Health inspection·June 4, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's Daily Skilled Note (DSN), dated 9/1/23 at 9:50 AM was reviewed. The DSN indicated, . Patient C/O (complained of) some discomfort to the skin on R (right) side of the chest and stated that he did not want to wear his neck collar because it feels like something is poking him there when he wears it. Small raised area with redness noted, but skin was otherwise intact with no open areas noted. Placed padded dressing to cover for comfort and neck brace was reapplied . RN 1 stated, the small raised area with redness seemed like the bump which was mentioned in Complaint's email, when asked. During a concurrent interview and record Review on 5/10/24 at 11:30 AM with Registered Nurse (RN) 1, Resident 1's Daily Skilled Note (DSN) dated 9/9/23 at 7:23 PM, and the pictures dated 9/6/23 and 9/20/23 which were sent by the complainant on 2/29/24 via email were reviewed. The DSN indicated, . No active symptoms effecting the Integumentary system observed . RN 1 acknowledged the redness of Resident 1's right chest in the pictures were new onset of redness when asked. The DSN also indicated that the same statement was documented on the following dates: 1) 9/8/23; 2) 9/10/23; 3) 9/12/23; 4) 9/13/23; 5) 9/14/23; 6) 9/15/23; 7) 9/17/23; 8) 9/19/23 without additional documentation. She acknowledged the statements were not accurate assessment when asked. She stated, They should write as an additional . when asked what to do with the redness in the nursing documentation titled, Daily Skilled Note. During a concurrent interview and record review on 5/10/24 at 1:19 PM with RN 1, the doctor's progress notes (PN), dated 8/28/23 reviewed. The PN indicated, . Keflex (One of antibiotics, a drug used to treat infections caused by bacteria and other microorganisms) 500mg (milligram) every 8 hours until September 1 . UA (urinalysis, a test of your urine) on August 20 showed pyuria (the presence of pus in the urine, typically from bacterial infection) but urine culture (a lab test to check for bacteria or other germs in a urine sample) negative (the urine sample showed no signs of bacteria or yeast) . pain control for drainage from right hip 10 days of antibiotics currently on Keflex . RN 1 stated, Resident 1 already had an infection in his right hip before his admission to the facility, so the antibiotic was already started from the hospital. During a concurrent interview and record review on 6/4/24 at 1:58 PM with RN 1, Resident 1's pictures dated 9/1/23, 9/6/23 and 9/20/23 which were sent by Complainant on 5/14/24 were reviewed. RN 1 acknowledged the small raised area of his right chest in the pictures looked red. During a concurrent interview and record review on 6/4/24 at 2:10 PM with RN 1, the facility's policy and procedure (P&P) titled, Charting and Documentation undated was reviewed. The P&P indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record . 6. To ensure consistency in charting and documentation of the resident's clinical record . RN 1 stated, there should be consistency for the accuracy of the skin documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 2 of 4 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 06/04/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 5 sampled residents (Resident 1) receive care in accordance with professional standards of practice when there was no evidence that the facility monitored a small raised area with redness on the right side of the chest from PM shift on 9/1/23 to PM shift on 9/5/23. Residents Affected - Few This failure had the potential to delay identifying symptoms of infection. Findings: Review of Resident 1's clinical record indicated, Resident 1 was admitted on [DATE] (Saturday) for rehab after his hospital stay from 8/12/23 to 8/26/23 due to his fall. He was diagnosed with multiple fractures including displaced intertrochanteric fracture of right femur (a type of broken hip), nondisplaced type II dens fracture (a type of a crack or break in the bone but retains its proper alignment- positioning), and other fracture of first, second, and third lumbar vertebra (types of broken lower back). Then he was discharged to XXXXX (a hospital name) on 9/20/23 after vomiting blood. He had had Left Ventricular Assist Device (LVAD, a device to help the heart pump blood effectively for patients who have reached end-stage heart failure in which the heart does not pump blood as well as it should) since 2021. Review of Resident 1's death certificate, dated 10/11/23, indicated, his date of death was 9/23/23 with the causes of death with (A) Sepsis (a life-threatening complication of an infection) (B) Left Ventricular Assist Device Infection (C) Ischemic Cardiomyopathy (heart muscle can't pump well because of damage from a lack of blood supply to the muscle). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 8/31/23, indicated, Resident 1 was cognitively intact. Review of an email from Complainant, dated 2/29/24 indicated, . On September 1, 2023, **** (Resident 1's daughter's name) visited her father . He immediately informed her of a bump on his chest that was causing him severe pain, aggravated by a protruding (sticking out) wire in the neck collar (known as a neck brace or cervical collar which is an instrument used to support the neck and spine and limit head movement after an injury) he was wearing. Before **** (Resident 1's daughter's name) left that morning, she brought this issue to . nurse's attention and was assured that she would take care of it. ***** (Resident 1's daughter's name) called Pacifica several times in the days that followed, asking staff to please address the issue as ##### (Resident 1's name) was still in pain . During a concurrent interview and record review on 3/6/24 at 3:04 PM with Registered Nurse (RN) 1, Resident 1's Daily Skilled Note (DSN), dated 9/1/23 at 9:50 AM was reviewed. The DSN indicated, . Patient C/O (complained of) some discomfort to the skin on R (right) side of the chest and stated that he did not want to wear his neck collar because it feels like something is poking him there when he wears it. Small raised area with redness noted, but skin was otherwise intact with no open areas noted. Placed padded dressing to cover for comfort and neck brace was reapplied . RN 1 stated, the small raised area with redness in the DSN seemed like the bump which was mentioned in Complaint's email, when asked. During an interview on 5/10/24 at 10:38 AM with RN 1, RN 1 stated, It can be anything . an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 3 of 4 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 06/04/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few irritation . when asked what the small raised area with redness in the DSN dated 9/1/23 at 9:50 AM, meant. RN 1 stated, Redness, drainage, fever, warm to touch when asked about signs and symptoms of infection. She acknowledged, the redness can be a sign and symptom of infection. She stated, That's why we called the doctor. She stated, nurses should monitor the redness every shift per the standard of nursing practice. She stated, . I don't see any specific monitoring from September 1st (in 2023) to September 5th (in 2023) when asked if there was evidence of monitoring the small raised area with redness on the right chest in September 2023. She verified again, there was no monitoring for the redness from PM shift on 9/1/23 to PM shift on 9/5/23 when asked again. During a concurrent interview and record review on 5/10/24 at 1:19 PM with RN 1, the doctor's progress notes (PN), dated 8/28/23 reviewed. The PN indicated, . Keflex (One of antibiotics, a drug used to treat infections caused by bacteria and other microorganisms) 500mg (milligram) every 8 hours until September 1 . UA (urinalysis, a test of your urine) on August 20 showed pyuria (the presence of pus in the urine, typically from bacterial infection) but urine culture (a lab test to check for bacteria or other germs in a urine sample) negative (the urine sample showed no signs of bacteria or yeast) . pain control for drainage from right hip 10 days of antibiotics currently on Keflex . RN 1 stated, Resident 1 already had an infection in his right hip before his admission to the facility, so the antibiotic was already started from the hospital. During a concurrent interview and record review on 6/4/24 at 1:58 PM with RN 1, the facility's policy and procedure (P&P) titled, Charting and Documentation undated was reviewed. The P&P indicated, . 2. The following information is to be documented in the resident medical record . d. Changes in the resident's condition . RN 1 stated, the redness corresponds to the change of condition. Review of the facility's P&P titled, Significant Change in Condition, Response dated January 2022, indicated, . It is the policy of this facility to ensure each resident received quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being . Change in medical condition . 2. The Nurse will perform and document an assessment of the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 4 of 4