Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coastal Post Acute during CMS and state inspections, most recent first.
A resident with a history of independent ambulation and prior exit-seeking behavior left the facility without staff knowledge and was later found unresponsive at a bus stop, ultimately passing away at a hospital. Despite previous incidents indicating elopement risk, staff did not complete required assessments, care planning, or documentation, and failed to recognize or respond to the resident's risk, resulting in inadequate supervision.
The facility failed to maintain sanitary conditions in the food and nutrition services, as observed during a survey. A plastic spatula with a burned handle and nine rusted steel pan trays with blackish substance were found in the kitchen. A bug light trap was not cleaned as needed, and staff did not check the expiration date of test strips used for testing kitchen sanitizer. These deficiencies had the potential to cause food contamination and illness for 69 out of 70 residents receiving food from the kitchen.
The facility failed to implement proper infection control measures, including improper storage of a nasal cannula, lack of hand hygiene by staff, missing enhanced barrier precautions signage for a resident with an E. coli infection, improper disinfection of a medication bottle cap, and inappropriate handling of a foley catheter bag by a PTA.
Two residents' dignity and privacy were compromised when their foley catheter bags were left uncovered. One resident's bag was visible while in a wheelchair, and another's was hung on a PTA's pants pocket. Both instances were confirmed by the DON and ADON, who acknowledged the lack of privacy covers, contrary to facility policy.
A resident's confidentiality was compromised when an RN left a computer screen displaying medication orders unattended on a medication cart in a busy hallway. The DON confirmed that nurses should log out when leaving computers, as per facility policy on privacy and confidentiality.
A facility failed to accurately code a PASARR Level 1 assessment for a resident with depression and bipolar disorder, who was prescribed psychotropic medications upon admission. The PASARR form incorrectly indicated no prescribed medications, a discrepancy confirmed by the DON during a review. This error highlights a lapse in the facility's adherence to its PASRR completion policy.
The facility failed to properly document and account for controlled medications for two residents, leading to discrepancies between the Controlled Drug Record (CDR) and Medication Administration Record (MAR). The DON confirmed issues with documentation, including incorrect dates and unaccounted medications, which violated the facility's policy on handling controlled substances.
The facility failed to follow its policy for medication storage, as food was found stored with medications on two medication carts. An opened cup of applesauce was found with medications in one cart, and an unopened cup was found in another, intended for mixing with medications. The DON confirmed that food should not be stored with medications, as per the facility's policy.
Failure to Supervise Resident at Risk for Elopement Resulting in Death
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision for a resident who was at risk for elopement. The resident, who had a history of walking independently with a front wheel walker and required supervision or touching assistance for ambulation, left the facility premises without staff knowledge. The resident had previously demonstrated exit-seeking behavior, including being observed walking toward the parking lot and expressing a desire to go outside, as well as leaving the facility to visit his old apartment without informing staff. Despite these incidents, there was no documented elopement risk assessment, care plan, or interdisciplinary team (IDT) note addressing the resident's behavior or risk for elopement. On the day of the incident, the resident was last seen in his room in the morning, but staff did not notice his absence until several hours later. The resident's walker was found by reception, but he was not in the building. Staff initiated a search after realizing the resident was missing, and a Code Orange was called. The facility was later informed that the resident had been found unresponsive at a nearby bus stop by a bystander, who called emergency services. The resident was resuscitated and transported to an acute care hospital, where he subsequently died. The facility's records revealed multiple missed opportunities to identify and address the resident's risk for elopement. There was no SBAR communication, elopement evaluation, or care plan initiated after previous incidents of the resident leaving the facility or expressing a desire to do so. Staff interviews indicated a lack of understanding regarding when to conduct elopement assessments and what constitutes an elopement. The facility's policy defined elopement as leaving the premises without authorization or necessary supervision, but this was not consistently applied in practice.
Removal Plan
- The ADM, DON and ADON initiated in-service for staff (Licensed Nurses, Certified Nursing Assistants, dietary, housekeeping and laundry, rehabilitation department, admissions, activities and maintenance) on how to locate missing residents and what is considered elopement.
- The facility's Interdisciplinary Team (IDT) completed a facility-wide audit to evaluate 65 residents for the risk for elopement.
- 13 residents at risk for elopement were monitored by Licensed Nurses for episodes of exit seeking behavior every shift and documented in the Medication Administration Record (MAR).
- LVN, RN, CNA and staff from other departments who did not attend the in-service will be provided education at the beginning of their next scheduled shift by the DON, DSD or ADON.
- The facility's ADON initiated an in-service to LVN and RN on the policy and procedures titled Elopements Resident Behavior and Facility Practice, including how to locate a missing resident, completion of elopement assessment for new admissions and residents who exhibit wandering behavior, interventions for residents at risk, how to initiate an elopement care plan, and obtaining orders/consent for wander guard devices if indicated.
