Health inspection·December 13, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, the facility failed to protect a resident's right to be free from sexual abuse for one of two sampled residents (Resident 1) when Certified Nursing Assistant (CNA A) observed kissing Resident 1 on the face. This failure had the potential to endure emotional and psychological harm for Resident 1. Findings: During a review of Resident 1's admission Record, dated 10/31/23, admission Record indicated, diagnosis information of metabolic encephalopathy (a disorder causing brain dysfunction), muscle weakness, unspecified dementia (a condition where the person loses ability to think, remember, learn or makes decisions), and major depressive disorder. During a review of Verification of Incident/ Administrative Summary, dated 10/20/23, indicated an incident with Resident 1 and CNA A occurred on 10/24/23. Summary indicated, Type of incident: Allegation of Sexual Abuse. The brief description of the incident/event when C.N.A. witnessed a kiss between CNA A and Resident 1. Futhermore, the immediate actions taken: Resident 1 had a BIMS [brief interview for mental status-exam used to determine cognitive level] of 8 [indicating Resident 1 was not cognitively intact] and dependent to max assist with ADLs [activities of daily living]. After facility investigation we found the allegation was substantiated. During a review of Resident 1's SBAR-[Situation, Background, Assessment, and Recommendation: type of report used to communicate the condition of a resident] Alleged Abuse report of incident dated 10/24/23, SBAR indicated, 2. This patient was involved in an incident of alleged: d. Sexual Abuse.2a. Which occurred at approximately 10/23/23 11:00. A. Assessment Pertinent Assessment Findings: 1. Cognitive State/Status of Resident a. Oriented to person. SBAR indicated, Resident 1 was only oriented to person, not oriented to the place he is at, not oriented to the time of day, and does not have the capacity to make decisions. SBAR indicated, Briefly describe the nature of the occurrence: [Resident 1] introduced a staff [CNA A] as his fiancé to another staff [CNA B]. [CNA B] thought it was a joke. When he came back to that room, he witnessed [CNA A] leaning over [Resident 1] who was on his bed. They were found kissing. During a review of Resident 1's Speech Therapy SLP [Speech Language Pathology-professional who assesses diagnoses and treats speech and cognitive communication] Evaluation and Plan of Treatment dated 9/7/23, Speech Therapy note indicated, Clinical Impressions.Brief Cognitive Impairment Scale[BCIS-screening assessment for cognitive dysfunction: deficit in memory, problem solving, decision making] administered. [Resident 1] scoring 8/14, which was consistent with patients who have severe stage (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 12/13/2023 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)