility did not develop care plan for bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making);2. Resident 49, facility did not develop care plan for missing/broken teeth; and3. Resident 6, facility did not develop care plan for edentulous (no natural teeth);4. Resident 72, facility did not develop care plan for use of oxygen therapy. These failures had the potential for above sampled residents not meeting their highest practicable physical, mental, and psychosocial plan of care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure to updated and revised comprehensive person-centered care plans for 3 of 21 sample residents (Resident 9, 25 and 88) when;1. Care plans was not revised or updated after the fall for Resident 9;2. Care plan was not revised or updated after the fall for Resident 25;3. Care plan for smoking not revised or updated for non-compliance with smoking for Resident 88. This failure had the potential to result in not meeting sampled Residents 9, 25 and 88's plan of care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to follow policy and procedure for electrical and smoking safety for two of six sampled residents (Resident 52 and 88) and in room one out of eleven sampled room (room [ROOM NUMBER]) when;1. Observed long cell phone charging cord on floor while charging in room [ROOM NUMBER]. Observed ungraded (not certified for safe use in healthcare setting) power strip (an electrical device to be powered from a single plug in electric socket with many electrical devices to charge at same time) in Resident 52's bed;3. Observed cigarette lighter with Resident 88. Above failures had the potential for accidental hazard for fire for above sampled residents, risk for tripping and fall with or without injury for residents and staff in room [ROOM NUMBER].

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications for one of two medication carts (a mobile, secured, and organized cart to store, transport and administer medications to residents) (Medication Cart AA), when expired bottle of brimonidine eyedrop (used primarily as eye drops to lower high pressure in the eye caused by open-angle glaucoma [group of eye diseases that can cause vision loss and blindness]) or ocular hypertension (high pressure inside your eye) and latanoprost eyedrop (used to treat glaucoma) medications were not removed from medication cart's active stock. These failures had the potential for residents to receive medications with reduced efficacy. During an inspection of Medication Cart AA on 2/9/26 at 10:23 a.m., with Registered Nurse I (RN I), RN I confirmed the following

Inspectors wroteBased on interview and record review, the facility failed to offer the influenza (flu, respiratory infection) vaccine timely for one of five sampled residents (Resident 4). This failure had the potential to negatively affect the resident's health and well-being. Review of Resident 4's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). Review of Resident 4's Immunization Audit Report indicated there was no documentation that the resident received or was offered the flu vaccine in 2025. During an interview on 2/12/26 at 12:32 p.m., the infection preventionist (IP) confirmed Resident 4 was admitted to the facility in March 2025. The IP stated Resident 4 was offered and recieved the flu vaccine on 2/11/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure fall management was implemented for one of three sampled residents (Resident 1) when: 1. Resident 1 was not monitored after 5 falls;2. No interdisciplinary team meeting was conducted after 3 falls;3. No care plan was developed after one fall; and4. Resident 1's Responsible Party was not notified after 2 falls. These failures had the potential for Resident 1 to develop ill effects from a fall, to result in future falls and injury, and for Resident 1's responsible party being uninformed and unaware of his condition. A review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including unspecified fall, muscle weakness, abnormalities of gait and mobility, and cellulitis (bacterial infection of the skin) of the left lower limb. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to develop care plans and implement interventions to meet the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD: a written instruction, such as a living will or durable power of attorney [a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) and completion of physician orders for life-sustaining treatment (POLST: a document that specifies the medical treatments the resident wants to receive during serious illness) form for 9 of 9 sampled residents (Residents 39, 37, 92, 43, 11, 85, 58, 91, and 78). These failures could lead to the delivery of unnecessary or inappropriate medical services against sampled resident's goals and wishes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper use of side rails for six (Residents 303, 304, 91, 44, 75, and 12) of 30 residents when: 1. For Residents 303 and 304, there were no signed informed consents for the use of side rails by the resident or the responsible party for either resident. 