- The facility's ADM initiated an in-service to Social Services, ADON, MDS nurse, Activities Director, Central Supply, Admissions Assistant/receptionist, Accounts payable, occupational therapist on steps to take when a resident is newly admitted or exhibits new wandering/exit seeking behaviors, including elopement risk assessment, notification of MD, obtaining orders/consent for wander guard device, monitoring for exit seeking behavior every shift, initiating elopement care plan, and every 2 hour visual checks.
- The facility ADM and DON reviewed facility elopement policy and procedure, related to the recent incident, with the Medical Director.
- The facility's RCRN provided education to the DON and ADM on what is considered elopement and the reporting requirements.
- 13 residents at risk for elopement were monitored by Licensed Nurses for episodes of exit seeking behavior every shift and documented in the MAR.
- The facility's Licensed Nurses initiated the completion of head count rounds at the beginning of the shift and documented on the census sheet for residents not identified as at risk for elopement.
- The facility's ADON, DON and RN supervisor initiated validation of the completion of daily head count monitoring by Licensed Nurses, with corrections communicated as needed.
- The facility's maintenance supervisor/designee checked the operation of door monitors and resident wandering system (Wander Guard System) and will continue to check weekly.
- A new measure was put in place when the Maintenance Director installed exit door alarms on 3 of the 4 exit doors; when the doors are opened an alarm will sound to alert staff.
- The facility's Social Services Director, Maintenance Director and DON initiated in-service to Licensed Nurses and CNAs regarding the new alarm doors, emphasizing response to alarms and use of only the main entrance for entry/exit.
- The facility's IDT initiated daily review of new admissions and residents with new wandering/elopement behavior to ensure care plans are updated and interventions implemented (monitoring, increased visual checks, individualized activity plan, wander guard).
- The facility's HIM initiated admission audits and change of condition audits for residents with new wandering/exit seeking behaviors, including completion of elopement risk assessment, IDT note, orders/consent for wander guard, care plan for risk of elopement, monitoring for exit seeking behaviors every shift, updating elopement binder with resident's picture and identification, and visual checks. Missing items are reported to DON/designee.
- The facility's HIM will present elopement-related audits to the QAPI committee for review with Medical Director, evaluation, trending and tracking until compliance is reached.
Sanitation Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to maintain sanitary conditions in the food and nutrition services, as observed during a survey. A plastic spatula with a burned handle was found hanging in the kitchen, which the Dietary Manager (DM) acknowledged should not be used. Additionally, nine large-sized steel pan trays were observed with a blackish colored substance on their edges, which the DM confirmed were old, rusted, and should not be used. The facility's policy and procedure on sanitation, revised in November 2022, requires that all utensils and equipment be kept clean and in good repair, free from breaks and corrosion. Further observations revealed a bug light trap with several black colored dots, indicating it was not cleaned as needed, despite the facility's policy stating that all kitchen areas should be kept clean. Moreover, staff failed to check the expiration date of test strips used for testing kitchen sanitizer, as demonstrated by Dietary Aide B and another staff member. The DM confirmed that checking the expiration date is part of the process when using the test strips. These deficiencies had the potential to cause food contamination and illness for 69 out of 70 residents receiving food from the kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control measures in several instances. Resident 26's nasal cannula tubing was observed hanging and exposed on the resident's side rails, which was confirmed by RN A. The facility's policy, aligned with WHO guidelines, indicates that such equipment should be stored in a plastic bag when not in use to prevent contamination. Additionally, the Maintenance Director did not perform hand hygiene before and after wearing gloves, which is against the facility's policy that emphasizes the importance of handwashing in conjunction with glove use to prevent healthcare-associated infections. This was acknowledged by the Maintenance Director during an interview. Further deficiencies were noted with Resident 62, who was on enhanced barrier precautions due to an E. coli skin infection. The required signage indicating these precautions was missing from the resident's door. Moreover, a Licensed Vocational Nurse used a facial tissue instead of antimicrobial wipes to clean a medication bottle cap that had fallen on the floor, contrary to the facility's disinfection policy. Lastly, a Physical Therapy Assistant improperly hung a foley catheter bag on his cargo pants pocket, which was confirmed by the DON and ADON as inappropriate for infection control and resident dignity.
