Health inspection·June 16, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS, a comprehensive assessment tool) discharge assessment in a timely manner for two of five residents (Residents 69 and 23). Residents Affected - Few This failure resulted in the resident's discharge assessment not being transmitted and received by the Center for Medicare and Medicaid System (CMS) within the time requirement. Findings: 1. During a concurrent interview and record review on 6/16/2023 at 1:44 p.m., the MDS Director (MDS D) reviewed Resident 69's clinical records. Resident 69 was admitted to the facility on [DATE] and Resident 69 was discharged to home on 1/30/2023. The MDS discharge assessment was completed on 6/14/2023. MDS D confirmed the discharge assessment was completed late. MDS D stated she missed completing the MDS discharge assessment on time. 2. During a concurrent interview and record review on 6/16/2023 at 1:50 p.m., the MDS D reviewed Resident 23's clinical records. Resident 23 was admitted to the facility on [DATE] and was discharged to assisted living facility (ALF) on 2/8/2023. MDS D confirmed she missed to complete Resident 23's MDS discharge assessment. Review of Center for Medicare and Medicaid Services' Resident Assessment Instrument (CMS's RAI - a guide for facility staff to existing coding and transmission) Version 3.0 Manual, dated October 2019, indicated, 09. Discharge Assessment-Return Not Anticipated .Must be completed within 14 days after the discharge date ; Must be submitted within 14 days after the MDS completion date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 2 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and record review, the facility failed to accurately complete the PASRR (pre-admission screening and resident review, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) for one of two residents (Resident 3). This failure had the potential to put the resident at risk for not receiving appropriate care and services. Findings: Review of Resident 3's clinical record indicated he had the diagnoses of depression (a group of conditions associated with the elevation or lowering of a person's mood), dementia (disorder of the mental process caused by brain disease or injury), schizoaffective disorder (a combination of schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly] and mood disorder), and unspecified psychosis (a mental disorder characterized by a disconnection from reality). Resident 3's preadmission PASRR Level 1 screening, dated 12/03/22, was reviewed. Question number 10, section 3 asked, Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? The person who filled out the PASRR Level 1 screening marked no. Resident 3's physician's order, dated 3/14/23, indicated he was receiving Risperidone (medication used to treat schizophrenia, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive low to manic high), or irritability associated with autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact) 0.25 milligrams (mg, unit of dose measurement) one tablet by mouth one time a day for schizoaffective disorder evidenced by striking out/continued yelling. During an interview with the Minimum Data Set Consultant (MDS C) on 6/16/23, at 10:07 a.m., she stated the admissions personnel or the MDS was responsible for the PASRR program. During a concurrent interview and record review with the MDS Director (MDS D) on 6/16/23, at 1:34 p.m., she verified that Resident 3's PASRR Level 1 screening, dated 12/03/22, was filled out incorrectly. The MDS director confirmed the person who filled out the form should have marked yes for question number 10, section 3. According to Center for Medicare & Medicaid Services (CMS.gov) [was created to administer oversight of the Medicare Program and the federal portion of the Medicaid program], titled Preadmission Screening and Resident Review (PASRR) Technical Assistance for States dated 9/30/2009, description ,The state uses the evaluation to determine, prior to admission , whether Nursing Facilities (NF) placement is appropriate for the individuals, and whether the individuals requires specialized services for mental illness (MI)/mental retardation (MR),These screens generally consist of forms completed by hospital discharge planners, community health nurses , or other as defined by the state. Individuals who do or may have MI/MR are referred for a level II PASRR evaluation .( https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/activeprojectreports/active-projects accessed on 6/22/23). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 3 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow professional standards for one of 22 sampled selected residents (Resident 6) when Licensed Vocational Nurse G (LVN G) did not wait for the recommended time between each puff of the inhaler medications. Residents Affected - Few This deficient practice had the potential for Resident 6 to not receive the full amount of each medication and the adverse effects on resident's health. Findings: During a record review of Resident 6's clinical record indicated he was admitted to the facility with diagnosis including Chronic Obstructive Pulmonary Disease (COPD, a common lung disease causing restricted airflow and breathing problems). During a record review of Resident 6's physician orders included the following: - Tiotropium Bromide Monohydrate (Spiriva, oral inhaler to treats asthma) 18 micrograms (mcg, unit of mass), 1 capsule inhale orally in the morning for 2 inhalations. Symbicort 80-4.5 mcg (oral inhaler, used long-term to improve symptoms of chronic obstructive pulmonary disease), 1 puff inhale orally and two times a day. During a medication pass observation on 6/14/2023 at 9:17 a.m., LVN G administered the Spiriva inhaler to Resident 6. Resident 6 self-administered the inhaler and performed two inhalations. Following this, the nurse immediately administered the Symbicort to Resident 6. Resident 6 self-administered the inhaler with one puff. However, LVN G did not instruct Resident 6 to wait five minutes between the two different medications. During an interview with LVN G on 6/15/2023 at 5:27 p.m., LVN G confirmed the above observation and she stated that she was not aware of the requirement to wait between different medications. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Operating Standard Guideline, dated 12/2012, indicated, Inhalers - .Wait 5 minutes between different medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 4 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 145's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (mental health condition that may develop after a traumatic event). Review of Resident 145's physician orders indicated she had an order for oxygen at 2 liters per minute via nasal cannula (a device used to deliver supplemental oxygen or airflow) as needed for oxygen saturation less than 92% on room air, dated 7/17/22 and discontinued on 6/5/23. Review of Resident 145's Smoking Safety Screen, dated 1/11/23 indicated the answer, Yes to Resident has expressed continued desire to smoke despite explained health and safety risks. The Smoking Safety Screen also indicated, Resident is a safe smoker and may smoke independently. (Note: Residents on Oxygen may not be independent smokers.) During an interview on 6/15/23 at 10:15 a.m., the director of nursing (DON) confirmed Resident 145 should not have been assessed to be an independent smoker because the resident was on oxygen. Review of the facility's policy, Smoking Policy, revised 2/2018 indicated the IDT (interdisciplinary team, a group of health care professionals from diverse fields who work toward a common goal for residents) was responsible for evaluating safety risks and staff will provide appropriate supervision for prohibiting smoking in the presence of oxygen use. Based on interview and record review, the facility failed to ensure residents were free of accidents and hazards for two of 22 sampled residents (39 and 145) when: 1. Resident 39's smoking safety was not reviewed quarterly and the smoking care plan was not followed; and 2. Resident 145 was not properly assessed for Smoking Safety Screen. These failures had the potential to result in serious injury to the residents in the facility. Findings: 1. Review of Resident 39's admission Record indicated, Resident 39 was admitted to the facility with diagnoses including unspecified dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning), ataxia (impaired balance or coordination), polyneuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), history of falling, nicotine dependence and unspecified visual loss. Review of Resident 39's Annual Minimum Data Set (MDS-an assessment tool), dated 2/25/2023, indicated Resident 39's Brief Interview for Mental Status (BIMS, cognition level) score was 13, meaning he was cognitively intact. A review of Resident 39's Quarterly MDS, dated [DATE], indicated Resident 39's BIMS score dropped to a 10, meaning he was moderately impaired with his cognition. Review of Resident 39's Smoking Safety Screen dated 2/27/2023, indicated, Resident is safe to smoke independently and smokes about 2 cigarettes daily. Staff keeps his lighter while resident may keep (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 5 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0689 his cigarettes in his own possession. Resident agrees with the plan. Level of Harm - Minimal harm or potential for actual harm Review of Resident 39's care plan titled, At Risk for accidental injury; smoking . date initiated 8/5/2021, indicated, Interventions .Review smoking safety quarterly .Smoking Plan: Independent Smoking; staff keep the lighter. Resident may keep tobacco products in his possession. Residents Affected - Few During an interview with Resident 39 inside his room on 06/12/23 at 3:34 p.m., Resident 39 stated he smoked 2 cigarettes a day and did not notify nurses whenever he went out to smoke. Resident 39 further stated he kept his cigarettes and lighter in his secret compartment. During an interview with the nurse supervisor (NS) on 6/14/2023 at 12:10 p.m., NS confirmed they never kept Resident 39's smoking materials like lighter, and cigarettes. During a concurrent interview and record review on 6/14/2023 at 1:10 p.m., social service director (SSD) reviewed Resident 39's Smoking Safety Screen dated 2/27/2023 and the Smoking care plan. SSD stated Smoking Safety Screen should have been done quarterly, annually and if there was a significant change in resident's condition. SSD confirmed Resident 39's Smoking Safety Screen should have been done in May 2023. SSD agreed nurses should have kept Resident 39's lighter in the medication cart as care planned. During a review of the facility's policy and procedure titled, SMOKING POLICY, date revised February 2018, indicated, .PURPOSE: To assess, monitor, and manage resident safety specific to smoking .PROCEDURE .2. Staff will control the distribution of smoking material (cigarettes, cigars, tobacco, lighters). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 6 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 72's clinical record, indicated resident was re-admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Presence of Left Artificial Knee Joint; Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination); Obesity, unspecified; History of falling, unspecified; Abnormalities of gait and mobility. During a concurrent observation and interview on 6/15/2023 at 10:30 a.m. with Resident 72, in resident's room, it was observed that the right bed rail of the resident's bed was loose and wobbly. Resident 72, who was alert and oriented, confirmed that the facility's staff was aware of the issue but had not addressed it. Resident 72 verbalized feeling unsafe when attempting to use the bed rail. During a concurrent observation and interview on 6/15/2023 at 10:45 a.m., with the MD, in Resident 72's room. MD acknowledged the observation and confirmed that the right bed rail was indeed loose and wobbly. During a concurrent observation and interview on 6/16/2023 at 2:04 p.m. with the Certified Nursing Assistant J (CNA J), in Resident 72's room, the CNA J stated the loose bed rail had been reported verbally to the MD a few months ago, but unsure of the exact date. 3. During a review of Resident 53s clinical record indicated resident was admitted to the facility with diagnoses including history of falling. During a concurrent observation and interview on 6/15/2023 at 10:55 a.m. with MD in Resident 53's room, surveyor brought to MD's attention the right bed rail of Resident 53 was loose and wobbly. MD confirmed the issue, acknowledging the screw on the back of the bed rail needed to be tightened. MD proceeded to tighten the screw. During a review of the facility's policy and procedure (P&P) titled, Proper Use of Bed Rails, dated 10/2022, the P&P indicated, Installation and Maintenance of Bed Rails: Checking bed rails regularly to make sure they are still installed correctly, and have not shifted or loosened over time. Based on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) for three of 22 sampled residents (Residents 81, 72 and 53). This failure had the potential to put the residents at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails. Finding: 1. During a concurrent observation and interview on 6/12/23 at 9:49 a.m., in Resident 81's room, Resident 81 was lying in bed with half side rails up bilaterally (on both sides of the bed). Resident 81 stated her bed rails were very wobbly and seemed like they were going to break off. Review of Resident 81's clinical record indicated she was admitted on [DATE] and had the diagnoses of dementia (disorder of the mental process caused by brain disease or injury), muscle weakness, low (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 7 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few back pain, altered mental status, history of falling, anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (a group of condition associated with the elevation or lowering of a person's mood). During a concurrent observation and interview on 6/15/23, at 10:05 a.m., with Maintenance Director (MD), in Resident 81's room, MD verified the bed rails were loose and stated it was due to wear and tear. During an interview with director of nursing (DON) on 6/16/23 at 9:50 a.m., she stated the facility should have continued communication for loose bedrails to prevent injury of the residents. During an interview with Executive Director (ED) on 6/16/23 at 3:49 p.m., she stated the facility should check the bedrails often for safety of the residents. During a review of the facility's policy and procedure (P&P) titled, Proper Use of Bed Rails, dated October 2022, the P &P indicated, Installation and Maintenance of Bed Rails by Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment; Ensuring the bed frame, bed rails and mattress do not leave a gap wide enough to entrap a resident's head or body , regardless of mattress width, length, and/or depth. Checking bed rails regularly to make sure they are still installed correctly, and have not shifted, or loosened over time. Conducting routine preventable maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 8 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. 