Inspection·January 27, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/27/25 at 9:36 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Yes when asked if Resident 143 was deaf in his right ear. She stated, I was speaking to his left ear, when asked how she communicated with Resident 143. During a concurrent interview and record review on 1/27/25 at 9:37 a.m., with LVN 1, Resident 143's document titled, admission Summary dated 1/3/25 and Medical Visit 2.0 - V2 (doctor's note) dated 1/4/25 were reviewed. The admission summary indicated, . States hard of hearing to right ear due to ear wax build up . The doctor's note indicated, . decreased hearing r (right) cerumen . (earwax) . LVN 1 stated, Resident 143 had earwax in his right ear, and that's why Resident 143 had the hearing issue after reviewing the documents. LVN 1 stated, No care plan before the 24th (of January 2025) . when asked about Resident 143's care plan regarding his hearing loss in his right ear. During an interview on 1/27/25 at 9:56 a.m., with Director of Nursing (DON), DON acknowledged, they had updated Resident 143's care plan after this surveyor found that there was no care plan for Resident 143's hearing issue in his right ear on 1/24/25. DON stated, There was no care plan for communication when asked again if there was care plan until 1/24/25. DON stated, they irrigated Resident 143's right ear, then he stated that his hearing was ok, then he told DON that morning that his right ear was still bothering him. DON stated, SSD still needed to arrange Resident 143 with an ENT doctor. During an interview on 1/27/25 at 10:07 a.m., with SSD, SSD stated, she referred Resident 143 to the ENT on 1/24/25 after she was interviewed by this surveyor. SSD stated, the ENT doctor's office confirmed that they received the referral, so she would follow up to schedule an appointment for Resident 143. Review of the facility's policy and procedure (P&P) titled, ADMINISTRATIVE MANUAL revised in July 2024 indicated, . 1. Social services includes items such as . c. Arranging ancillary (providing necessary support to the primary activities or operation of an organization, institution, industry, or system) services that residents need such as . hearing . services . 3. Factors that have a potentially negative effect on psychosocial functioning include . d. Disability or loss of function . 4. Social services staff will be responsible for coordinating resident referrals to outside agencies . Review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered revised in February 2024 indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055116 If continuation sheet Page 2 of 9 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 01/27/2025 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview, and record review, the facility failed to ensure the Certified Dietary Manager (CDM), the position responsible for supervision of daily food service operations, was fully qualified when he did not have a dietetics manager's certification prior to assuming his full-time duty at the facility. This failure was likely to result in inadequate supervision of the dietary department for 42 residents who ate food from the kitchen out of a census of 42. Findings: State of California Health and Safety Code 1265.4(b)(4) describes the required qualifications for the full-time Dietetic Service Supervisor (DSS). The Statue indicates a DSS shall have completed dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, and maintains this certification prior to assuming full-time duties as a dietetic services supervisor at the health facility. During an interview on 1/21/25 at 9:28 a.m., with Dietary Manager (DM), DM introduced himself as a dietary manager. During a concurrent interview and record review on 1/23/25 at 10:37 a.m., with DM, DM did not provide evidence of a credential (a qualification such as certification) for certified dietary manager (CDM) when asked. DM instead provided a letter from University of OOOOO (name of the university) The letter indicated, . This letter serves as confirmation that ****** (DM's name) successfully completed the University of OOOOO (name of the university)'s Dietary Manager Course. The dates of enrollment were 4/17/2023 1/14/2025. The Dietary Manager Course provided 120 hours of classroom education and 150 hours of filed work for a total of 270 contact hours . DM stated, Currently no when asked if he has the credential for CDM. DM stated, he needs to take a final test to get the CDM certification. DM stated, he started his role full time on 5/23/24, almost 8 months ago. DM stated, he was the facility's cook before becoming the dietary manager. During an interview on 1/23/25 at 11:00 a.m., with Registered Dietitian (RD), RD stated, she works full time for the cooperation and part time for the facility. RD stated, she was precepting DM. RD stated, there is also another RD. RD stated, she or another RD visits to the facility at least twice a week. During an interview on 1/23/25 at 12:36 p.m., with RD, RD stated, DM needs to be approved by Association of food and nutrition professionals before he applies for the exam to get his CDM certificate. During an interview on 1/23/25 at 4:15 p.m., with Administrator (ADM), ADM stated, He is not the kitchen manager, when asked about DM. ADM stated, DM was the dietary supervisor. ADM acknowledged, the facility did not have a certified dietary manager at this time. Review of the facility's document titled, Lindar Mar Care Center Organization Chart undated indicated, Registered Dietitian is under ADM and supervises the director of dietary services. The organization chart also indicated, the dietary manager was under the director of dietary services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055116 If continuation sheet Page 3 of 9 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 01/27/2025 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Review of DM's JOB DESCRIPTION dated 5/23/24 indicated, JOB TITLE: Dietary Manager . The Dietary Manager assists the Dietary Director with the planning, organizing, and day-to-day operations of the Dietary Department and food services within the facility in accordance with current