Health inspection·March 13, 2024

F 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 failed to ensure one of 21 shared resident bedrooms (room [ROOM NUMBER]) measured at least 80 square feet (sq ft) per resident, was included on the facility's approved waiver. This failure had the potential for an inadequate space for provision of resident cares. Findings: On 3/5/24 an announced facility visit was conducted to investigate a resident complaint regarding Resident 1 and his facility bedroom size. During a review of Resident 1's medical record it indicated his room was room [ROOM NUMBER]B on 3/11/23. During an interview on 3/5/24 at 10:32 AM with the Director of Staff Development (DSD), she confirmed Resident 1's room was room [ROOM NUMBER]B. She further stated the facility had no known complaints of rooms being too small, even the rooms which have an approved waiver for resident use, measuring under 80 sq ft per resident. During a concurrent observation and interview on 3/5/24 at 10 AM, with the Maintenance Director 1 (MD 1), three beds, 108A, 108B and 108C, were observed. MD 1 stated they had a room waiver for several facility rooms, which he believed included room [ROOM NUMBER]. The Administrator provided a certified document which granted a room waiver dated April 4, 2018, which indicated the following rooms were approved for resident use and measuring under 80 sq ft per resident. The following rooms were included on the approved room waiver: Rooms 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, and 122. room [ROOM NUMBER] was not listed as approved on the waiver. During a concurrent observation and interview at on 3/5/24 at 10:15 AM, MD 1 measured room [ROOM NUMBER]. MD 1 provided the following documented room measurement for room [ROOM NUMBER] which indicated it was under the square footage requirement of 80 square feet per resident. (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: 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 03/13/2024 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)