Failure to Maintain Dignity and Privacy for Residents with Catheters
Penalty
Summary
The facility failed to maintain the dignity and privacy of two residents, Resident 121 and Resident 226, by not covering their foley catheter drainage bags. During an observation, Resident 121 was seen in his wheelchair with an uncovered urine bag, making the yellow urine visible. His clinical record indicated he was admitted with benign prostatic hyperplasia and had an order for an indwelling catheter. The Director of Nursing confirmed the lack of a privacy cover and stated that the resident should have had a privacy bag cover both in bed and when leaving the room. Similarly, Resident 226 was observed walking with a Physical Therapy Assistant, who had the resident's uncovered foley catheter bag hanging from his cargo pants pocket. Resident 226 was admitted with a diagnosis of malignant neoplasm of the vulva and had an order for an indwelling catheter. The Director of Nursing and the Assistant Director of Nursing both confirmed the absence of a privacy cover and stated that the catheter bag should not have been hung on the PTA's pants pocket. The facility's policy on dignity emphasized that residents should be treated with dignity and respect at all times.
Breach of Resident Confidentiality Due to Unattended Computer
Penalty
Summary
The facility failed to protect a resident's right to confidentiality of protected health information (PHI) when a registered nurse (RN) left a computer screen on and unattended. This computer, which displayed the resident's medication orders, was placed on top of a medication cart in a hallway, facing away from resident rooms. The incident was observed during a survey, and the RN confirmed leaving the computer screen on while attending to other tasks elsewhere in the facility. The Director of Nursing (DON) acknowledged that nurses are expected to sign out from computers when leaving them unattended. The hallway where the computer was left was described as busy, with frequent passersby, including housekeepers, visitors, and other staff. The facility's policy on resident rights emphasizes the importance of privacy and confidentiality, prohibiting unauthorized access or disclosure of resident information. This incident represents a breach of these policies, as outlined in the facility's procedures.
Inaccurate PASARR Level 1 Assessment for Resident with Mental Health Conditions
Penalty
Summary
The facility failed to ensure the PASARR Level 1 assessment was accurately coded for a resident with mental health conditions, including depression and bipolar disorder. Upon admission, the resident was prescribed psychotropic medications, specifically divalproex sodium and doxepin, to manage these conditions. However, the PASARR Level 1 Screening Form inaccurately indicated that the resident had no prescribed psychotropic medications for mental illness. This discrepancy was identified during a review of the resident's clinical records and acute care discharge summary, which clearly documented the prescribed medications. During an interview and record review with the Director of Nursing, it was confirmed that the resident was indeed on psychotropic medication upon admission, contradicting the information on the PASARR Level 1 screening form. The Director of Nursing acknowledged the error and stated that the PASARR should be corrected to ensure appropriate placement for the resident. The facility's policy on PASRR completion, revised in 2024, mandates that all admissions have the appropriate assessments completed, highlighting a lapse in adherence to this policy in this instance.
Controlled Medication Documentation Discrepancies
Penalty
Summary
The facility failed to ensure proper accountability and administration of controlled medications for two residents, leading to discrepancies in medication records. For Resident 51, there was a physician's order for tramadol to be administered as needed for pain. However, the Controlled Drug Record (CDR) indicated that two tablets were removed on a specific date, but the Medication Administration Record (MAR) showed administration on a different date. The Director of Nursing (DON) confirmed that the nurse documented the wrong date on the CDR. For Resident 66, there were similar issues with controlled medications. A tablet of Norco was signed out on the CDR but not documented on the MAR, resulting in an unaccounted tablet. Additionally, an evening dose of tramadol was documented as administered on the MAR but not signed out on the CDR. The DON acknowledged these discrepancies and noted awareness of ongoing issues with CDR and MAR documentation by the nursing staff. The facility's policy on handling controlled substances requires accurate documentation and reconciliation to prevent loss or diversion, which was not adhered to in these cases.
Improper Storage of Food with Medications
Penalty
Summary
The facility failed to adhere to its policy and procedure for the proper labeling and storage of medications, as observed during a survey. On two separate medication storage carts, food items were found stored alongside medications. Specifically, an opened and dated cup of applesauce was discovered in the top drawer of medication storage cart AA, mixed with bottles of medication. Licensed Vocational Nurse E acknowledged that the applesauce should have been discarded at the end of the shift. Additionally, an unopened cup of applesauce was found in the top drawer of medication storage cart BB, which Licensed Vocational Nurse F stated was intended for mixing with medication for some residents. The Director of Nursing confirmed that no food should be stored on or inside the medication carts. The facility's policy, revised in February 2023, clearly states that medications must be stored separately from food and labeled accordingly. This practice of storing food with medications had the potential to cause cross-contamination, which could affect the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Salinas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor The Ridge Rehabilitation Center | 0 mi | ★★★★★ | 13 | 0 |
| Katherine Healthcare | 2.2 mi | ★★★★★ | 22 | 0 |
| Salinas Valley Post Acute | 2.6 mi | ★★★★★ | 29 | 0 |
| Pacific Coast Post Acute | 2.6 mi | ★★★★★ | 4 | 0 |
| Carmel Hills Care Center | 12.8 mi | ★★★★★ | 31 | 0 |
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