Other·April 9, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. For Complaint Number CA00613501 regarding Admission, Transfer & Discharge Rights, the Department identified a violation of Federal regulations and issued a deficiency. Representing the California Department of Public Health: ID# 38491, Health Facilities Evaluator Nurse

F623 SS=E Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 04/19/2019 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZXKQ11 Facility ID: CA220000069 If continuation sheet 1 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055116 (X3) DATE SURVEY COMPLETED 03/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINDA MAR CARE CENTER 751 San Pedro Terrace Rd Pacifica, CA 94044 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZXKQ11 Facility ID: CA220000069 If continuation sheet 2 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055116 (X3) DATE SURVEY COMPLETED 03/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINDA MAR CARE CENTER 751 San Pedro Terrace Rd Pacifica, CA 94044 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZXKQ11 Facility ID: CA220000069 If continuation sheet 3 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055116 (X3) DATE SURVEY COMPLETED 03/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINDA MAR CARE CENTER 751 San Pedro Terrace Rd Pacifica, CA 94044 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview and record review, the facility failed to provide documentation of residents' transfer and discharge notifications to the State Long Term Care Ombudsman office for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) who were discharged at the facility from 3/1/18 to 5/10/18. This failure had the potential to result in lack of protection to residents from being inappropriately discharged and access to an advocate who can inform them of their options and rights. Findings: 1. Resident 1 was admitted on 1/8/18 for antibiotic therapy, wound care, physical and occupational therapy, with diagnoses including methicillin susceptible staphylococcus aureus infection (MSSA-type of bacteria that responds well to medicine to treat infection), chronic kidney disease (moderate), osteomyelitis (inflammation of bone usually due to infection) and gout (a form of arthritis characterized by severe pain, redness and tenderness in joints). Resident 1 was discharged to home on 3/10/18. Review of Resident 1's physician's order dated 2/27/18, at 5:17 PM, indicated a verbal order for Resident 1 to be discharge to home on 3/10/18 with home health RN, PT, OT, home health aide, and current medications. Review of Resident 1's "Notice of Proposed Transfer/Discharge" record dated 2/27/18, indicated Resident 5 was for discharge to home on 3/10/18 for resident's health was improved sufficiently that he no longer requires the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZXKQ11 Facility ID: CA220000069 If continuation sheet 4 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055116 (X3) DATE SURVEY COMPLETED 03/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINDA MAR CARE CENTER 751 San Pedro Terrace Rd Pacifica, CA 94044 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services provided at the facility. Review of Resident 1's nursing progress notes documentation, electronically signed by Registered Nurse (RN) 1 dated 3/10/18, at 8:56 AM indicated Resident 1 was discharged to home. Record review showed no documentation the Ombudsman was notified on Resident 1's discharge. 2. Resident 2 was admitted on 2/17/18 with diagnoses including chronic venous insufficiency (failure of the veins to adequately circulate the blood), obesity (excessive amount of body fat), cellulitis (bacterial skin infection) of left lower limb, hypertension (high blood pressure) and muscle weakness. Resident 2 was discharged to home on 3/29/18. Review of Resident's 2's physician's order dated 3/28/18, at 6:43 PM indicated an order to discharge Resident 2 to home on 3/29/18 with home health RN [Registered Nurse], PT [physical therapy], OT [occupational therapy], current medications and for wound care. It also indicated, Resident 2 required a bariatric (extra wide or heavy duty) wheelchair and commode. Review of Resident 2's nursing progress notes documentation, electronically signed by RN 2 dated 3/29/18, at 3 PM, indicated Resident 2 was discharged to home. Review of Resident 2's "Notice of Proposed Transfer/Discharge" record dated 3/28/18, indicated Resident 2 was to be discharged on 3/29/18 for the reason of Resident 1's health had been improved sufficiently that he no longer required services provided at the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZXKQ11 Facility ID: CA220000069 If continuation sheet 5 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055116 (X3) DATE SURVEY COMPLETED 03/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINDA MAR CARE CENTER 751 San Pedro Terrace Rd Pacifica, CA 94044 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Record review showed no documentation the Ombudsman was notified on Resident 2's discharge. 