Health inspection·April 2, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's MD (medical doctor) Progress note dated 1/23/25, note indicated, Pt [patient] admitted for fall at home.Assessment/Plan.10. OSA (obstructive sleep apnea) G47.33 [diagnosis code] Continue home CPAP. Residents Affected - Few During a review of Resident 1's Order Summary Report dated 3/25/25 at 10:40 am, current orders indicated, no active orders for the use of a CPAP machine. During a review of Resident 1's Medication Administration Record (MAR) dated 1/21/25-2/28/25, MAR indicated no administrations charted for the use of a CPAP machine for any day. During an observation on 3/25/25, at 10:40 a.m., in Resident 1's room, no CPAP machine was observed in the room. During a review of Resident 1's Facesheet, dated 3/25/25, facesheet indicated Resident 1 had a diagnosis listed for Obstructive Sleep Apnea (Adult).onset date 12/20/24. During an interview on 3/25/25 at 11:59 a.m., with Licensed Vocational Nurse (LVN) A. LVN A stated, she was assigned nurse to Resident 1 and took care of Patient 1 multiple times. LVN A stated, Resident 1 had a complaint that he did not have a CPAP machine to use at night and trying to get him the CPAP. LVN A stated, she knows Resident 1 had a CPAP machine when he was here at the facility but he had no CPAP during this current admission. During a review of Resident 1's Progress Note dated 2/28/25, note indicated, Received call from [MD B-medical doctor B] .states he feels resident was having cognitive issues perhaps related to CPAP not using at bedtime. [MD C & NP D-Nurse Practitioner D] notified to obtain CPAP order. Signed by LVN A. During a review of Resident 1's Progress Note dated 3/13/25, note indicated, [MD B] contacted nurse.Asked about getting a CPAP machine for the pt [patient-Resident 1]. During an interview on 3/25/25, at 12:55 p.m., with Director of Nursing (DON), DON stated, the MD should have put an order (for CPAP) for the resident (Resident 1). They (MD/NP) are responsible for putting their orders in. During an interview on 3/25/25 at 3:09 p.m., with MD C, MD C stated, he was not sure the protocol for getting the CPAP machine once it was recommended to use. MD C stated the Director of Nursing would know. (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 2 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 04/02/2025 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)