2. For Resident 91, the informed consent on file was missing a signature from the resident or responsible party. 3. For Residents 44, 75 and 12, there were no care plans for the use of side rails for any of the three residents These failures had the potential to compromise the resident's rights to fully make informed decisions on the use of side rails, and had the potential to put residents at risk for entrapment or serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe use and disposition of medications, and accurate accountability of controlled drugs (those with high potential for abuse and addiction), when: 1. There were discrepancies between the controlled drug record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for 2 out of 4 residents (Residents 34 and 83). The failure had the potential for abuse or misuse of controlled drugs; 2. The pharmacy failed to label 3 insulin pens in accordance with the current standards of practice to prevent mix-ups or administration errors; and 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the consultant pharmacist (CP) identified irregularities and make recommendations to the facility during the monthly medication regimen review (MRR) for 4 of 23 sampled residents (Residents 72, 40, 44 and 2). This failure had the potential for unsafe medication use and/or residents not achieving highest therapeutic outcomes.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two of 23 sampled residents (Residents 72 and 91) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 72 received pimavanserin (an antipsychotic medication to treat hallucinations and delusions associated with Parkinson's disease psychosis) without specific target behaviors, side effect monitoring, quarterly psychotropic review, care plan, and evidence of informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for over 8 months. Also, Resident 72 did not receive periodic monitoring of the blood lipids while being on Seroquel (antipsychotic medication) that would affect the blood lipids). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 11.11% when four (5) medication errors occurred out of 45 opportunities during the medication administration for four out of nine residents (Resident 3, 38, 45, and 78). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which resulted in residents not receiving the full therapeutic effect of the medications and may cause preventable side effects for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage as per facility's policy and procedures (P&P) and/or manufacturer's specifications, and expired medications were removed from active stock. Inspection of two of two medication refrigerators and three of four medication carts identified: 1. Four medications were not stored as in accordance with the manufacturer's guidance, and a discontinued medication for a resident was not discarded to prevent medication errors; 2. An insulin pen without visible resident's name on it. This had potential for it to be given to the wrong resident; and 3. One opened inhaler and four eye drop medications did not have an open date; and eight eye medications were used past their respective discard date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen and foods were stored under sanitary conditions when: 1. The kitchen floor and corner were seen with dark black areas; 2. Kitchen cleaning cloths were found in the sink and on a food storage container; 3. A container with sliced cheese had no opened date; 4. A food blender was seen with dry and dark brown particles. These failures had the potential to result in food borne illnesses among residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. The blood pressure cuff was not disinfected between resident use; 2. The shared glucometer (blood glucose meter to measure and display the amount of sugar (glucose) in your blood) was not sanitized and disinfected between resident use; 3. Unlabeled urinals, wash basins, and resident's care items in residents bathrooms; and 4. Resident's care items on the floor. These failures could result in cross-contamination and the spread of infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the minimum date set (MDS, an assessment tool) for 2 of 3 sample residents (Resident 39 and 78) when their MDS assessments did not reflect the current status of the residents. This failure had the potential to affect inappropriate care and interventions.

