Health inspection·September 11, 2023

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure social services advocating and assisting residents to promote resident's rights for one of three residents (Resident 1) and significant family members (SFM). Residents Affected - Few This failure had the potential to result in the Resident 1 for not receiving necessary mental, psychosocial, emotional support, care, and services to attain Resident 1's highest practicable well-being. Findings: During the review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated, Resident 1 admitted to facility on 5/10/2023 with diagnoses including alcoholic cirrhosis of liver with ascites (a disease caused by heavy use of alcohol with buildup of fluids in the abdomen), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), adjustment disorder (an emotional or behavioral reaction to a stressful event or change in person's life), chronic pain (pain that lasts for over three months despite medication or treatment) hypertension (a condition in which the force of the blood against the artery walls is too high), and malignant neoplasm of breast (a cancer that forms in the cells of the breasts). Review of Resident 1's Minimum data set (MDS- clinical and functional assessment tool) dated 8/6/2023 indicated Resident 1's brief interview for mental status (BIMS) score of 14 of 15 (13-15 means Intact cognition). During an observation and interview with Resident 1 on 8/28/2023 at 1:47 p.m., Resident 1 was observed up in w/c in her room. Resident 1 stated social service director (SSD) was judgmental, uncooperative, won't listen. Resident 1 also stated SSD came on to her (Resident 1) face and talked to her with loud voice made Resident 1 intimidated and threatened. Resident 1 further stated she (Resident 1) felt scarred and terrified to talk to SSD and Resident 1 avoiding talking to SSD directly. During an interview with Resident 1's SFM 1 over the telephone on 8/18/2023 at 10:23 a.m., SFM 1 stated facility's social service director (SSD) threatened SFM 1 for sending Resident 1 to a facility 152 miles away from this facility while Resident 1's family lives in this area. SFM 1 stated SSD was unprofessional, uncooperative, used loud voice, and did not listen SFM 1's concerns for Resident 1. SFM 1 also stated SSD's showed bullying personality towards SFM 1 while dealing with facility's proposed discharge to a homeless shelter for Resident 1. During an interview with license vocational nurse A (LVN A) on 8/18/2023 at 12:36 p.m., LVN A (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056048 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 09/11/2023 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)