Health inspection·May 9, 2024

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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 2 of 3 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 05/09/2024 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 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056048 If continuation sheet Page 3 of 3