3. Resident 3 was admitted on 3/23/18 with diagnoses including, congestive heart failure (CHF- a weakness of the heart that leads to a buildup of fluids in the lungs), pancreatitis (inflammation of the pancreas), waldenstrom macroglobulinemia (is a type of non-Hodgkin lymphoma [cancer that starts in the lymphatic system]- the cancer cells make large amounts of an abnormal protein), and generalized muscle weakness. Resident 4 was discharged to home with hospice care on 4/3/18. Review of Resident 3's physician order dated 4/3/18, at 1:56 PM, indicated a verbal order for Resident 3 to be discharge to home with family and with hospice care. Review of Resident 3's "Notice of Proposed Transfer/Discharge" record dated 4/2/18, indicated Resident 3 was for discharge to home with hospice care on 4/3/18 for resident's health was improved sufficiently that she no longer required the services provided at the facility. Review of Resident 3's nursing progress notes documentation, electronically signed by facility's RN 1 dated 4/3/18, at 11:12 AM, indicated Resident 3 was sent to home via ambulance with hospice arrangement. Record review showed no documentation the Ombudsman was notified on Resident 3's discharge. 4. Resident 4 was admitted on 3/22/18 with diagnoses including cholecystitis (inflammation of the gall bladder), CHF, chronic kidney disease, stage 4 (advanced kidney damage), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZXKQ11 Facility ID: CA220000069 If continuation sheet 6 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055116 (X3) DATE SURVEY COMPLETED 03/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINDA MAR CARE CENTER 751 San Pedro Terrace Rd Pacifica, CA 94044 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and dementia. Resident 4 was discharged to a hospital on 4/21/18. Review of Resident 4's nursing progress notes documentation, electronically signed by Charge Nurse 1 dated 4/21/18, indicated Resident 4 had nausea, dry heaves and chest pain. It also indicated Resident 4's physician was notified and ordered for Resident 4 to be transferred to ER for further evaluation. Review of Resident 4's "Discharge Summary" record dated 4/21/18, indicated Resident 4 was discharged to hospital. Review of Resident 4's "Notice of Proposed Transfer/Discharge" record dated 4/21/18, indicated Resident 4 was discharged to the hospital for Resident 4's welfare, and the facility was not able to meet her needs. Record review showed no documentation the Ombudsman was notified on Resident 4's discharge. 5. Resident 5 was admitted on 12/7/18 with diagnoses including acute post hemorrhagic anemia (acute blood loss), muscle weakness, abnormalities of gait and mobility, atrial fibrillation (an irregular rapid heart rate), and dementia (decline in mental ability severe enough to interfere with daily life). Resident 5 was discharged to a hospital on 5/8/18. Review of Resident's 5's physician's order dated 5/8/18, at 2:21 PM, indicated a telephone order to transfer Resident 5 to a hospital's emergency room. Review of Resident 5's nursing progress notes documentation, electronically signed by RN 1 dated 5/8/18, at 2:42 PM, indicated Resident 5 was discharged to the hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZXKQ11 Facility ID: CA220000069 If continuation sheet 7 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055116 (X3) DATE SURVEY COMPLETED 03/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINDA MAR CARE CENTER 751 San Pedro Terrace Rd Pacifica, CA 94044 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 5's transfer record documentation signed by RN 1 dated 5/8/18 indicated Resident 5 was transferred to the hospital because of critical low hemoglobin level, had an episode of black tarry stool, and positive for stool occult blood test (laboratory test used for hidden blood in the stool). Review of Resident 5's "Notice of Proposed Transfer/Discharge" record dated 5/8/18, indicated Resident 5 was transferred to the hospital for Resident 5's welfare and the facility was not able to meet his needs. Record review showed no documentation the Ombudsman was notified on Resident 5's transfer. During an interview with the Ombudsman on 11/30/18, at 9:45 AM, she stated the Long Term Care Ombudsman office did not receive any notification of residents' discharge or transfer from the facility since 2/28/18 to 5/11/18. During a concurrent interview and record review with the Director of Nursing (DON) on 11/30/18, at 1:20 PM, DON reviewed residents' (Resident 1, 2, 3, 4 and 5) clinical records and was unable to find documentation of discharge notification to the Ombudsman on their records. DON acknowledged the findings. During a concurrent interview and record review with the Director of Social Services on (DSS) 11/30/18, at 1:35 PM, DSS reviewed (Residents' 1, 2, 3, 4 and 5) clinical records and was unable to find documentation of discharge notification to the Ombudsman on their records. DSS verified the findings. During a telephone interview with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZXKQ11 Facility ID: CA220000069 If continuation sheet 8 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055116 (X3) DATE SURVEY COMPLETED 03/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINDA MAR CARE CENTER 751 San Pedro Terrace Rd Pacifica, CA 94044 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Administrator on 3/12/19, at 3 PM, he stated that the discharge notification form was usually faxed to the ombudsman. He stated he was not able to find the confirmation fax receipts for Residents 1, 2, 3, 4, and 5. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZXKQ11 Facility ID: CA220000069 If continuation sheet 9 of 9