Health inspection·November 22, 2024

F 0658 Administration Procedures- IIB13: Transdermal Drug Delivery System (Patch) Application, dated October 2019, indicated, G. Label patch with date and nurse's initials, H. Apply new patch firmly against skin. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 2 of 6 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 11/22/2024 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident's discharge summary (provides necessary information to continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plans for care after discharge) included an accurate recapitulation of stay (a concise summary of the resident's stay and course of treatment in the facility) and reconciliation of medications (a process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use) for one of three sampled residents (Resident 1). This failure may result in residents to not receive continuous and coordinated, person-centered care; and may place residents at risk for harm due to inaccuracies in medication. Findings: Review of Resident 1's admission record indicated, was admitted on [DATE] with diagnoses including displaced fracture of lateral condyle of the left tibia (a break in the bone on the outside of the shin, near the knee, that occurs due to trauma like a fall or direct blow to the leg); fracture of upper and lower end of left fibula (a break in the bone caused by a traumatic injury such as a fall, rolling your ankle, or direct blow to the leg); abnormalities of gait and mobility (any deviation from a normal walking pattern); need for assistance with personal care; pain in right hip; unspecified neuralgia (a severe, sharp, shock-like pain that follows the path of a nerve) and neuritis (nerve inflammation). Review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/6/24, indicated, Resident 1 had no cognitive impairment. During an interview on 10/7/24 at 12:50 p.m., Resident 1 stated that she was discharged from the facility on 8/15/24 and received a discharge summary that contained information not pertaining to her. Resident 1 added, her discharge summary indicated status and history of hypertension and falling, and fracture of left pubis which she did not have. During further interview, Resident 1 stated the nurse did not review the discharge summary/instructions with her, the packet was simply given to her and was instructed to sign the forms. On the same interview, Resident 1 stated she was discharged with medications including metoprolol (used to treat high blood pressure), pantoprazole (used to treat heartburn, acid reflux, stomach ulcers), and metformin (used to treat type 2 diabetes (high blood sugar)), which belongs to another resident (Resident 2). During further interview, Resident 1 stated she does not take those medications (referring to metoprolol, pantoprazole, and metformin) because she does not have hypertension (high blood pressure), acid reflux nor diabetes. Resident 1 further stated, I did not pay attention to medicines 'coz I know what I take. Review of Resident 1's Discharge Instructions, dated 8/13/24, indicated, [Resident 1's Name] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 3 of 6 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 11/22/2024 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .discharge date : [DATE] Recapitulation Of Stay: Resident was admitted to the facility for short term rehab and made improvement. Medical Status & History (include diagnosis) OTHER FRACTURE OF LEFT PUBIS, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING (S32.592D), ESSENTIAL (PRIMARY) HYPERTENSION (I10), HISTORY OF FALLING (Z91.81), HYPERLIPIDEMIA, UNSPECIFIED (E78.5), OTHER ABNORMALITIES OF GAIT AND MOBILITY (R26.89), NEED FOR ASSISTANCE WITH PERSONAL CARE (Z74.1) . Under the medication list on the Discharge Medication Instructions page (4) indicated, SEE ATTACHMENTS FOR D/C (discharge) MEDLIST FROM [Name of Hospital/Insurance]. The Discharge Medication Instructions also indicated Resident 1 and Licensed Vocational Nurse (LVN) 1's signature at the bottom of the page. Review of the facility's document titled Discharges indicated, two residents (Resident 1 and Resident 3) were discharged to home on 8/15/24. Review of Resident 3's Discharge Instructions dated 8/15/24, indicated, [Resident 3's Name] .discharge date : [DATE] Recapitulation Of Stay: Resident was admitted to the facility for short term rehab and made improvement. Medical Status & History (include diagnosis) OTHER