Health inspection·May 6, 2021

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents receive their medication according to manufacturer's specification when one resident (Resident 137 ) of 13 sample residents, did not rinse mouth after taking Symbicort Aerosol 2 puffs (corticosteroid medication inhaled through the mouth used to open airway for easy breathing). Residents Affected - Some Reference: https://online.[NAME].com/lco/action/home ( a nationally recognized drug reference) accessed 5/10/21, indicated .after use of the inhaler, patient should rinse mouth/oropharynx with water and spit out rinse solution .localized infections with Candida albicans or Aspergillus niger have occurred frequently in the mouth and pharynx with repetitive use of oral inhaler of corticosteroids . This failure had the potential for residents receiving inhaler, unnecessary discomfort caused by mouth infection. Findings: During a medication pass observation on 5/4/21, at 9:20 am, Registered Nurse 1 (RN) 1, handed the Symbicort Aerosol Inhaler to Resident 137 for him to administer himself. RN 1, stated Resident 137 had been taking the medication for years so he knew what to do. Resident 137 took 2 puffs and handed the Symbicort Aerosol inhaler back to RN 1. Resident 137 did not rinse mouth after use and RN1 did not give instruction to rinse mouth. During an interview on 5/6/21, at 9:24 am, with Resident 137, Resident 137 stated, he had been taking Symbicort for years and did not know to rinse mouth after using inhaler. During an interview on 5/6/21, at 9:30 am, with RN1, RN1 stated, Resident 137 had been taking the Symbicort for years so she did not remind him to rinse mouth after use. RN1 further stated rinsing mouth after use would prevent mouth infection. During a review of Resident 137's comprehensive care plan, (undated), the comprehensive care plan did not indicate care after use of inhaler. During a review of the clinical records for Resident 137, the face sheet, indicated, [AGE] years old, admitted on [DATE], with diagnosis including acute and chronic respiratory failure. The Skilled Charting, dated 5/3/21, indicated, Resident 137, has short term and long term memory problems with impaired decision making. During a review of the facility policy and procedure (P&P) titled, Medication Administration Oral Page 1 of 6 055116 055116 05/06/2021 Linda Mar Care Center 751 San Pedro Terrace Road Pacifica, CA 94044

F 0760 Inhalations, dated 5/17, the P&P indicated . (11) Steroid inhalers provide resident with cup of water and instruct him/her to rinse mouth . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055116 Page 2 of 6 055116 05/06/2021 Linda Mar Care Center 751 San Pedro Terrace Road Pacifica, CA 94044

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interview and record review, the facility failed to serve food in accordance with professional standards for food service safety when: Residents Affected - Many Two (2) of five(5) dietary staff did not wear appropriate hair restraints e.g. hairnet, hat and/or beard restraint to prevent hair from contacting food. This failure had the potential to cause food borne illness to 42 residents who received food from the kitchen out of the facility census of 42. Findings: During the initial kitchen observation on 5/3/21, at 10:27 am, Dietary Supervisor 1 (DS1) was at the food preparation area. DS1 had a cap (brimless head covering) on, partly covering his head, his hair above the nape and behind his ears were exposed, part of his beard exposed outside his face covering. No beard restraint. During a follow up kitchen observation on 5/5/21, at 11:02 am, DS1 was assisting the cook at the food preparation area. DS1 had a cap on, hair partly covered, his beard exposed outside face covering. The Dietary Manager (DM) was at the other side of the food preparation area assisting staff in the food tray line. The DM had hair hanging outside her hair net. During an interview on 5/6/21 at 10:30 am, with DM, DM stated, the dress code for women staff included hairnet, men with short hair will use hat. During a review of the facility Dress Code for Women and Men, dated 2018, the Dress Code indicated recommendation for, .Women (6) hair net or hat which completely covers the hair .Men (6) hat for hair if hair is short .(8) beards and mustaches (any facial hair) must wear beard restraint. According to the 2017 Food Code (US food standard for food safety), food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair that are designed and worn to effectively keep hair from contacting exposed food. 055116 Page 3 of 6 055116 05/06/2021 Linda Mar Care Center 751 San Pedro Terrace Road Pacifica, CA 94044

F 0867 Level of Harm - Minimal harm or potential for actual harm Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to implement their Quality Performance Improvement(QAPI)program when: Residents Affected - Many 1. There is no evidence the QAPI committee regularly review and analyze data collected under the QAPI program. 2. There is no evidence of established measures to track effectivity, corrective actions and monitoring of events to assure that programs improvements were sustained. This failure had the potential to cause systemic failures affecting outcomes of care and quality of life for all residents. Findings: During an interview on 5/6/21 at 11:16 am, with Director of Nursing (DON), the DON stated, they track process during rounds to find out if the issue had been fixed and they do not always write once the problem was corrected. During an interview on 5/6/21 at 11:30 am, with Administrator (Adm), the Adm stated, the Quality Assurance and Performance Improvement (QAPI) committee meets quarterly or even sooner depending on the issues. The committee, review presenting issues and once the issue was resolved they do not discuss it anymore. He further stated there is no established tracking system. During a review of the facility QAPI minutes, dated 10/27/20, the QAPI minutes indicated, list of topics discussed but no systematic analysis and corrective actions. There is no evidence the QAPI committee had subsequent meetings or follow up to evaluate if the corrective actions were effective or not. No policies established on systematic approach determining underlying causes of problems, corrective actions and program effectivity. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance (QAPI) Plan, dated 4/2014, the P&P indicated, .this facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care . 055116 Page 4 of 6 055116 05/06/2021 Linda Mar Care Center 751 San Pedro Terrace Road Pacifica, CA 94044

