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 Page 1 of 2 056048 056048 12/13/2023 Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dementia. From BCIS Report: Caregiving demands are significant. The ability to make new memories, learn new things, and control executive functions was very impaired. ' Working memory ' (Temporarily storing, organizing, and manipulating information) was severely impaired. During a review of Resident 1's BIMS Score dated, 10/28/23, BIMS Score indicated, a score of 8, which indicated cognitive impairment. During an interview on 10/31/23, at 10:55 a.m., with CNA B, CNA B stated, he went to assist Resident 1's roommate to walk to the restroom on 10/23/23 around 11 a.m. to use the restroom. CNA B stated, he saw CNA A and Resident 1 in the room. Resident 1 told CNA B You haven't met my fiancé yet and gestured toward CNA A. CNA B thought it was a joke and laughed then left the room. CNA B stated, he went back to Resident 1's room after a few moments to assist Resident 1's roommate back to bed. CNA B stated, he went back into Resident 1's room, he saw CNA A leaning over Resident 1 and heard two kissing sounds and saw CNA A was kissing Resident 1 somewhere on the face. During an interview on 10/31/23, at 11:38 a.m., with Social Services (SS), SS stated she considered sexual abuse when CNA A kissed Resident 1. During an interview on 10/31/23, at 12:45 p.m., with Director of Staff Development (DSD), DSD stated, CNA A was given a one-on-one in-service(education) on 9/25/23, after CNA A was recently observed by staff giving Resident 1 more attention and care while she was not assigned to care for Resident 1. DSD stated, she considered sexual abuse when CNA A kissed Resident 1 on 10/23/23. During an interview on 10/31/23, at 2:08 p.m., with Administrator, Administrator stated, the facility did substantiate the allegation of sexual abuse between CNA A and Resident 1 on 10/23/23. During a review of the facility's policy and procedure (P&P) titled Alleged or Suspected Abuse and Crime Reporting, dated 11/2016 , P&P indicated, Each resident has the right to be free from abuse. 056048 Page 2 of 2