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. During a document review titled, Census and Direct Care Service Hours Per Patient Day, from January through March 2023, indicated the following dates with actual DHPPD were below 3.5: 1/1- 2.73; 1/2-3.08; 1/3-3.17; 1/4-3.21; 1/7-2.8; 1/8-2.85; 1/9-3.19; 1/10-3.18; 1/14 -2.36; 1/15-2.64; 1/17-3.29; 1/18-3.3; 1/19-3.06; 1/20-2.88; 1/21-2.84; 1/22-2.53; 1/28-3.06; 1/29-2.56; 1/31-3.34; 2/4-3.02; 2/5-3.28; 2/6-3.12; 2/7-3.34; 2/8-3.31; 2/11-3.22; 2/12-2.92; 2/17-3.35; 2/18-3.10; 2/19-3.07; 2/21-3.37; 2/25-3.38; 3/5-3.19; 3/11-3.24; 3/12-2.83; 3/18-2.71; 3/25-2.84; and 3/27-3.07. During a review of the facility's Certified Nursing Assistant's (CNA) waiver from the California Department of Public Health (CDPH) dated, June 20, 2022, indicated, Your request is approved, only as applicable to the required 2.4 CNA staffing standard, and valid from July 1, 2022, until June 30, 2023, under the following conditions .2. The facility shall provide no less than 3.5 direct care hours per patient day. During a review of the All Facilities Letter (AFL) 21-11 dated March 17, 2021, indicated, The 3.5 DHPPD staffing requirement, of which 2.4 hours per patient day must be performed by CNAs, is a minimum requirement for SNFs (Skilled Nursing Facility). SNFs shall employ and schedule additional staff and anticipate individual patient needs for the activities of each shift, to ensure patients receive nursing care based on their needs. The staffing requirement does not ensure that any given patient receives 3.5 or 2.4 DHPPD; it is the total number of actual direct care service hours performed by direct caregivers per patient day divided by the average patient census. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 9 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) reconciled with the corresponding Medication Administration Records (MAR) for two of 3 randomly selected residents (Residents 53 and 13). This deficient practice had the potential to result in medication error and/or drug diversion. Findings: 1. During a review of Resident 53's physician order for Percocet (Oxycodone with Acetaminophen, a controlled medication for pain) 5-325 milligrams (mg, unit of measurement), 1 tablet by mouth every 4 hours as needed for moderate pain, dated 4/18/2023. During a review of Resident 53's Controlled Drug Record (CDR) for Percocet 5-325 mg and MAR for May and June 2023 reflected the nursing staff removed and documented on the Controlled Drug Record: 1 tablet on 5/9/23 at 4:40 a.m.; 5/30/23 at 5:55 p.m.; and 6/8/23 at 9:00 p.m., but did not document in the MAR. During a concurrent interview and record review on 6/13/2023 at 5:20 p.m., with the Director of Nursing (DON) and Health Information Manager (HIM), Resident 53's Controlled Drug Records and MAR for May and June 2023 were reviewed. DON and HIM confirmed the above findings. 2. During a review of Resident 13's physician's order for Oxycodone (controlled medication for pain) 5 mg, 1 tablet by mouth every 4 hours as needed for moderate to severe pain, dated 2/8/2023. During a review of Resident 13's Controlled Drug Record for Oxycodone 5 mg and the May and June 2023 MAR reflected the nursing staff removed and documented on the Controlled Drug Record: 1 tablet on 5/21 at 1:11 p.m.; 5/22 at 4:22 p.m.; 6/1 at 9:39 p.m.; 6/13 at 9:58 a.m., but did not document in the MAR. During a concurrent interview and record review on 6/13/2023 at 5:30 p.m., with the DON and HIM, Resident 13's Controlled Drug Record and MAR for May and June 2023 were reviewed. DON and HIM confirmed the above fndings. The DON acknowledged that ideally, license nurses should have documented the administration of narcotics in both the controlled drug record and the MAR. During a review of the facility's policy and procedure (P&P) titled, Safeguarding Controlled Substances, dated 10/08, the P&P indicated, The licensed nurse is to immediately enter the following information when removing doses from controlled storage on the residents individual controlled substance accountability record: 1. Date medication was removed; 2. Time medication was removed; 3. Amount of medication removed; 4. Amount of medication remaining; 5. Signature of nurse removing the medication. Following removal and administration the nurses is to document on the resident's MAR the date, time, and reasons a controlled substance had been given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 10 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of 8 sampled residents (Residents 57, 63, and 59) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 57 received Seroquel (used to treat certain mental or mood conditions) without an appropriate diagnosis and monitoring behavior, as recommended by the Pharmacy Consultant (PC); 2. Resident 57 received PRN (as needed) Lorazepam (medication used to treat anxiety) beyond 14 days and without supportive rationale for its continued use; 3. Resident 63 received prn (as needed) Temazepam (used to treat insomnia (difficulty falling asleep or staying asleep) without monitoring hours of sleep; and 4. Resident 59 received Lorazepam without documentation of its specific duration in the resident's