federal, state, and local standards, guidelines, and regulations. The Dietary Manager ensures that quality dietary services are provided daily, and that the dietary department is maintained in a clean, safe, and sanitary manner . Collaborates with Dietitian . Supervises, trains, and schedules dietary personnel to maintain sufficient and competent dietary department . The job description indicated, it was signed by ADM and DM on 5/23/24. Event ID: Facility ID: 055116 If continuation sheet Page 4 of 9 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 01/27/2025 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 Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary condition was met for food storage in the kitchen when there was one pack of expired frankfurters (a seasoned smoked sausage made of beef and pork) in the freezer. This failure was likely to result in putting a resident at risk for foodborne illnesses. Findings: During a concurrent observation and interview on 1/21/25 at 10:03 AM with Dietary Manager (DM) in the kitchen, there was one pack of frankfurters with date of 11/11/24 in the freezer. DM stated, the pack was received on 11/11/24 when asked what the date meant. DM stated, 1-2 months would be okay when asked how long it would be safe to store it in the freezer. DM stated, Yes when asked if the frankfurters were expired. Review of the facility's document titled, Food Storage Chart -Frozen Foods dated 2023 indicated, the recommended storage time for frozen frankfurters was for 1-2 months. The Federal Food Code 2022 describes foodborne illness. The Food Code indicates, . Foodborne illness in the United States is a major cause of personal distress, preventable illness and death . Most foodborne illnesses occur in persons who are not part of recognized outbreaks. For many victims, foodborne illness results only in discomfort or lost time from the job. For some, especially . older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening . Epidemiological (relating to the branch of medicine which deals with the incidence, distribution, and control of diseases) outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in . food service establishments as contributing to foodborne illness: . Improper holding temperatures, . Inadequate cooking, such as undercooking raw shell eggs, . Contaminated equipment, . Food from unsafe sources, and . Poor personal hygiene . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055116 If continuation sheet Page 5 of 9 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 01/27/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to accurately assess one out of two sampled resident's (Resident 32) primary language. Residents Affected - Few This failure has the potential for a resident to not meet their highest practicable physical, functional, mental, and psychosocial well-being due to a language barrier. Findings: A review of Resident 32's face sheet (front page of the chart that contains a summary of basic information about the resident), dated 01/24/25, indicated that Resident 32's primary language is English. During an interview on 01/22/25 at 9:56 a.m., with Resident 32, Resident 32 stated that she speaks primarily Spanish and that she is happy with staff but they often don't use a translator to speak to her. During an interview on 01/23/25 at 10:07 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated that she can communicate with Resident 32 because I speak Spanish so she explains things and talks to Resident 32 in Spanish. During an interview on 01/24/25 at 2:27 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that she communicates with Resident 32 verbally in English .for the basic things but will get someone to translate for more complex assessments or needs. During a concurrent interview and record review on 01/24/25 at 2:39 p.m., with LVN 2, Resident 32's care plan for impaired communication, initiated on 03/07/24, was reviewed. The care plan indicated that Resident 32's IMPAIRED COMMUNICATION was MANIFESTED BY .[RESIDENT 32] DOES NOT COMMUNICATE IN FACILITIY'S PRIMARY-LANGUAGE - SPANISH-SPEAKER. LVN 2 stated that Resident 32 speaks Spanish. During a concurrent interview and record review on 01/24/25 at 4:29 p.m., with the Director of Nursing (DON), Resident 32's Quarterly Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/13/24, was reviewed. The Quarterly MDS indicated that Resident 32's preferred language is English. The DON stated that this is an accurate assessment of Resident 32's language preference. During a concurrent interview and record review on 01/24/25 at 4:29 p.m., with the DON, Resident 32's care plan for impaired communication, initiated on 03/07/24, was reviewed. The care plan indicated that Resident 32's IMPAIRED COMMUNICATION was MANIFESTED BY .[RESIDENT 32] DOES NOT COMMUNICATE IN FACILITIY'S PRIMARY-LANGUAGE - SPANISH-SPEAKER. The DON stated that this was inaccurately documented if you update it for today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055116 If continuation sheet Page 6 of 9 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 01/27/2025 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review, facility failed to ensure that the resident or the resident representative was provided education about the benefits, risks, and potential side effects associated with the COVID-19 (an infectious virus) vaccine in 4 out of 5 sampled residents (Resident 16, 12, 142 and 92) This failure has the potential for residents to accept vaccination without fully informed consent or decline vaccination due to a lack of knowledge about the COVID-19 vaccine. Findings: A review of facility policy and procedure (P&P) titled, Corona Virus Disease (COVID-19) - Vaccination of Residents, last revised 05/2023, indicated that COVID-19 vaccine education, documentation, and reporting are overseen by the infection preventionist and coordinated by his or her designee .Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine .The resident's medical record includes documentation that indicates, at a minimum, the following: a. That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine, including: (1) samples of the educational materials used; (2) the date the education took place; and (3) the name of the individual who received the education . A review of Resident 12's electronic COVID-19 Immunization record, dated 09/24/24, indicated an answer of no for the section education provided. During a concurrent interview and record review on 01/24/25 at 1:07 p.m., with the Infection Preventionist (IP), Resident 12's consent form, titled Consent for COVID-19 Vaccine, dated 09/24/24, was reviewed. The consent form indicated that Resident 12's Responsible Party (RP, person responsible for making health care decisions when the resident is unable to make said health care decisions for themselves) declined COVID-19 vaccination. The consent form further indicated that the section indicating Yes, I have been educated and provided with and have had sufficient opportunity to review the COVID-19 'FACT SHEET' which includes information about the COVID-19 disease the vaccine I am being offered . was unchecked. The IP stated that the line that education was provided should be checked regardless of if the Resident or RP consented to or declined vaccination. A review of Resident 16's electronic COVID-19 Immunization record, dated 12/23/24, indicated an answer of no for the section education provided. During a concurrent interview and record review 01/24/25 at 1:15 p.m., with the IP, Resident 16's consent form, titled Consent for COVID-19 Vaccine, dated 12/20/24, was reviewed. The consent form indicated that Resident 16 declined the COVID-19 vaccination. The consent form further indicated that the section indicating Yes, I have been educated and provided with and have had sufficient opportunity to review the COVID-19 'FACT SHEET' which includes information about the COVID-19 disease the vaccine I am being offered . was unchecked. The IP stated that since line is unchecked, I don't know if they did it [the education]?. A review of Resident 142's electronic COVID-19 Immunization record, dated 01/14/25, indicated an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055116 If continuation sheet Page 7 of 9 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 01/27/2025 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 0887 answer of no for the section education provided. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review 01/24/25 at 1:11 p.m., with the IP, Resident 142's consent form, titled Consent for COVID-19 Vaccine, dated 01/11/25, was reviewed. The consent form indicated that Resident 142 declined the COVID-19 vaccination. The consent form further indicated that the section indicating Yes, I have been educated and provided with and have had sufficient opportunity to review the COVID-19 'FACT SHEET' which includes information about the COVID-19 disease the vaccine I am being offered . was unchecked. The IP stated that that section should be checked. Residents Affected - Some A review of Resident 92's electronic COVID-19 Immunization record, dated 01/16/25, indicated an answer of no for the section education provided. During a concurrent interview and record review 01/24/25 at 1:22 p.m., with the IP, Resident 92's consent form, titled Consent for COVID-19 Vaccine, dated 01/15/25, was reviewed. The consent form indicated that Resident 92 declined the COVID-19 vaccination. The consent form further indicated that the section indicating Yes, I have been educated and provided with and have had sufficient opportunity to review the COVID-19 'FACT SHEET' which includes information about the COVID-19 disease the vaccine I am being offered . was unchecked. The IP stated that this form is indicative that education was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055116 If continuation sheet Page 8 of 9 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 01/27/2025 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 - Some 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 at least 80 square feet of living space per resident (sq ft/resident) for 14 of 21 bedrooms (Rooms 108, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121 and 122). This failure has the potential for residents to not to have enough appropriate space for the provision of care or daily living. Findings: A review of facility-submitted entrance documents (documents provided by the facility as part of their re-certification), titled Does not meet requirement for 80ft, undated, indicated that the following rooms do not meet the square footage requirement of 80 sq ft/resident, Rooms #108, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #121 and #122. During an interview on 01/27/25 at 9:07 a.m., with Resident 18 in room [ROOM NUMBER], Resident 18 was asked how the space was in their room. Resident 18 stated, it's okay During an observation on 01/27/25 at 9:08 a.m., in room [ROOM NUMBER], Resident 3 was observed able to propel themself in their wheelchair from inside the room to the corridor independently without issue. During an interview on 01/27/25 at 9:15 a.m., with Resident 16 in room [ROOM NUMBER], Resident 16 was asked about his room. Resident 16 stated it's great and his belongings fits just right. Resident 16 stated that everything fits good and he denied any issues with his room size. During a concurrent observation and interview on 01/27/25 at 9:22 a.m., with Resident 9, in room [ROOM NUMBER], Resident 9 was observed independently propelling self in their wheelchair into the room and reposition at the side of their bed. Resident 9 stated that his wheelchair can fit in and out of the room fine. During a concurrent observation and interview on 01/27/25 at 12:05 p.m., with the Director of Maintenance (DOM), in room [ROOM NUMBER], the DOM was observed measuring the room with a tape measure. The DOM stated the room measured at about 18.25 feet by 13 feet. With three resident beds, this room provided about 79.08 sq ft/resident. During a concurrent observation and interview on 01/27/25 at 12:07 p.m., with the DOM, in room [ROOM NUMBER], the DOM was observed measuring the room with a tape measure. The DOM stated the room measured at about 18.5 feet by 12.75 feet. With three resident beds, this room provided about 78.63 sq ft/resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055116 If continuation sheet Page 9 of 9