Health inspection·August 24, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lower strap hanging loose below the chin. When asked, HKS 1 stated he came out from the resident's room. HKS 1 stated he forgot to remove the gown and gloves prior to exiting the resident's room. Review of the facility's Policy and Procedures (P&P), titled, Personal Protective Equipment - Using Gloves, with revision dated 8/2009, the P&P indicated, Objectives: 1. To prevent the spread of infection . Removing Gloves . Discard the glove into the designated waste receptacle inside the room. Review of the facility's Policy and Procedures (P&P), titled, Personal Protective Equipment - Gowns, Aprons, Lab Coats, with revision dated 8/2009, the P&P indicated, .Soiled gowns, aprons, and lab coats must be removed prior to leaving the work area and discarded into the appropriate receptacle located in the work area. Review of the facility's Policy and Procedures (P&P), titled, Infection Control Policy and Procedure Manual Example of Safe Donning and Removal of Personal Protective Equipment (PPE), with revision dated 8/2007, the P&P indicated, DONNING PPE .Mask or Respirator - Secure ties or elastic band at the middle of head and neck .Fit snug to face and below chin . REMOVING PPE - Remove PPE at doorway before leaving patient room or in anteroom. 2. During an interview on 8/21/23, at 3:32 PM, with HKS 1, HKS 1 confirmed he did not wear the N95 respirator correctly. During an interview on 8/24/23, at 10:15 AM, with the facility's Infection Preventionist (IP), IP stated staff should remove personal protective equipment (PPEs) such as gown and gloves before leaving the patient's room. IP also confirmed that staff should wear N95 respirators correctly. Review of the facility's Policy and Procedures (P&P), titled, Infection Control Policy and Procedure Manual Example of Safe Donning and Removal of Personal Protective Equipment (PPE), with revision dated 8/2007, the P&P indicated, DONNING PPE .Mask or Respirator - Secure ties or elastic band at the middle of head and neck .Fit snug to face and below chin . REMOVING PPE - Remove PPE at doorway before leaving patient room or in anteroom. 3. During an observation on 8/21/23, at 11:27 AM, LS 1 came out from an office, on the first floor of the facility, wearing a gown. During an interview on 8/21/23, at 11:28 AM, with LS 1, LS 1 stated she was at the housekeeping office. When asked, LS 1 explained that prior to speaking with her supervisor in the office, she was at the laundry room, in the soiled linen area, and had worn the same gown. LS 1 stated she forgot to take off the gown before leaving the soiled linen area. During an interview on 8/24/23, at 10:25 AM, with the facility's Infection Preventionist (IP), the IP confirmed the laundry staff should have removed the gown in the soiled linen area before going to another location in the facility. IP stated this practice by the staff was not acceptable. Review of the facility's Policy and Procedures (P&P), titled, Personal Protective Equipment - Gowns, Aprons, Lab Coats, with revision dated 8/2009, the P&P indicated, .Soiled gowns, aprons, and lab coats must be removed prior to leaving the work area and discarded into the appropriate receptacle located in the work area. 4. During a concurrent observation and interview on 8/21/23, at 3:34 PM, in the facility's COVID-19 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 2 of 5 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 08/24/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unit, LVN 1 was wearing a surgical face mask. LVN 1 stated she was a full-time employee at the facility and was assigned to residents in the designated COVID-19 unit. When asked, LVN 1 stated she was supposed to wear an N95 respirator and not a surgical face mask. Review of the facility's Policy and Procedures (P&P), titled, Personal Protective Equipment, with revision dated 8/2009, the P&P indicated, .During COVID Outbreak - 4. An N95 mask should be worn in the COVID unit or with COVID positive or suspected patients. 5. During an interview on 8/21/23, at 3:36 PM, with LVN 1, LVN 1 stated she was not fit-tested for an N95 respirator. During an interview on 8/24/23, at 10:08 AM, with the facility's IP, the IP stated that it was communicated to the staff that they must wear an N95 respirator before coming into the building. IP stated this was the expectation and practice with the COVID-19 outbreak at the facility. When asked about the facility's policy on N95 respirator fit test, IP stated nurses should be fit-tested on N95 respirators. Review of the facility's Policy and Procedures (P&P), titled, Fit Testing Employees, with revision dated 11/30/20, the P&P indicated, .Process . Medically evaluate each employee before that employee is fit tested . Provide instruction on the uses and limitations of all respirators worn in the work area . Instruct and demonstrate to employees how to properly don and adjust any respirators worn according to the manufacturers' instructions. Allow the employees an opportunity to practice these procedures. Provide user seal check instructions . Fit test each employee to be assigned a respirator. Document the successful completion of training and fit testing for all employees wearing respirators . After the initial fit test, fit tests must be completed at least annually, or more frequently if there is a change in status of the wearer or if the employer changes model or type of respiratory protection. 