Inspection visit
Inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
(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 6
Event ID:
055116
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
055116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/06/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Linda Mar Care Center
751 San Pedro Terrace Road
Pacifica, CA 94044
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 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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055116
If continuation sheet
Page 2 of 6
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
055116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/06/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Linda Mar Care Center
751 San Pedro Terrace Road
Pacifica, CA 94044
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055116
If continuation sheet
Page 3 of 6
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
055116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/06/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Linda Mar Care Center
751 San Pedro Terrace Road
Pacifica, CA 94044
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 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 .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055116
If continuation sheet
Page 4 of 6
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
055116
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/06/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Linda Mar Care Center
751 San Pedro Terrace Road
Pacifica, CA 94044
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055116
If continuation sheet
Page 5 of 6
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
055116
B. Wing
(X3) DATE SURVEY
COMPLETED
A. Building
05/06/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Linda Mar Care Center
751 San Pedro Terrace Road
Pacifica, CA 94044
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 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).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055116
If continuation sheet
Page 6 of 6
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Back to topCitations
11 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0024GeneralS&S Dpotential for harm
Establish policies and procedures for volunteers.
- 0030GeneralS&S Dpotential for harm
List the names and contact information of those in the facility.
- 0041GeneralS&S Epotential for harm
Implement emergency and standby power systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0511GeneralS&S Dpotential for harm
Have properly installed electrical wiring and gas equipment.
FAQ · About this visit
Common questions about this visit
What happened during the May 6, 2021 survey of LINDA MAR CARE CENTER?
This was a inspection survey of LINDA MAR CARE CENTER on May 6, 2021. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LINDA MAR CARE CENTER on May 6, 2021?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.