Health inspection·November 8, 2023

F 0550 covered when they are moved down the hallway. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/08/2023 at 1:10 PM, the Director of Nursing (DON) stated staff should transfer the resident into the shower chair, make sure they are fully covered with no exposed skin, and push them down the hallway to the shower room. The DON said residents' dignity should always be respected. Residents Affected - Few During an interview on 11/08/2023 at 1:39 PM, the Administrator stated every resident should be treated with dignity. The Administrator stated she expected residents to be fully covered when being transported to the shower room. During an interview on 11/08/2023 at 2:51 PM, Resident #196 stated they thought CNA #4 made sure they were covered. Resident #196 reported they did not want to be going down the hall with their unclothed body exposed. 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 11/08/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interviews, record review, and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) for 1 (Resident #96) of 12 sampled residents. Specifically, Resident #96's MDS did not indicate the resident received hospice care. Residents Affected - Few Findings included: A review of a facility policy titled, Comprehensive Assessments and the Care Delivery Process, revised in February 2023, revealed, Comprehensive assessments will be conducted to assist in developing person-centered care plans. The policy specified, 1. Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. 2. Assessment and information collection includes. The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about a patient. A review of Resident #96's admission Record revealed the facility most recently admitted Resident #96 on 08/07/2023 with diagnoses that included pneumonia and Alzheimer's disease. A review of Resident #96's Order Summary Report, with active orders as of 11/08/2023, revealed an order dated 08/31/2023, which indicated Resident #96 was admitted to hospice services. Review of Resident #96's care plan initiated on 09/01/2023, indicated the resident was admitted to hospice services due to a terminal diagnosis of Alzheimer's disease. A review of Resident #96's significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/07/2023, revealed Resident #96 did not receive hospice care. During an interview on 11/08/2023 at 1:06 PM, the Director of Nursing (DON) acknowledged she signed off on the accuracy of the MDS assessments, and she expected them to be accurate. The DON stated the importance of accurate MDS assessments was that they were used to determine the focused care areas for the residents. According to the DON, she reviewed Resident #96's assessment and missed coding that resident received hospice care. During an interview on 11/08/2023 at 2:00 PM, the Administrator stated she expected MDS assessments to be accurate. Per the Administrator, the MDS assessment information was used to develop appropriate care plans to provide specific care to the residents. 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 11/08/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review, interviews, and facility policy review, the facility failed to maintain records of ongoing communication with a dialysis clinic for 1 (Resident #39) of 1 sampled resident reviewed for dialysis. Residents Affected - Few Findings included: A review of the facility policy titled, Dialysis care, revised 05/11/2023, revealed, Purpose To provide care guidelines for the resident who receives dialysis at another facility. Policy This facility assures that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice including the: - Arrangement for safe transportation to and from the dialysis facility; - Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility; and - Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The policy indicated 7. Maintain the dialysis transfer form in the resident's medical record. A review of Resident #39's admission Record revealed the facility admitted the resident on 10/08/2023 with diagnoses that included end-stage renal disease (ESRD) and dependence on renal dialysis. A review of Resident #39's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/2023, revealed Resident #39 received dialysis while a resident of the facility. A review of Resident #39's care plan initiated on 10/11/2023, indicated the resident had regular ongoing hemodialysis sessions due to a diagnosis of ESRD. Interventions directed staff to maintain communication between the facility and dialysis center to ensure the resident's needs were met and continuity of care was provided. A review of Progress Notes from Resident #39's dialysis provider revealed the resident received dialysis on the following dates: 10/11/2023, 10/13/2023, 10/16/2023, 10/20/2023, 10/23/2023, 10/25/2023, 10/27/2023, 10/30/2023, 11/01/2023, 11/03/2023, and 11/06/2023. During an interview on 11/08/2023 at 9:15 AM, the Administrator said they were only able to locate four of Resident #39's dialysis communication forms and did not know what happened to the rest. The Administrator stated Licensed Vocational Nurse (LVN) #1 reported she gave the forms to whoever sat at the front desk when the resident returned from dialysis, but they did not know what happened to the forms after that. During an interview on 11/08/2023 at 9:48 AM, Receptionist #5 said she left work around 4:30 PM every day, so most days she just missed Resident #39 when they came back from their dialysis appointments. Receptionist #5 said the nurses filled out their portion of the forms, then returned them to her so she could file them in the dialysis folder. During a telephone interview on 11/08/2023 at 11:33 AM, a dialysis staff stated Resident #39 came to the dialysis clinic with an envelope. Per the dialysis staff, the nursing facility staff filled out the top portion, and the dialysis clinic filled out the middle section of the form and sent the form back to the facility. According to the dialysis staff, the dialysis clinic did not keep copies of the forms. (continued on next page) 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 11/08/2023 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a telephone interview on 11/08/2023 at 12:52 PM, Registered Nurse (RN) #6 stated Resident #39 brought the dialysis communication forms back when they returned from dialysis, and she filled out the bottom portion of the form after assessment of the resident. RN #6 said once she filled out her portion, she gave the form to the receptionist to place in the dialysis folder. During an interview on 11/08/2023 at 1:10 PM, the Director of Nursing (DON) stated that when a resident went to dialysis, facility staff filled out the top portion of the dialysis communication form and sent it with the resident. Per the DON, while the resident was at dialysis, dialysis staff completed the middle section of the form, and when the resident returned to the facility, the receiving nurse filled out the lower section of the form. The DON said the receiving nurse should return the form to the receptionist to file in the dialysis folder. The DON acknowledged they were unable to locate all of Resident #39's dialysis communication forms. During an interview on 11/08/2023 at 1:39 PM, the Administrator stated she expected staff to maintain any communication between the dialysis provider and the facility. 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 A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and facility policy review, the facility failed to implement the Legionella (a bacteria found naturally in [NAME] environments that could cause health concerns when it grew and spread in a building water systems) Water Management Program to prevent, detect, and control the spread of Legionnaire's disease (a form of atypical pneumonia caused by the bacteria Legionella; signs and symptoms usually include cough, shortness of breath, high fever, muscle pain, and headaches). This had the potential to affect 44 of 44 residents who resided in the facility. Residents Affected - Many Findings included: A review of a facility policy titled, Legionella Water Management Program, revised in July 2017, revealed, Policy Statement Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The policy indicated 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. During an interview on 11/08/2023 at 2:49 PM, the Administrator said the facility had a Water Management Program, but it had not been implemented. She indicated she ordered the testing kit on 11/08/2023 and it should be delivered on 11/09/2023. She said her expectation was that the Water Management Program be implemented to identify areas in the water system where Legionella could grow and spread and to reduce the risk of Legionnaire's disease. During an interview on 11/08/2023 at 2:54 PM, the Director of Nursing (DON) said she was not aware the facility's Water Management Program had not been implemented. She indicated her expectation was that the Water Management Program be implemented to ensure the facility identified areas in the water system that may encourage the growth of Legionella. During an interview on 11/08/2023 at 3:55 PM, the Maintenance Director stated the facility had never implemented the Water Management Program. He indicated he was made aware that there was a program after the Administrator went over it with him this week and told him that a testing kit had been ordered and should arrive on 11/09/2023. He also indicated he still needed to talk to the Administrator about what else he needed to do to fully develop and implement the program once the testing kit arrived. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055116 If continuation sheet Page 6 of 6