clinical record. These failures had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents physical mental and psychosocial well-being. Findings: 1. During a review of Resident 57's clinical record, indicated resident was admitted on [DATE]. Diagnoses included, but were not limited to, Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Unspecified Psychosis not due to a substance or known physiological condition (a mental state characterized by a loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes). During a review of Resident 57's Order Summary Report, dated 6/16/2023, indicated the following: Seroquel 25 milligrams (mg, unit of measurement), 1 tablet by mouth 2 times a day for hallucinations manifested by concerns of absence of wife. Seroquel 50 mg, 1 tablet by mouth at bedtime for Parkinson's Disease manifested by hallucinations about wife. During a review of the Psychiatrist Visit Note, dated 3/9/2023, indicated: Problem list: Unspecified Psychosis Not Due to A Substance or Known Physiological Condition. Subjective: Staff report that Resident 57 has been having hallucinations of people playing instruments in his room. Patient also having ongoing delusions that his wife is dead which she is not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 11 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0758 During a review of the Pharmacist Consultation Report, dated 4/19/2023, indicated: Level of Harm - Minimal harm or potential for actual harm Comment: Resident 57 receives an antipsychotic, Seroquel 25 milligrams twice a day and 50 milligrams at bedtime for hallucination and Parkinson's. These are not appropriate diagnosis for antipsychotics. Per psych note on 3/9/2023, patient has a diagnosis for psychosis manifested by hallucination about hearing people playing instrument in his room and that his wife is dead. Residents Affected - Few Recommendation: Please update this order to include appropriate diagnosis and monitoring behavior. The Pharmacist Consultation Report above indicated that the recommendation was documented as updated, done, and signed by the Director of Nursing (DON). However, during the surveyor's investigation, there was no proof that the order was updated to reflect the appropriate diagnosis and monitoring behavior, as recommended by the PC. During a concurrent interview and record review on 6/15/2023 at 5:00 p.m., with the DON, the Pharmacist Consultation Report, dated 4/19/2023 was reviewed. Surveyor informed the DON, there was no proof of documentation that the order was updated or a follow-up response by the physician. DON stated the order may not have been updated because she disagreed with the recommendation. During a phone interview on 6/16/2023 at 4:00 p.m. with the Pharmacy Consultant (PC), PC confirmed the above recommendation was not implemented. The PC stated she had sent the recommendation to the facility again, three days ago. During a review of the facility's policy and procedure titled, Psychotropic Medication Management, dated 11/2022, indicated, When psychoactive medications are prescribed, the clinical record should reflect the diagnosis and specific condition, or targeted behavior being treated. 2. During a review of Resident 57's physician's order, indicated, resident was admitted to Santa [NAME] Hospice for Parkinson's Disease on 3/11/2023 and discharged from Hospice on 5/24/2023 due to improvement. Upon further review, indicated, Ativan every 4 hours as needed for a period of 90 days for Parkinson's manifested by yelling, restlessness, agitation, and combative behaviors. This order was issued by Hospice on 4/3/2023 and had an end date of 7/2/2023. During a concurrent interview and record review on 6/15/2023 at 4:30 p.m., with the Director of Nursing (DON), Resident 57's physician's order, dated 6/2023 was reviewed. Surveyor inquired regarding Resident's Ativan order from Hospice when the Hospice services ended on 5/24/2023. DON acknowledged that this should have been evaluated by the physician, and she stated Resident 57's medications would be reviewed accordingly. During a review of facility's policy and procedure (P&P) titled, Use of Psychotropic Medication, dated 2/2022, the P&P indicated, 12. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: a. Upon physician evaluation (routine and as needed); b. During the pharmacist monthly medication regimen review. During a Minimum Data Set (MDS, an assessment tool) review; d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturers specifications, and the resident's comprehensive plan of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 12 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0758 Level of Harm - Minimal harm or potential for actual harm 3. During a review of Resident 63's clinical record indicated she was admitted to the facility with diagnoses including Insomnia, Unspecified (inability to sleep). During a review of Resident 63's physician orders, indicated, Temazepam 7.5 mg PRN for sleep for 30 days at bedtime. Residents Affected - Few During a concurrent interview and record review on 6/15/2023 at 4:50 p.m. with the DON, the physician's