FRACTURE OF LEFT PUBIS, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING (S32.592D), ESSENTIAL (PRIMARY) HYPERTENSION (I10), HISTORY OF FALLING (Z91.81), HYPERLIPIDEMIA, UNSPECIFIED (E78.5), OTHER ABNORMALITIES OF GAIT AND MOBILITY (R26.89), NEED FOR ASSISTANCE WITH PERSONAL CARE (Z74.1) . Resident 1 and Resident 3 had the same information entered on the Recapitulation of Stay section of the Discharge Instructions. During an interview on 10/8/24 at 11:16 a.m.,, Assistant Director of Nursing (ADON) stated, [Name of Facility/Insurance] residents are not seen on the day of discharge, the case manager involved will see the resident and/or fax the discharge instructions to the facility. The ADON also stated that the nurse scheduled that day would complete the discharge process which includes reviewing the discharge instructions with the resident and/or resident representative (RP) to ensure understanding before acknowledging and signing the forms. Review of [Name of Hospital/Insurance] document titled, Skilled Nursing Facility Discharge Instructions dated 8/14/24, indicated, Resident 1's medication list included the following medications: - Ibuprofen (Motrin) 600 mg oral tab (tablet). Take 1 tablet by mouth 3 times a day as needed for pain. Take with food. - Omeprazole Magnesium (acid reducer, Omeprazole) 20 mg oral CP DR SR Cap (capsule). Take 1 capsule by mouth daily 30 minutes before breakfast. - Aspirin (Ecotrin Low Strength) 81 mg oral TBEC DR Tab. Take 1 tablet by mouth daily. Use for 30 days from the date of knee surgery. Then stop. This is to prevent blood clots. - Acetaminophen (Tylenol) 325 mg oral tab. Take 2 tablets by mouth every 6 hours as needed for pain. Do not exceed 4,000 mg of acetaminophen per day from all sources. - Gabapentin (Neurontin) 300 mg oral cap. Take 3 capsules by mouth 3 times a day. - Metoprolol Tartrate (Lopressor) 50 mg oral tab. Take 1 tablet by mouth the night before CT scan and 1 tablet one hour before CT scan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 4 of 6 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 11/22/2024 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 0661 Level of Harm - Minimal harm or potential for actual harm - Docusate Sodium (Colace) 250 mg oral cap. Take 1 capsule by mouth daily for bowel regularity. Hold for loos stools. - Magnesium Hydroxide (Milk of Magnesia) 400mg/5 ml oral suspension. Take 30 ml by mouth daily as needed for constipation. Hold if creatinine is greater than 2.5. use as first line medication. Residents Affected - Few - Oxycodone IR (Roxicodone) 5 mg oral tab. Take 1 tablet by mouth every 6 hours as needed for severe pain. During a telephone interview on 10/9/24 at 4:06 p.mp., Licensed Vocational Nurse (LVN) 1 stated, she took all of Resident 1's medications from the med cart and explained the medication list provided by [Name of Facility] Case Manager. LVN 1 also stated that there was a rubber banded of gabapentin. Unfortunately, I did not open that bundle thinking it was all gabapentin. I did not see there was a metformin included in the bundle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 5 of 6 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 11/22/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm 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 operations when swirl bowls were stored wet. Residents Affected - Many Findings: According to the 2022 Federal Food Code, equipment and utensils are to be air dried. During a concurrent observation and concurrent interview on 11/20/24 at 1:15 p.m., in the kitchen, with Dietary Aide (DA) 1, clear bowls were placed on a tray stacked within one another that were wet on the inside. DA 1 stated tableware (term for all the dishes, utensils used for eating and serving food) were dried before stacking. During a concurrent observation and concurrent interview on 11/20/24 at 1:18 p.m., with the Director of Food and Nutrition Services (DFNS), showed clear bowls placed on a tray stacked within one another that were wet on the inside. The DFNS stated these were swirl bowls. DFNS confirmed there were six wet swirl bowls stacked within one another and stated, It's moist. It should be dry before stacked. We don't use it all the time, it could get moldy. Review of facility policy titled Dishwashing dated 2023, indicated, .Procedure: 5. Dishes are to be air dried in racks before stacking and storing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056205 If continuation sheet Page 6 of 6