6. During a concurrent observation and interview on 8/21/23, at 11:16 AM, with Staff 1 (S1), S1 stated she was assigned with screening of visitors for COVID-19 at the facility. S1 was noted wearing a disposable face mask that had elastic ear loops. S1 stated she was aware that all staff were required to wear N95 respirators, and that this practice started several weeks ago with the COVID-19 outbreak at the facility. When asked, S1 stated she was not sure if the face mask she wore was an N95 respirator. S1 confirmed she was wearing a KN95 face mask. During a concurrent observation and interview on 8/21/23, at 12:24 PM, with Staff 2 (S2), S2 confirmed she was assigned to work with residents, at the third floor of the facility. S2 was noted wearing a disposable face mask that had elastic ear loops. When asked, S2 stated she was wearing a KN95 face mask. S2 explained she was under the impression that it was okay to wear a KN95 face mask at the facility. During an interview on 8/24/23 at 9:56 AM, with the facility's Infection Preventionist (IP), IP stated that as recommended by the county public health office, all staff must wear an N95 respirator during COVID-19 outbreak at the facility. IP stated the facility had a COVID-19 outbreak on 8/7/23 and had continued at present. IP stated staff were supposed to wear N95 respirators during COVID-19 outbreak at the facility. IP also stated that it was communicated to the staff that they must wear an N95 respirator before coming into the building. IP stated this was the expectation and practice with the COVID-19 outbreak at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 3 of 5 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 08/24/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7. During an observation on 8/21/23 at 12:11 PM, with Staff 2 (S2) present, Resident 1 was in bed and wore a nasal cannula that was attached to an oxygen source. S2 stated she did not know when the nasal cannula was replaced. S2 confirmed the nasal cannula had no label indicating when it was initially used or date of replacement. During an observation on 8/21/23 at 10:30 AM, in Resident 21's room, Resident 21 was receiving oxygen therapy via nasal cannula, with use of emergency tank running at 1L/min. Oxygen cannula has no label. During an interview on 8/21/23 at 10:30 AM of Resident 21, Resident 21 stated, I dont know why they put this oxygen on me. I never had it before. During a review of facility admission Record, dated 8/24/23, the admission record indicated Resident 21 was admitted on [DATE] with admitting diagnoses including: Spinal Stenosis, Other Displaced Fracture of Upper End of Left Humerus. During a review of Physician Orders, dated 8/9/23, indicated, O2 at 1-2 L/min via nasal cannula for desaturation below 90%. During a review of Care plan undated, indicated, administer oxygen 1-2 L/min via nc as needed for SOB desat less then 90%. No issues with care plan. During an interview on 8/24/23 at 10:22 AM, with the facility's Infection Preventionist (IP), IP explained that either the licensed nurses or certified nursing assistants had to label the resident's nasal cannula with the date it was initially placed or used by the resident. IP stated nasal cannulas were to be replaced once a week, or as needed, such as when soiled. During a review of undated facility's Patient Care Policies, Use of Oxygen indicated, Purpose: to promote safety in administering oxygen. A. The O2 cannula or mask does not require scheduled changing when used on one patient. It should be changed when soiled or dirty. I. Change the O2 tubing every 7 days. 8. During an observation of Staff 3 (S3), on 8/21/23 at 10:45 AM, Staff 3, came out of a resident's room, carrying a resident's gown, with ungloved hand, dumped gown in dirty linen room. No hand hygiene observed. During an interview on 8/21/23 at 10:45 AM with Staff 3, Staff 3 stated, I know I was supposed to place in plastic bag, the used gown, but I did not tie it. I helped the patient change gown. Staff 1 left. During an interview on 8/21/23 at 10:48 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated, I go into the room and do patient care, change linens. All dirty linens go into a plastic bag, I take to the dirty linen room. During an Interview on 8/21/23 at 11:50 AM with CNA 2, CNA 2 stated, everyday I bring plastic bags to the room, put dirty linens in the plastic bag and carry it out to the dirty linen room. For patient's own clothes, there is a separate laundry bag in their room. During a review of facility's Policy and Procedure, Laundry and Bedding, Soiled, dated 7/2009, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 4 of 5 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 08/24/2023 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated, Policy statement, Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. Policy 1. Soiled laundry and beddings .must be handled as little as possible with a minimum of agitation. 2. Place contaminated laundry in a bag or container at the location where it is used and do not sort .3. Place and transport contaminated laundry in bags or containers in accordance with .disposal of contaminated items. 4.Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment . During a review of the facility's Policy and Procedures (P&P), titled, Infection Control Policy and Procedure Manual - Example of Safe Donning and Removal of Personal Protective Equipment (PPE), with revision dated 8/2007, the P&P indicated, REMOVING PPE . HAND HYGIENE - Perform hand hygiene immediately after removing all PPE. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 5 of 5