Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Linda Mar Care Center during CMS and state inspections, most recent first.
The facility failed to ensure the Certified Dietary Manager (CDM) was fully qualified, as he lacked the necessary certification before assuming his role. Despite completing a dietary manager course, the CDM had not taken the final test for certification, potentially leading to inadequate supervision of the dietary department for all 42 residents. The Registered Dietitian confirmed the CDM needed further approval before certification, and the administrator acknowledged the absence of a certified dietary manager.
The facility failed to provide education on the COVID-19 vaccine to four residents, as required by policy. The residents' records showed that the education section was marked 'no,' indicating that they did not receive information about the vaccine's benefits, risks, and side effects. The Infection Preventionist confirmed that the consent forms were incomplete, lacking confirmation of education.
A facility failed to create a comprehensive care plan for a resident with right-sided hearing loss. Despite the resident's request for communication through his left ear, no care plan addressed this issue. The SSD had not scheduled an ENT appointment, and the LVN confirmed the hearing issue was due to earwax buildup. The DON acknowledged the absence of a care plan for communication, contrary to facility policies requiring comprehensive care plans.
The facility was found to have an expired pack of frankfurters in the freezer, as observed during an inspection with the Dietary Manager. The frankfurters were stored beyond the recommended time, posing a risk of foodborne illness to residents, especially vulnerable older adults.
A resident's primary language was inaccurately documented as English, despite the resident primarily speaking Spanish. Interviews revealed that staff often did not use a translator, although some staff communicated with the resident in Spanish. The care plan and MDS contained conflicting information about the resident's language preference, which the DON acknowledged as inaccurate.
The facility failed to provide the required 80 square feet of living space per resident in multiple resident bedrooms, affecting 14 out of 21 rooms. Despite some residents expressing satisfaction with their room sizes, measurements confirmed the deficiency, potentially impacting care provision.
A resident with multiple health issues experienced an unwitnessed fall resulting in a laceration. The facility failed to report the incident to the State Agency and Ombudsman as required by their policy, despite the resident being on blood thinners and sustaining an injury. Interviews and record reviews confirmed the lack of documentation and reporting.
A resident with extensive assistance needs for bed mobility rolled out of bed during incontinent care, resulting in a forehead laceration. The CNA providing care reported increased confusion in the resident prior to the incident. The facility's policies for accident reporting and fall risk management were not fully followed, and the care plan did not address the resident's visual deficits.
Unqualified Dietary Manager Lacks Certification
Penalty
Summary
The facility failed to ensure that the Certified Dietary Manager (CDM), responsible for supervising daily food service operations, was fully qualified before assuming full-time duties. The CDM did not possess the necessary dietetics manager's certification as required by the State of California Health and Safety Code 1265.4(b)(4). The CDM had completed a dietary manager course but had not yet taken the final test to obtain the certification. This oversight was likely to result in inadequate supervision of the dietary department, affecting all 42 residents who consumed food from the facility's kitchen. Interviews and record reviews revealed that the CDM began his role full-time approximately eight months prior to the survey without the required certification. The Registered Dietitian (RD) confirmed that the CDM needed approval from the Association of Food and Nutrition Professionals before applying for the certification exam. The facility's administrator acknowledged the absence of a certified dietary manager at the time of the survey. The facility's organizational chart and job description indicated that the CDM was responsible for assisting with planning, organizing, and managing the dietary department, yet lacked the necessary credentials to fulfill these duties effectively.
Failure to Provide COVID-19 Vaccine Education
Penalty
Summary
The facility failed to ensure that residents or their representatives were provided with education about the benefits, risks, and potential side effects associated with the COVID-19 vaccine. This deficiency was identified in four out of five sampled residents. The facility's policy requires that education be provided and documented before offering the COVID-19 vaccine. However, the records for Residents 12, 16, 142, and 92 indicated that the section for education provided was marked as 'no,' suggesting that the required education was not given. During interviews and record reviews with the Infection Preventionist (IP), it was confirmed that the consent forms for these residents were incomplete. The forms lacked confirmation that the residents or their representatives had been educated and had the opportunity to review the COVID-19 'FACT SHEET.' The IP acknowledged that the unchecked sections on the consent forms indicated that education was not provided, which is contrary to the facility's policy and procedure.
Failure to Develop Comprehensive Care Plan for Hearing Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with right-sided hearing loss. The resident, who was cognitively intact, had been admitted with diagnoses including nontraumatic intracerebral hemorrhage, hypertension, and generalized muscle weakness. Despite the resident's request for communication through his left ear due to deafness in the right ear, there was no care plan addressing this hearing loss. The Social Services Director (SSD) was responsible for scheduling appointments but had not scheduled an ENT appointment for the resident, as the resident's name was not on the appointment schedule. The Licensed Vocational Nurse (LVN) confirmed the resident's hearing issue was due to earwax buildup, as noted in the resident's admission summary and doctor's note. However, there was no care plan for the hearing loss until after the surveyor's inquiry. The Director of Nursing (DON) acknowledged the absence of a care plan for communication and stated that the resident's ear was irrigated, but the issue persisted. The facility's policies required comprehensive care plans with measurable objectives, which were not in place for this resident's hearing loss.