orders was reviewed. DON confirmed there was no hours of sleep monitored. DON stated it should have been monitored. During a review of the facility's policy and procedure titled, Use of Psychotropic Medication, dated 2/2022, the P&P indicated, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnose and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 4. During a review of Resident 59's admission Record indicated Resident 59 was admitted to the facility with diagnoses including pneumonia (a lung infection), malignant neoplasm (cancer) of prostate (a gland in the male reproductive system), insomnia (a disorder in trouble falling asleep or staying asleep), depression (an illness characterized by persistent sadness and a loss of interest in activities), repeated falls, and alcohol dependence, in remission (a decrease in or disappearance of signs and symptoms). During a review of Resident 59's Order Summary Report, indicated, Lorazepam (an anti-anxiety medication to help treat anxiety) Tablet 0.5 mg Give 1 tablet by mouth every 4 hours as needed for Anxiety (a feeling of worry, nervousness, or unease) m/b (manifested by) excessive worry, panic, with order date on 4/21/2023. The order for Lorazepam did not indicate a stop date. During a review of Resident 59's medication administration record (MAR) from May 2023 through June 14, 2023, indicated Resident 59 have not taken Lorazepam since May 7 through June 14, 2023. During a review of the Pharmacist Consultation Report, dated 5/15/2023, indicated, Comment: Resident 59 has a PRN (Pro Re Nata - Latin phrase as necessary) order for an anxiolytic (anti-anxiety), which has been in place for greater than 14 days without a stop date . Recommendation: Please document the intended duration of therapy, and the rationale for the extended time period. Further review of the above document the attending physician's (AP) response, indicated, I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: not appropriate on comfort care, signed by AP on 5/23/2023. During an interview with DON on 6/15/2023 at 4:38 p.m., DON acknowledged Resident 59's use of Lorazepam should have been reviewed with the interdisciplinary team (IDT - (a group of health care professionals from diverse fields who work toward a common goal for residents). DON stated the use of Lorazepam should have been reassessed and should have been ordered for 14 days. During a phone interview with PC on 6/16/2023 at 4:00 p.m., PC confirmed there should be a duration for the use of PRN Lorazepam. PC stated she would follow up with MD. During a review of the facility's policy and procedure titled, Psychotropic Medication Management, dated November 2022, indicated, PURPOSE: To avoid unnecessary medications and facilitate the proper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 13 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0758 Level of Harm - Minimal harm or potential for actual harm use, dose, and duration of psychotropic agents in accordance with Resident assessed need(s) and condition(s) .PROCEDURAL GUIDELINES .4. Clinically necessary PRN psychotropic drug orders are limited to 14 days. If the prescribing practitioner determines a need for continued PRN use beyond the original 14 days, it is accompanied by supporting documentation in the electronic health record (EHR) including the rationale for continued use and duration. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 14 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to appropriately label a Tuberculin (TB, aid in the detection of infection with Mycobacterium tuberculosis) vial for 1 of 2 medication rooms observed. This deficient practice had the potential to affect residents' health and well-being in the facility. Findings: During a concurrent observation and interview on 6/12/2023 at 02:04 p.m., with Registered Nurse F (RN F) in the Station 1 medication room, there was an opened TB vial inside the refrigerator without an open date. RN F acknowledged the TB vial should have been dated upon opening. During a review of the facility's policy and procedure, titled, Medication Administration Operating Standard Guideline, dated 12/2012, the P&P indicated, Date tuberculin . when opened. Discard TB vial after 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 15 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure safe food storage when food brought by visitors to one of 22 residents (Resident 46) was not properly stored. This failure had the potential to result in food-borne illness and food contamination. Residents Affected - Few Findings: During an observation and concurrent interview on 6/15/23 at 10:20 a.m., with the director of nursing (DON), the DON confirmed there was an employee refrigerator in the parlor that had a sign that indicated, No residents food. There was an undated container of yogurt in the employee refrigerator labeled with Resident 46's name and room number. During an interview on 6/15/23 at 10:22 a.m. with registered nurse A (RN A), RN A stated Resident 46's visitors brought food for Resident 46 all the time, but was unsure where the food was stored. During an observation