Health inspection·May 7, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision and interventions for one of three residents ( Resident 1) when: Resident 1, extensive assist with bed mobility per MDS section G, rolled out of bed during incontinent care. This failure resulted in Resident 1 hitting the side of the table and sustained laceration on the forehead. Findings: During a review on 5/7/24 at 10 AM, of admission Record, dated 5/7/24, indicated, admitted to facility on 4/26/23 with diagnoses including: Congestive Heart Failure (a condition in which the heart does not pump as it should), Atrial Fibrillation (an irregular heartbeat that causes heart to beat too quickly), Abnormalities with Gait and Mobility(abnormal walking and movement).Resident discharged to acute 5/10/23. During an interview on 5/7/24 at 10:48 AM, with CNA, per CNA who have worked at facility for 14 years, to prevent falls, put bed on low position, mattress on the floor, read the fall sticker or dot on the patient ' s bed or wheelchair, that indicates patient I s fall risk. Meeting every day at 11 am, they talk about Fall risks patients .involve activities. If patient falls, do not touch the patient till assessed by Licensed Nurse and tells us what to do next. During an interview on 5/7/24 at 11:43AM, with Director of Nursing (DON), per DON, the patient had a fall, unwitnessed fall in the room and nurse found him on the floor at change of shift. Patient admitted on [DATE], had been here before, alert and oriented, more debilitated from last time. admitted for short term rehab, plans to go back to group home. Daughter is emergency contact #1. Per DON, when asked for the report to state agency and Ombudsman, per DON, not reportable, it ' s a minor injury only a laceration. Will know the extent when patient is seen in the hospital. Patient was sent to ER on [DATE]. Per DON, the daughter called her and told her that her dad was sent home from ER with Home Health. Per DON daughter upset with facility for sending him to ER, concerned about ambulance bill. Hearing aid is kept in the medication cart for safe keeping, since it was early, 911 came already, patient left without the hearing aid. No documentation found of reporting incident to state agency and Ombudsman. Review of PT Evaluation and Plan of Treatment dated 4/27/23, Start of Care is 4/27/23, total (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 3 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 05/07/2024 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)