Expired Food Item Found in Facility Freezer
Penalty
Summary
The facility failed to maintain safe and sanitary conditions for food storage in the kitchen, as evidenced by the presence of an expired pack of frankfurters in the freezer. During an observation and interview with the Dietary Manager (DM), it was revealed that the frankfurters had been received on a specific date and were stored beyond the recommended storage time of several months as indicated in the facility's Food Storage Chart for Frozen Foods. The DM confirmed that the frankfurters were expired. This deficiency was identified through a combination of observation, interview, and record review, highlighting a lapse in adherence to professional standards for food storage. The Federal Food Code 2022 underscores the importance of preventing foodborne illnesses, particularly in vulnerable populations such as older adults in healthcare facilities. The presence of expired food items in the facility's freezer posed a risk of foodborne illness to residents, which is a significant concern given the potential severity of such illnesses in this population.
Language Assessment Deficiency for Resident
Penalty
Summary
The facility failed to accurately assess the primary language of a resident, identified as Resident 32, which led to a potential communication barrier. The face sheet of Resident 32, dated January 24, 2025, incorrectly indicated that the resident's primary language was English. However, during an interview on January 22, 2025, Resident 32 stated that she primarily speaks Spanish and noted that staff often do not use a translator to communicate with her. A Certified Nursing Assistant (CNA) confirmed that she communicates with Resident 32 in Spanish, while a Licensed Vocational Nurse (LVN) mentioned using English for basic communication and seeking translation assistance for more complex needs. Further review of Resident 32's care plan for impaired communication, initiated on March 7, 2024, revealed documentation indicating that the resident does not communicate in the facility's primary language and is a Spanish speaker. Despite this, the Director of Nursing (DON) reviewed the Quarterly Minimum Data Set (MDS) dated December 13, 2024, which inaccurately stated that Resident 32's preferred language was English. The DON acknowledged the discrepancy in the care plan documentation, indicating it was inaccurately documented and needed updating.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that residents in multiple resident bedrooms had at least 80 square feet of living space per resident. This deficiency was identified in 14 out of 21 bedrooms, specifically in rooms 108, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, and 122. The facility's entrance documents, which were part of their re-certification process, indicated that these rooms did not meet the required square footage. During observations and interviews, it was noted that some residents were able to maneuver their wheelchairs independently within their rooms, and they expressed satisfaction with their room sizes. However, measurements taken by the Director of Maintenance confirmed that the rooms did not meet the required space per resident. The Director of Maintenance measured two rooms, finding that one room measured approximately 18.25 feet by 13 feet, providing about 79.08 square feet per resident with three beds, and another room measured approximately 18.5 feet by 12.75 feet, providing about 78.63 square feet per resident with three beds. Despite some residents expressing contentment with their room sizes, the measurements confirmed the deficiency in meeting the required space per resident, which could potentially impact the provision of care or daily living for the residents.
Failure to Report Fall with Injury
Penalty
Summary
The facility failed to promptly report an incident involving a fall with injury to the State Agency (California Department of Public Health) and the Ombudsman, as required by their policy. The incident involved a resident who was admitted with diagnoses including Congestive Heart Failure, Atrial Fibrillation, and Abnormalities with Gait and Mobility. The resident experienced an unwitnessed fall in their room, resulting in a laceration on the forehead. Despite the injury and the resident being on blood thinners, the Director of Nursing (DON) deemed the incident as minor and did not report it to the appropriate authorities. The resident was subsequently sent to the emergency room and later discharged home with Home Health services. There was no documentation found of the incident being reported to the state agency or the Ombudsman. Interviews with staff revealed that the Certified Nursing Assistant (CNA) involved in the incident was not available for an interview as they were out of the country. The Licensed Vocational Nurse (LVN) who assessed the resident after the fall reported that the resident was alert and verbally responsive but had a bleeding forehead. The facility's policy on Unusual Occurrence Reporting mandates that such incidents be reported within 24 hours, but this protocol was not followed. The failure to report the fall with injury has the potential for further accidents to go unreported, compromising resident safety.
Failure to Provide Adequate Supervision and Interventions
Penalty
Summary
The facility failed to provide adequate supervision and interventions for a resident who required extensive assistance with bed mobility. During incontinent care, the resident rolled out of bed and hit the side of the table, resulting in a laceration on the forehead. The resident was admitted with diagnoses including congestive heart failure, atrial fibrillation, and abnormalities with gait and mobility. The resident was noted to be at high risk for falls, with a fall risk score of 16, and required total dependence for bed mobility and transfers as per physical and occupational therapy evaluations. During the incident, a CNA was providing care and turned the resident to the side to change a diaper. The resident began moving towards the edge of the bed and rolled off before the CNA could reach him. The CNA reported increased confusion in the resident prior to the incident. The Licensed Vocational Nurse (LVN) assessed the resident, who was on a blood thinner, and found a bleeding laceration on the forehead. The resident was then transferred back to bed using a Hoyer lift and 911 was called. The Director of Nursing (DON) was informed, and the resident was sent to the emergency room. The facility's policies and procedures for accidents and incidents, as well as falls and fall risk management, were reviewed. The policies indicated that all accidents should be investigated and reported to the administrator, and that a resident-centered fall prevention plan should be implemented. However, there was no documentation found of the incident being reported to the state agency or Ombudsman, and no investigation summary was sent to the state agency office. The care plan for the resident did not address visual deficits, which was a contributing factor to the fall risk.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pacifica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacifica Nursing And Rehabilitation Center | 4.4 mi | ★★★★★ | 4 | 0 |
| San Bruno Skilled Nursing | 5.2 mi | ★★★★★ | 18 | 0 |
| Golden Pavilion Healthcare | 6 mi | ★★★★★ | 2 | 0 |
| Golden Heights Healthcare | 6 mi | ★★★★★ | 0 | 0 |
| Millbrae Care Center | 6.1 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.