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to implement their infection control program for 2 (Resident 137 and Resident 88) of 13 sampled residents when: Residents Affected - Some 1. Registered Nurse 1 (RN1) did not wash hands after removing gloves during and after medication administration administration of Resident 88 and Resident 137. 2. Intravenous (IV- administer medications through a vein) tubing intended to be used for Resident88's next IV antibiotic dose did not have a sterile cap on the end of the tubing which was opened and exposed. This failure had the potential for contamination to spread infection and communicable diseases in the facility. Findings. During a med pass observation on 5/4/21, at 8:33 am, RN1, removed gloves after preparing medications for Resident 88. RN1, then put on a new pair of gloves, proceeded inside Resident 88's room and gave meds. RN1 went back out of the room, removed gloves then put on a new pair of gloves before preparing medications for Resident 137 in the next room. RN1 did not perform hand hygiene in between donning gloves. A concurrent interview with RN1, RN1 stated she should have washed her hands after removing gloves. During a med pass observation on 5/4/21, at 9 am, an empty IV bag was on IV pole at Resident 88's bedside, IV tubing labeled 4/4/21-4/5/21. Connector end of tube not capped. RN1, stated, she will use tubing for the next dose of IV antibiotic this afternoon and is good for 24 hours. RN1 further stated, previous RN who disconnected the tube should have placed a sterile cap on the end of the tubing to prevent contamination. During a review of the Medication Administration Record (MAR) for Resident 88, dated 5/4/21 at 6:57 am, the MAR indicated, .Cefazolin Sodium Solution Reconstituted 1 gm .administered intravenously .left wrist . During a review of the Setting Up a Primary Infusion Policies (P & P), dated 8/16, the P&P stated, .Procedures .(11) .if the tubing will be used again within 24 hours place a sterile cap on the end of the tubing. During a review of the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, dated 11/20, indicated, .hand hygiene the primary means to prevent the spread of infection . (7)(m) .after removing gloves. 055116 Page 5 of 6 055116 05/06/2021 Linda Mar Care Center 751 San Pedro Terrace Road Pacifica, CA 94044

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that residents in multiple resident bedrooms had adequate useable living space for 13 of 21 bedrooms (Rooms 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121 and 122). This failure had the potential for residents not to have enough space for the provision of care. Findings: During an interview on 5/3/2021 at 10:30am, with the Adm, the Adm stated that the 13 rooms provided less than the required 80 square feet per resident and currently had a waiver for the rooms not in compliance. A review of the facility client accommodation analysis indicated the following: room [ROOM NUMBER] measured 77.233 sq. ft. per resident room [ROOM NUMBER] measured 78.240 sq. ft. per resident room [ROOM NUMBER] measured 78.167 sq. ft. per resident room [ROOM NUMBER] measured 78.243 sq. ft. per resident room [ROOM NUMBER] measured 78.580 sq. ft. per resident room [ROOM NUMBER] measured 78.223 sq. ft. per resident room [ROOM NUMBER] measured 78.167 sq. ft. per resident room [ROOM NUMBER] measured 78.240 sq. ft. per resident room [ROOM NUMBER] measured 78.580 sq. ft. per resident room [ROOM NUMBER] measured 78.033 sq. ft. per resident room [ROOM NUMBER] measured 78.167 sq. ft. per resident room [ROOM NUMBER] measured 78.243 sq. ft. per resident room [ROOM NUMBER] measured 78.167 sq. ft. per resident During Observation on 5/3/21 at 10:30 am in room [ROOM NUMBER] - Certified Nursing Assistant (CNA) able to assist resident into wheel chair and provide care without issues. During Interview at resident council on 5/3/21 with Residents #9, #16, #30, #99 No issues regarding room size identified. During interview on 5/4/21 with Resident # 32 at 9:30 am in room [ROOM NUMBER] states, my room is okay. During interview on 5/4/21 with Resident # 9 at 1:30pm am in room [ROOM NUMBER] Bed I've been here 12 years, I love it here During interview on 5/4/21 with Resident #7 at 1:35pm am in room [ROOM NUMBER] Bed I like my room During observation on 5/4/21 2:30pm ADM Measured sample rooms 111 (measured 78.240 sq. ft. per resident) & room [ROOM NUMBER] (measured 78.167 sq. ft. per resident Room). 055116 Page 6 of 6