Pacific Coast Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 14, 2026

  Based 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).Findings:Review of Resident 1's face sheet (summary page of a patient's important information) indicated Resident 1 was admitted to the facility on [DATE], with… […]

• No harm, potential for more than minimal, widespreadF812Feb 13, 2025

  Based 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. Findings: 1. […]

• No harm, potential for more than minimal, patternF684Aug 20, 2026

  Based on interview and record review the facility failed to ensure one of three residents (Resident 1) met the care and services according to professional healthcare standards of practice when:1. An assessment to determine the continued need for Eliquis (Apixaban, a medication that is used to prevent blood clots) for Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) was not conducted following the discontinuance related to nosebleed on 10/31/24 was not done. Eliquis not given since 10/31/24 through 7/13/26;2. Resident 1 did not have a follow-up appointment with Cardiology (a medical specialty focused on diagnosing, treating and preventing health diseases) after 1/6/25;3. […]

• No harm, potential for more than minimal, patternF806Feb 13, 2025

  Based 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. Findings: Review of Resident 36's Admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 58's Admission Record indicated she was admitted to the facility on [DATE]. During a tray line observation with the dietary director (DD) on 2/11/25 at 12:15 p.m., Resident 58's lunch ticket indicated she preferred to have low-fat milk, but whole milk was served for her. […]

• No harm, potential for more than minimal, patternF880Feb 13, 2025

  Based 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. Findings: 1. […]