Health inspection·May 14, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's 5-Day Investigative Report (5-DIR), dated 3/22/2024, the 5-DIR indicated on 3/19/2024 Resident 1 reported to staff the inappropriate touching of her left breast by a male resident (Resident 2) that happened the day before on 3/18/2024. She relayed that she and the alleged perpetrator were going opposite directions in the hallway of Station 2, when he stopped to touch my cast and then quickly went up toward my left breast.The perpetrator wheeled away after she stopped him from the act. When questioned, Resident 2 made statements in Spanish that maybe he could have done it. During a record review of Resident 1's Psychology Notes, dated 3/25/2024, the Psychology Notes indicated, Resident 1 had a depressed mood with intermittent periods of anxiety and Resident 1 stated, I'm not doing great. The psychology notes further indicated, Resident 1 described incident of inappropriate contact with a male resident and male residents wandering into her room as well as a documented incident of inappropriate contact made by a male resident. During a review of Resident 2's care plan, dated 10/18/23, the care plan indicated Resident 2 has impaired cognitive function. A review of facility policy and Procedure (P/P) titled Abuse Prevention and Prohibition Program dated October 1, 2023 indicated, I. Each resident has the right to be free from abuse .II The facility is committed to protecting residents from abuse by anyone . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055991 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Park Healthcare Center 623 West Junipero Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interviews and record review, the facility failed to report sexual abuse within two hours per regulation and their abuse policy and procedure when one of three residents (Resident 3) was the victim of sexual abuse by Resident 2. This failure had the potential to result in further harm to Resident 3 and harm to other female residents. Findings: During a review of the facility'ss policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, dated October 1, 2023, the P&P indicated, IX. Special Considerations for Reporting Suspected Incidents of Criminal Sexual Abuse A. Anyone who suspects that criminal sexual abuse has been committed against a resident must immediately report this information to Administrator and to the Director of Nursing Services. i. The Facility will treat allegations as criminal sexual abuse wherein the Facility determines that the resident does not have the decision-making capacity to consent to the sexual act. B. The Director of Nursing Services or designee will immediately report this information to the Attending Physician. C. The Administrator then acts to ensure the following steps are taken: i. The proper authorities and individuals are notified immediately or within two (2) hours, including but not limited to law enforcement, the Attending Physician, the resident's representative, the state survey agency, and adult protective services. X. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder or dependent adults. B. The Administrator is the Abuse Coordinator. i. In order to facilitate reporting, ensure confidentiality, and promote order at the Facility, the Administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of residents at the Facility to the proper authorities. ii. Facility Staff will report known or suspected instances of abuse to the Administrator, or his/her designee. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055991 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Park Healthcare Center 623 West Junipero Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few iii. Facility Staff members shall be notified that the Administrator, or his/her designee, has this responsibility, and that inquiries concerning resident abuse and reporting requirements should be referred to the Administrator, or his/her designee. During a review of Resident 3's Alert note, dated 3/18/2024 at 11:45 p.m., the Alert Note indicated, When RN passed by (Resident 3's room number) RN noticed that patient was grabbing and rubbing a female patient ' s right breast. RN stopped the patient ' s behavior right away and examined female patient with no injury findings. Female patient appeared shocked and stoned. Patient's daughter notified, MD and supervisor made aware. Advised all CNAs to monitor patient and female patients' safety. During a review of Resident 3's Incident Report, dated 3/18/24 at 7:40 p.m., the Incident Report indicated, Spoke with resident, in her room, regarding alleged inappropriate contact from another resident on 3/18/24. Resident did not recall incident and stated everything was going well. Then, she stated, I don't mind, I'm lonely anyway. She denies feeling harmed or unsafe. Explained to resident the behavior from the other resident, if it happened, is inappropriate and staff is here to ensure she feels safe. Resident verbalized understanding. Resident has a BIMs- ([BIMS] used to assess cognitive status) score of 9/15 which indicated moderately impaired cognition and doesn't always have good recall or insight. During a review of Resident 3's Incident Report, dated 3/19/24 at 9:10 a.m., the Incident Report indicated, Met with (Resident 3) in the living room to follow-up on allegation of inappropriate touching by a male resident. (Resident 3) told me, 'what are you talking about?' Asked her if there was any encounter with a man the night before, planned or unplanned encounter, she claimed, 'I don't recall anything.' (Resident 3) is smiling and expressed wanting to go to activities. During a review of Resident 3's Medical Record, the Medical Record indicated, Resident 3 had diagnoses including, unspecified dementia (loss of brain function) and was pleasantly confused. During an interview on 4/2/24 at 12:06 p.m., with the Director of Nursing (DON), the DON stated, (Resident 3) was saying that (Resident 3) was touched, and then when the nurse went there to ask (Resident 3) about that (Resident 3) said didn't recall . We did the monitoring for the behavior and then we made the decision if it's reportable, we investigate and talk to the patient and notify the MD and family. During an interview on 4/2/24 at 1:44 p.m., with the Social Services Director (SSD), the SSD stated, They did mention that (Resident 2) did touch (Resident 3), but (Resident 3) has no recollection, and I could not get (Resident 3) to remember. (Resident 3's) short-term memory is really poor. When asked if the incident was reported to authorities, the SSD stated, I'm not sure if it was or not. During a review of Resident 2's Medical Record, the Medical Record indicated, Resident 2 had diagnoses including, cognitive communication deficit (difficulty with thinking and how somebody uses language), mild cognitive impairment, unspecified dementia (loss of brain function)/unspecified severity/with other behavioral disturbance. During a review of Resident 2's Minimum Data Set (MDS an assessment tool used to guide care), dated 10/23/2023, the MDS indicated Resident 2 had a BIMS score of 9/15 which signified moderately impaired cognition. During a concurrent interview and P&P review on 4/2/24 at 2:20 p.m., with the DON, the facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055991 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Park Healthcare Center 623 West Junipero Street Santa Barbara, CA 93105 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete P&P titled, Abuse Prevention and Prohibition Program, dated October 1, 2023, was reviewed. The P&P indicated, IX. Special Considerations for Reporting Suspected Incidents of Criminal Sexual Abuse . i. The Facility will treat allegations as criminal sexual abuse wherein the Facility determines that the resident does not have the decision-making capacity to consent to the sexual act . C(i) The proper authorities and individuals are notified immediately or within two (2) hours, including but not limited to law enforcement, the Attending physician, the resident's representative, the state survey agency, and adult protective services . The DON stated, We didn't report it because of the fact that when we investigated it, (Resident 3) was denying it. The DON further verbalized Resident 2 is not independent in decision making. The DON stated, We did not report it. We should have reported it, and further verbalized, they did not follow their P&P. Event ID: Facility ID: 055991 If continuation sheet Page 5 of 5