and concurrent interview on 6/15/23 at 10:25 a.m., with certified nursing assistant B (CNA B), CNA B confirmed Resident 46's container of yogurt was stored inside the employee refrigerator in the parlor. During an observation and concurrent interview on 6/15/23 at 10:30 a.m., the dietary supervisor (DS) confirmed the employee refrigerator in the parlor did not have a thermometer and the refrigerator temperature was not monitored or maintained by kitchen staff. The DS stated staff should not be storing resident's food in the employee refrigerator in the parlor. During an interview on 6/16/23 at 8:59 a.m., the DS stated the facility's storage of outside food policy was still on hold because of COVID-19. He stated the facility was not allowing storage of outside food. Review of the facility's policy, Use and Storage of Food Brought in by Family or Visitors, reviewed/revised on 2/2022 indicated the facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. Review of the U.S. Food and Drug Administration's 2022 Food Code, indicated time/temperature control for safety foods (requires time/temperature control for safety (TCS) to limit pathogenic microorganism growth or toxin formation) must be stored within refrigeration units and held at temperatures of 41°F or below. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 16 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. During an observation on 6/13/2023 at 9:38 AM, in Resident 37's room, CNA H applied Resident 37's Foley catheter's dignity bag with both gloved hands. However, after leaving the resident's room, the CNA H disposed of her gloves in the trash bin located in the hallway without performing hand hygiene immediately. The CNA H proceeded to open the storage closet in the hallway, removed linens, and then returned to Resident 37's room. CNA H did not perform hand hygiene promptly after disposing of her gloves and handling the linens in the hallway. Residents Affected - Some During an interview on 6/13/2023 at 1:44 p.m., with CNA H, she acknowledged the observation and stated she should have performed hand hygiene after disposing of her gloves. During an interview on 6/16/2023 at 4:00 p.m., with the Infection Preventionist (IP), IP stated hand hygiene should have been performed between tasks and after removing gloves. During a review of the facility's policy and procedure titled, Hand Hygiene, dated October 2022, indicated, .2.Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to .After handling contaminated objects .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 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. During a dining observation on 6/12/2023 at 12:35 p.m., inside the facility's dining room, Resident 42 was sitting on his wheelchair. CNA I placed Resident 42's lunch tray on the table, repositioned Resident 42's wheelchair closer to the table by touching the wheels and started removing the cover of the plate and juice. CNA I did not perform hand hygiene prior to setting up Resident 42's lunch tray. CNA I stood up, went outside the dining room, came back with some clean table napkins, sat down beside Resident 42 and touched the utensils again. CNA I did not perform hand hygiene prior to touching Resident 42's utensils. CNA I stood up again, checked something inside the lunch cart, touched her hair, sat down beside Resident 42, and assisted Resident 42 with his lunch. CNA I did not perform hand hygiene prior to meal assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 17 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with CNA I on 6/12/2023 at 1:46 p.m., CNA I confirmed above observation. CNA I stated, It's my fault. I should have performed hand hygiene after touching the wheelchair. CNA I further stated, It is important to perform hand hygiene before assisting resident to eat to prevent the spread of germs. 1b. During another dining observation on 6/12/2023 at 12:37 p.m., inside the facility's dining room, the restorative nursing assistant (RNA) have been touching the lunch cart, giving out lunch trays to residents inside the dining room. Once the lunch trays were distributed inside the dining room, RNA sat down beside Resident 57, set up Resident 57's lunch tray by touching the utensils, assisted Resident 57 with his drinks, adjusted his chair, and continued feeding Resident 57. RNA did not perform hand hygiene prior to touching Resident 57's lunch tray, and prior to feeding Resident 57. During an interview with the RNA on 6/12/2023 at 2:19 p.m., RNA confirmed the above observation. RNA stated, It is easy to spread bacteria if we don't wash our hands. RNA further stated he was aware that he touched the lunch cart and he missed to perform hand hygiene before assisting Resident 57 with lunch. During an interview with the IP on 6/16/2023 at 9:00 a.m., IP acknowledged above observations. IP stated CNA I should have performed hand hygiene prior to assisting resident with meals. IP further stated staff should always perform hand hygiene prior to meal assistance. During a review of the facility's policy and procedure title, Hand Hygiene, dated October 