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 was completed and submitted for two of three sample residents (Resident 43 and 85). This failure had the potential for the mentally ill sample residents to not specialized health care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe and secure environment for three sampled residents (48, 74, and 91) when: 1. Resident 48 and 74 Wander Guard (a device that activates an alarm when a resident attempts to leave a safe area) devices were not checked for proper functioning; 2. The interdisciplinary team (IDT: a group of healthcare professionals with various areas of expertise who work together toward the goals of resident's care) 's reommendation and care plan intervetnion was not followed for Resident 91 after a fall; 3. Cleaning supplies were left in a shared bathroom used by multiple residents. These failures had the potential for elopement (leave a facility without staff knowledge) and compromise the residents safety of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care according to facility policy and procedures for one of 23 sampled residents (Resident 20) when a registered nurse (RN A) did not check gastrostomy tube (G-tube, a tube that goes directly into the stomach [part of digestive system] and used for giving tube feeding formula and medications) placement (by injecting air and listening to the stomach with a stethoscope) before tube feeding administration. This failure had the potential for enteral feeding complications that could cause harm to this resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for five sampled residents (5, 11, 32, 58, and 92) when: 1. For Resident 5 and 32, the facility administered oxygen with no physician order; 2. For Residents 58 and 92, the oxygen tubing was undated and uncovered when not in use. 3. For Resident 11, the facility administered oxygen without physician order and the oxygen tubing was undated. These failures had the potential to affect the residents' care and could jeopardize their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate food preferences for two of four sample residents (Resident 46 and 16). This failure had the potential for decreased meal intake, negative effect on health and well-being for the residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1), when Resident 1's MDS weight and continence were inaccurately documented. Failure to accurately assess had the potential to compromise the facility's ability to develop and implement interventions to meet the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan to address non-compliance (not cooperating with care) for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to implement interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a pain medication order was signed by the physician for one of three sampled residents (Resident 2). This failure had the potential to compromise the facility's ability to administer the pain medication to Resident 2 when needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Ombudsman (resident advocate) office was notified of hospital transfers for two of three sampled residents (Residents 2 and 3). This failure had the potential to result in the residents not having someone to advocate for their admission, transfer, and discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to provide skin treatments as ordered by the physician for one of three sampled residents (Resident 1). This failure put the resident as risk for developing further skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice for 6 of 8 sampled residents (Resident 1, 2, 3, 4, 5, and 6) when physician orders for monitoring of indwelling urinary catheters (tube placed inside the urinary bladder to drain urine) were not followed. These failures resulted in physician orders to monitor for changes to the urine character to not be carried out as ordered.

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses had specific competencies (the ability to do something successfully or efficiently) and skills sets necessary to care for residents' needs when: 1. Performance evaluations (a formal and productive procedure to measure an employee's work and results based on their job responsibilities) were not completed for licensed vocational nurses (LVN F (hire date 1/2/2012), LVN H (hire date 2/1/22), LVN J (hire date 1/17/22). 2. Skill check list (practical lists that detail for employees the skills they are required to perform and the level of performance that is expected for each skill) were not completed for five of six licensed nurses (LVN E, LVN F, LVN H, LVN J, and LVN L). 3. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide pharmaceutical services to meet the needs of four of 19 sampled residents (Residents 7, 22, 39, and 45) and one non-sampled Resident (Resident 194) in regards to controlled medications (medications with high potential for abuse and addiction) in that they were not fully reconciled after removal and accounted for during shift change when: 1. Resident 194 did not receive his Norco (a potent controlled medication for pain) timely, resulting in unnecessary and preventable pain for the resident; 2. Resident 45 did not receive his routine pain medication, buprenorphine (a potent narcotic for pain) for four and a half days, subjecting the resident to unnecessary pain; 3. Resident 22's Daptomycin (an antibiotic to treat various infections) was delayed for two days after it was ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications according to the facility policy and procedures (P&P) and/or manufacturer's specifications when: - Temperature (temp) monitoring was missing and/or not consistently documented twice daily on the temp log sheets for 3 months for one of one observed medication refrigerator; and - Medications were not properly labeled and stored in two of four inspected medication carts. These deficient practices had the potential for inadequately monitored medications, which could lead to unsafe and ineffective medications for the residents, unsafe and reduced efficacy from being used past their discard date, and medication errors due to medications not being labeled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dignity of one of 87 residents (Resident 33) when a staff member was standing over the resident while helping him to eat, instead of sitting down. This failure had the potential to have a negative effect on the resident's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman (organization that advocates for the residents) when two of 19 sampled residents (Residents 9 and 55) were transferred to the acute care hospital from the facility without notifying the Ombudsman. This failure had the potential to compromise the residents' admission, transfer, and discharge rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards and facility policy and procedures for three of 19 sampled residents (Residents 6, 44, and 82), when: 1. The nursing staff failed notify the physician when Resident 82 repeatedly refused his blood sugar checks and insulin (medication to lower blood sugar); 2. For Resident 44, Licensed Vocational Nurse (LVN) H failed to document his routine medication administration on the medication administration record (MAR) for 4 days in July and one day in August 2023 during her shift; and 3. For Resident 6, the facility staff did not carry out the physician's order timely. These failures had the potential to cause complications for the residents' medical conditions.

