Health inspection·February 20, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview, record reviews, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I Screening was updated to reflect the presence of newly diagnosed serious mental disorders for 1 (Resident #67) of 3 residents reviewed for PASARR requirements. Findings included: A facility policy titled, Resident Assessment - Coordination with PASARR Program, reviewed/revised 05/2024, revealed, This facility coordinates assessments with the preadmission screening and Resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy specified, 9. Any Resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level Il Resident review. Resident #67's admission Record indicated the facility admitted the resident on 12/01/2023. According to the admission Record, the resident had a medical history that included diagnoses of post-traumatic stress disorder (PTSD) (onset date 12/04/2023), anxiety disorder (onset date 02/20/2024), and unspecified psychosis not due to a substance or known physiological condition (onset date 05/21/2024). Resident #67's care plan included a focus area, initiated 02/21/2024, that indicated the resident had a mood problem related to a diagnosis of PTSD. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2025, revealed Resident #67 had short- and long-term memory problems and severely impaired cognitive skills for daily decision-making per a Staff Assessment of Mental Status (SAMS). According to the MDS, at the time of the assessment, the resident had active diagnoses that included anxiety disorder, psychotic disorder, and PTSD. Resident #67's Level I PASARR Screening, dated 11/30/2023, revealed Section III- Serious Mental Illness, question 10, was answered no to indicate the resident did not have a serious diagnosed mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions and/or mood disturbance. The Level I PASARR screening indicated the screening was Negative, due to No Serious Mental Illness, and a Level II evaluation was Not Required. (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 4 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 02/20/2025 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)