2022, indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 3a. During an observation on 6/12/23, at 2:12 p.m., CNA D entered resident 9's room and did not perform hand hygiene. He took a small pink pitcher of water then exited the room without performing hand hygiene. CNA D then went to another room and came out of the room without performing hand hygiene. During an observation on 6/12/23, at 2:20 p.m., CNA D stepped out of another room without performing hand hygiene. During an interview on 6/16/23, at 10:30 a.m., with Infection Preventionist (IP), IP stated staff should have perform hand hygiene before she went inside the room and after she comes out the resident room. 3b. During an observation on 6/12/23, at 10:49 a.m., CNA E entered Resident 8's room with a clean diaper in her hand, pulled the privacy curtain, and went to the resident's bathroom to wet a towel. CNA E stepped out of the room wearing gloves, then removed them. CNA E opened the door to the storage and got clean socks, then went to the resident again. She pulled the privacy curtain open, helped the resident into a wheelchair, and wheeled the resident out of the room. CNA E did not perform hand hygiene between these tasks. During a concurrent observation and interview on 6/12/23, at 11:08 a.m., CNA E entered in Resident'8 room and stated she should have performed hand hygiene in between tasks. During an interview on 6/16/23, at 10:30 a.m., with Infection Preventionist (IP), IP stated staff should perform hand hygiene in between tasks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 18 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, dated October 2022, the P&P indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident, and visitors. This applies to all staff working in all locations within the facility. The policy further indicated to perform hand hygiene between resident contacts. 4. During a concurrent observation and interview on 6/16/23, at 12:25 p.m., with IP, IP stated there were three Residents with clostridium-difficile (c-diff, inflammation of colon causing diarrhea). She stated the residents were cohorted (practice of grouping residents infected or colonized with the same infectious agent together) and other residents were being moved. IP stated she don't know who to report this to. During an interview on 6/16/23, at 03:05 p.m., with IP, she stated she did not have a line list of residents who had c-diff. She stated she was coordinating with her DON and residents were cohorted. During an interview and record review on 6/16/23, at 3:28 p.m., with Director of Nursing (DON), DON stated, Should I report to the local / state health? The DON then reviewed the facility's reporting policy and confirmed it was not followed because it indicated, An outbreak will be reported to the local and/or state health department in accordance with the state's reportable disease website. During a review of the facility's policy and procedure (P&P) titled, Infection Outbreak Response and Investigation, dated 3/2020 and reviewed on 4/2023, the P&P indicated An outbreak may involve only one case. An outbreak will be reported to the local and/or state health department in accordance with the state's reportable disease website. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 19 of 20 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 056048 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation, interview, and record review, the facility failed to conduct regular inspections of resident bed frames for one of 22 beds. The facility failed to ensure the footboard was securely, properly installed, and maintained according to the manufacturer's requirements. This failure had the potential to place the residents at risk for accidents and unsafe environment. Findings: During an observation on 6/12/23, at 9:16 a.m., in Resident 3' room, Resident 3 was lying in bed asleep. The wooden lining of the bed's footboard was in disrepair and coming off. There was a piece of surgical tape attached to the end of the wooden lining. During a concurrent observation and interview on 6/12/23, at 11:22 a.m., with Certified Nurse Assistant C (CNA C), in Resident 3's room, he verified the above observation and stated he would call someone to check on it. During a concurrent observation and interview on 6/12/23, at 11:26 a.m., with Maintenance Director (MD), in Resident 3's room, MD verified the above observation and stated that the footboard should have been securely and properly intalled accordingly. During a concurrent interview and record review on 6/15/23, at 10:05 a.m., MD stated he did not get a request to repair the footboard, and no work order was logged in. During an interview on 6/16/23, at 3:49 p.m., with the Executive Director (ED), she stated the beds should have been checked for resident safety. During a review of the facility's policy and procedure (P&P) titled, Preventive Maintenance Program, dated 5/26/2023, the P&P indicated, The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the building, ground, and equipment are maintained in a safe and operable manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 20 of 20