Inspectors wroteBased on interview and recorder review, the facility failed to ensure one of four hospice residents (Resident 17), received needed care and services when hospice orders were not transcribed into resident's chart timely. This failures had the potential to compromise the resident's comfort and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe environment was maintained when a bottle of disinfectant was found at the bedside of Resident 42. This had the potential for residents to access a hazardous substance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care according to facility policy and procedures for two of 19 sampled residents (Residents 6 and 55) and two non-sampled Residents (Residents 19 and 51) when: 1. Licensed Vocational Nurse (LVN) A did not check the tube placement before medication adminisration for Resident 19, 2. Tube feeding formula for Residents 6 was unlabeled, 3. An unlabeled and opened bag of tube feeding formula was left at Resident 55's bedside. These failures had the potential for enteral feeding complications that could cause harm to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services for one of 19 sampled residents (Resident 9) receiving renal dialysis (medical procedure for removing waste products and excess fluid from the blood through an artificial kidney) when: 1. There was no documentation of assesments and/or monitoring of the arteriovenous fistula shunt (AVF shunt, a connection surgically made between an artery and a vein for dialysis access), 2. Dialysis communication records (DCRs) were incomplete, 3. A dialysis care plan was not resident-centered, and 4. Licensed nurses were not trained on monitoring Resident 9's AVF shunt. These deficient practices had the potential for Resident 9 to be inadequately assessed and be at risk for developing undetected complications related to dialysis treatment.

Inspectors wroteBased on interview and record review, the Consultant Pharmacist (CP) failed to identify and report to the facility medication-related irregularities during the monthly medication regimen review (MRR) for two of 19 sampled residents (Residents 7 and 82). The failure resulted in inadequate medication monitoring for the residents which had the potential to compromise their health.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 19 sampled residents (Resident 7 and 193) were free from unnecessary medications when Resident 7 received atorvastatin (Lipitor: medication to treat high cholesterol and triglyceride levels in the blood) without lab work for lipid panel; and Resident 193 received an anticoagulant (a blood thinner to prevent blood clots) without the staff monitoring for signs and symptoms of bleeding. The failure resulted inadequate monitoring for effectiveness and side effects of medications for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 19 sampled residents (Residents 30, 45, and 82) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors), when: 1. Resident 82 received medications, Seroquel (quetiapine, an antipsychotic medication) and simvastatin (medication to treat high blood lipids), that could affect blood lipids without the monitoring for lipids; 2. Residents 45 and 82 received long-term use of Seroquel without periodic Abnormal Involuntary Movement Scale (AIMS, a rating scale designed to measure involuntary movements known as tardive dyskinesia [TD], a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications) assessment; and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 5.41% when two medication errors occurred out of 37 opportunities during the medication administration observation for two out of seven residents (Residents 19 and 43). The nursing staff did not flush the resident's gastrostomy tube (G-tube; a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications) prior to and after medication administration in accordance with accepted professional standards of practice. Resident 43 received his insulin (medication to lower blood sugar) 1 hour and 10 minutes before a meal, a practice inconsistent with the manufacturer's specifications. The failure had the potential for complications or adverse effects (such as clogging of G-tube or uncontrolled blood sugar) for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention practices were followed when two facility staff did not wear the appropriate personal protective equipment (PPE; gloves, gown, mask, and face shield) while providing care to Resident 4, who was on Contact Precaution (intended to prevent transmission of infectious agents spread by direct or indirect contact with the patient or the patient's environment). This failure had the potential to compromise the health and well-being of residents and staff members in the facility.