Health inspection·May 9, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect resident's right to be free from physical abuse for two of two sampled residents (Resident 1 & Resident 2) when: 1. Resident 1 was hit in the face by Resident 3 2. Resident 2 was kicked in the leg by Resident 3. These failures resulted in Resident 1 sustaining a minor laceration to the face and Resident 2 sustaining a minor laceration to the leg, both requiring minor medical care. Findings: 1. During an interview on 5/7/24, at 10:20 a.m., with Administrator (ADM), ADM stated, we got a report from Resident 4, he saw Resident 2 grab Resident 3's arm, then Resident 3 punched Resident 1 in the head. ADM stated both Resident 1 and Resident 3 have been involved in resident-to-resident altercations before. During a review of SBAR-Alleged Abuse Report of Incident dated 5/6/24, indicated, Resident 3 was involved in an incident of alleged: Physical abuse with redness [to] right hand 2nd and 3rd knuckle.Behavior status 1.Agitated.Staff responded to yelling from the room. [Resident 1] was holding onto his [Resident 3's] left wrist and [Resident 1] observed with blood coming from his left temple.[Resident 4] confirmed that [Resident 3] hit roommate on the face. During a review of Report of Suspected Dependent Adult/Elder Abuse form dated 5/6/24, form indicated Reported Types of Abuse (check all that apply).a.Physical abuse was reported by facility between Resident 1 and Resident 3. During a review of Interview/Investigative record dated 5/6/24, indicated, Resident 4 was interviewed by Social Services Director (SSD), Content of interview: [Resident 4] stated he saw [Resident 2] grabbing [Resident 3] and not letting go. [Resident 4] stated [Resident 3 then 'slapped [Resident 1] with his fist'. Record was signed by Resident 4 and SSD. During a review of Resident 3's Progress Note dated 5/6/24 at 11:28 a.m., note indicated, Was a behavior observed? YES. Pt [patient-Resident 3] appears irritated and short tempered. Using distraction and reorientation, and reassurance. Page 1 of 3 056048 056048 05/09/2024 Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 3's Progress Note dated 5/6/24 at 11:31 a.m., note indicated, Pt [patient-Resident 3] is still agitated.using distraction methods to calm patient. During a review of Resident 3's Progress Note dated 5/6/24 at 1:44 p.m., indicated, staff responded to yelling from the room. [Resident 1] was holding on to [Resident 3's] left wrist and [Resident 1] observed with blood coming from his left temple. Resident 4[roommate] confirmed that [Resident 3] hit [Resident 1] on the face. During a review of SBAR-Alleged Abuse Report of Incident dated 5/6/24, indicated, Resident 1 was involved in an incident of alleged: a. Physical abuse.on 5/6/24. Assessment 3.Laceration or cut. During a review of the Summary of Investigation dated 5/6/24, Summary indicated, Residents affected:[Resident 3 and Resident 1] on 5/6/24 about 11:30am.Allegation: On 5/6/24 it was reported to supervisory of an incident between two roommates [Resident 3 & Resident 1]. [Resident 1] had a cut to his eyebrow.Roommate [Resident 4] reported seeing [Resident 1] holding [Resident 3's] arm while in a wheelchair and [Resident 3] hitting him in the face.Conclusion: Based on interviews and record reviews, the incident did happen. During a review of Resident 3's Brief Interview for Mental Status (BIMS-screening used to determine cognitive condition) dated 2/12/24, indicated a BIMS score of 1 (indicating severe cognitive impairment: a very hard time remembering things, making decisions, concentrating, or learning). During a review of Resident 1's BIMS score, dated, 3/2/24, resident is rarely/never understood.skip. Indicating resident was cognitively impaired. 2. During a review of Summary of Investigation dated 5/8/24, Summary indicated, Residents affected: [Resident 3 and Resident 2].Allegation: it was reported of a resident to resident [incident] [Resident 2] and [Resident 3]. [Licensed Vocational Nurse (LVN) A] reported [residents] shaking fists and yelling at each other in the hallway and [Resident 3] stood up and kicked [Resident 2] in the leg.Conclusion: confirmed incident. During an interview on 5/7/24, at 10:02 a.m., with LVN A, LVN A stated, she was in the hallway during the incident between Resident 2 and Resident 3 on 5/6/24. LVN A stated, she saw Resident 2 in his wheelchair going towards Resident 3, and thought they were talking, then Resident 2 tried to punch Resident 3 and missed, then Resident 3 stood up and kicked Resident 2 in the leg. Resident 2 began bleeding from his shin. During a review of Resident 2's Order Summary Report dated 5/7/24, report indicated, Monitor right shin skin tear. During a review of Resident 2's Progress note dated 5/8/24, note indicated, [Resident 2] was in the hallway in w/c [wheelchair] when he moved his w/c forward and approached another male resident [Resident 3] in a threatening way to which the other residents stood up and kicked [Resident 2] on the right shin twice causing the skin tear. Incident observed by nurse nearby, no other physical contact, residents were separated immediately, [Resident 2's] wound attended. During a review of Resident 2's BIMS score, dated, 4/21/24, indicated a BIMS score of 08. Indicating moderate cognitive impairment. 056048 Page 2 of 3 056048 05/09/2024 Pacific Coast Manor 1935 Wharf Road Capitola, CA 95010

F 0600 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting dated 2022, P&P indicated, Each resident has the right to be free from abuse.Abuse is the willful infliction of injury.Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking.Resident-to-Resident abuse means the willful infliction of injury.willful as used in the above definition of abuse, means the individual must have acted deliberately. Residents Affected - Few 056048 Page 3 of 3