Health inspection·August 1, 2024

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure to follow their policy and procedure (P&P) to assess for history of psychosocial, trauma and stressors trigger an event, for two of two sample residents (Resident 1 and 2). This failure had the potential to effect health, psychosocial well-being, and person-centered trauma informed care for Resident 1 and 2. Residents Affected - Few Findings: Review of Resident 1's FS (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE] and readmitted to facility on 6/14/2024. Review of Resident 1's FS indicated Resident 1's admission diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in daily living activities), anxiety (a mental health condition involves persistent and excessive worry that interferes with daily living activities), and insomnia (a sleep disorder that make it hard to fall asleep or stay asleep). Review of Resident 1's physician medication orders dated 6/14/2024 indicated, buspirone (used to treat anxiety) 5 mg (milligram: unit of measurement equal to a thousandth of a gram) two times a day for anxiety. Sertraline (used to treat depression) 200 mg in the morning for depression dated 6/14/2024, and trazodone (used to treat depression) 100 mg at bedtime for depression dated 6/14/2024. Review of Resident 1's minimum data set (MDS: clinical assessment tool) assessment dated [DATE] indicated Resident 1's brief interview for mental status (BIMS, an assessment to test a person's cognition level) ) score of 14 of 15 meaning he had intact cognition (score of 0-7: severe impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition). Review of Resident's MDS assessment dated [DATE] indicated Resident 1's BIMS score of 14 of 15, intact cognition. Review of Resident 1's initial admission social service assessment dated [DATE] upon Resident 1's initial admission indicated, questions for history for psychosocial, trauma and stressors trigger an event were left blank, incomplete. Review of Resident 1's initial readmission social service assessment dated [DATE] indicated, questions for history for psychosocial, trauma and stressors trigger an event were left blank, incomplete. During an interview with Resident 1 on 7/9/2024 at 2:10 p.m., Resident 1 stated facility staff did not enquire or questioned Resident 1 for mental health history or history of trauma. Resident 1 also (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 3 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 08/01/2024 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)