Pacific Coast Post Acute: Cancer Referral Delays - CA
The resident, identified in inspection records only as Resident 1, had been diagnosed with invasive ductal carcinoma of the left breast and metastatic adenocarcinoma involving the left axillary lymph node. Her pathology report was dated December 13, 2024. Four days later, her physician reviewed those results and ordered referrals to both a general surgeon and an oncologist. Nobody scheduled them.
On January 31, 2025, the physician ordered the oncology referral again, this time specifically noting metastatic left breast cancer as the reason. Nobody scheduled that one either.
The oncologist who finally examined Resident 1 on October 13, 2025 reviewed the December 2024 pathology results and noted there had been no complete staging of the breast cancer. She said she did not know why the resident had not been referred for further evaluation or treatment. She ordered Letrozole, a PET scan, a CT scan, a referral to a surgeon, and a follow-up in four to six weeks — the full workup that should have begun the previous winter.
When inspectors reviewed the facility's records in June 2026, the Director of Nursing acknowledged the facility could not locate the scheduler's appointment calendar. There was no documentation showing either the December 2024 referrals or the January 2025 referral had been scheduled or completed. There was also no documentation that Resident 1 had ever refused them.
"There was no documentation indicating Resident 1 refused the referrals," the Director of Nursing told inspectors during a June 3 interview. She added that refusals and family notifications would normally be recorded in the Health Status Note. They were not there.
In a follow-up call the next day, the Director of Nursing confirmed the facility could not locate the physician orders related to the December 17 referrals at all. The January 31 order had been found, but nothing in the record showed it had led to any action.
Resident 1 also has dementia, a diagnosis that would have made her dependent on staff and administrators to ensure her medical appointments were tracked and kept. There is nothing in the inspection record indicating anyone in a position to act on her behalf raised an alarm during those ten months.
The cancer she was diagnosed with had already spread. Invasive ductal carcinoma is a breast cancer that moves beyond the milk ducts into surrounding tissue. The involvement of the left axillary lymph node indicated the disease had reached her lymphatic system. Staging, which the oncologist noted had never been completed, is the process that determines how far cancer has spread and drives every treatment decision that follows.
The inspection was triggered by a complaint and conducted on May 27, 2026. Inspectors rated the violation as causing minimal harm or the potential for actual harm, and noted that few residents were affected. The finding covered one of three residents reviewed in the sample.
The Director of Nursing did not dispute any of the inspector's findings during either interview. The facility had no explanation for the gap, no record of anyone noticing it, and no documentation suggesting the referrals had been tracked after they were written.
Resident 1 finally had her oncology consultation. Whether the ten-month delay changed what was possible for her, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pacific Coast Post Acute from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
PACIFIC COAST POST ACUTE in SALINAS, CA was cited for violations during a health inspection on May 27, 2026.
Her pathology report was dated December 13, 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.