Health inspection·September 13, 2019

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review, the facility failed to accommodate the needs of Residents 45, 120, and 121, three of 18 sampled residents, when they had to wait 15 - 30 minutes for the nurse call lights to be answered by staff. Residents Affected - Few This failure resulted in not meeting the needs of the residents. Findings: 1. Resident 45 was admitted to the facility with diagnoses including difficulty walking, muscle weakness, pressure ulcers on both heels, and depression. The resident's Minimum Data Set (MDS), an assessment tool, indicated some knowledge difficulties, no difficulties understanding or being understood, required a wheelchair/walker for mobility, and two person staff assist for transfer to bed/chair and bed positioning. During an interview on 9/9/19, at 9:35 AM, accompanied by Activity Director, Resident 45 was seated in his wheel chair in his two bed room and stated his call lights take 15 - 30 minutes for staff to answer and sometimes, they (staff) hang up on me. The resident stated he needs help to use the bathroom and had one or two accidents because staff did not come in time to help him. He stated he told Certified Nurse Aide 1 (CNA) on day shift (7-3 PM shift). But it hasn't gotten any better. He said this happens all the time on the evening shift (3-11 PM). During an interview on 9/9/19, at 10:45 AM, CNA 1 stated Resident 45 had complained about long waits for help on evening shift and had informed Administrator. During an interview on 9/10/19, at 12:35 PM, the Administrator knew of resident's complaints about slow responses to call lights on evening shift. He discussed the matter with staff. He expected an improvement. During an observation of the call light system on 9/9/19, at 2:10 PM, this surveyor stood in front of the nurses station next to Receptionist 1. Resident 45 put his call light on. Receptionist 1 answered the call light, on interoffice phone, replied quickly and unclear, and hung up. She did not wait to hear resident's response. The resident could not hear the receptionist's reply. 2. Resident 120 was admitted to the facility with diagnoses including intestinal surgery, anemia, kidney disease, muscle weakness, gait abnormalities (unsteady walking), and mobility issues. The residents Minimum Data Set (MDS), an assessment tool, indicated minimal knowledge difficulties, no difficulties understanding or being understood, required wheelchair or walker for mobility and one person staff assist for transfer to bed/chair. (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: 056205 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 056205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Nursing and Rehabilitation Center 385 Esplanade Avenue 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)