Pacific Coast Manor

In the surveyor’s words

From the most serious findings on record at Pacific Coast Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF725Jun 16, 2023

  Based on interview and document review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis based on Staffing Data Report submitted to Centers for Medicare & Medicaid Services (CMS). This failure had the potential to affect resident's care, health, and psychosocial wellbeing. Findings: During an interview with the staffing coordinator (SC) on 6/16/2023 at 4:10 p.m., SC confirmed staffing was a struggle. SC agreed the Direct Care Service Hours Per Patient Day (DHPPD) should have been 3.5. During an interview with the Excutive Director (ED) on 6/16/2023 at 4:23 p.m., ED stated the low staffing back on January - March 2023 was due to the storm, and Coronavirus disease (COVID-19, a disease caused by a contagious virus) outbreak. […]

• No harm, potential for more than minimal, patternF880Jun 16, 2023

  Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Two staff did not perform hand hygiene during meal assistance; 2. Certified nursing assistant H (CNA H) did not perform hand hygiene in between task and upon removal of gloves with Resident 37; 3. Two CNAs did not perform hand hygiene in between task with resident's care; and 4. Infection Preventionist (IP) did not implement the surveillance plan during clostridium difficile (C. Diff. colitis - inflammation of the colon caused by the bacteria Clostridium difficile) outbreak. These failures had the potential to spread infection among staff, visitors and 94 residents who reside in the facility. Findings: 1a. […]

• No harm, potential for more than minimal, patternF880Mar 7, 2023

  Based on observation, interview and record review, the facility failed to implement infection control measures for 14 of 14 residents when there were no designated unit and no dedicated staff for residents with Coronavirus disease (COVID-19, a disease caused by a contagious virus). These failures had the potential to result in transmission and spread of infection with the rest of 80 residents, visitors and staff. Findings: During an observation along the facility's hallways and interview with the infection preventionist (IP-a licensed nurse responsible for the facility's activities aimed at preventing healthcare-associated infections by ensuring that sources of infections are isolated to limit the spread of infectious organisms) on 1/19/2023 at 10:15 a.m., IP confirmed there was a COVID-19… […]

• No harm, potential for more than minimal, patternF880Apr 20, 2021

  Based on interview and record review, the facility failed to implement infection control and prevention practices when: 1. Two employees, who were symptomatic (showing symptoms) and tested positive for severe acute respiratory syndrome coronavirus 2 ([CONDITION(S)]-CoV-2, the virus that causes Coronavirus 2019 [COVID-19, a new strain of virus that can cause mild to severe respiratory illness]) were allowed to enter the facility and work; 2. The form for screening employees prior to entering the facility was incomplete. These failures had the potential to spread the COVID-19 virus. Findings: 1. Review of the facility's laboratory report dated 11/21/2020, indicated facility staff A and B (FS A and B) tested for [CONDITION(S)]-CoV 2 on 11/20/2020, the results came back positive. […]

• No harm, potential for more than minimal, isolatedF684Apr 2, 2025

  During a review of Resident 1's MD (medical doctor) Progress note dated 1/23/25, note indicated, Pt [patient] admitted for fall at home.Assessment/Plan.10. OSA (obstructive sleep apnea) G47.33 [diagnosis code] Continue home CPAP. During a review of Resident 1's Order Summary Report dated 3/25/25 at 10:40 am, current orders indicated, no active orders for the use of a CPAP machine. During a review of Resident 1's Medication Administration Record (MAR) dated 1/21/25-2/28/25, MAR indicated no administrations charted for the use of a CPAP machine for any day. During an observation on 3/25/25, at 10:40 a.m., in Resident 1's room, no CPAP machine was observed in the room. […]