Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 San Bruno Skilled Nursing during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was discharged to an emergency department solely after Medicare benefits were exhausted, despite no documented change in condition and no medical necessity for an ED transfer. The discharge care plan lacked specific problems, goals, interventions, and a documented destination preference, and it was not updated with the resident’s or representative’s wishes. Provider documentation conflicted, with orders for discharge home with home health services while social services arranged transport to a VA ED to check benefits and assign a social worker. The resident’s representative reported not being informed about applying for Medi-Cal or paying privately, and VA staff confirmed there was no scheduled benefits appointment, that the resident was brought directly to the ED without medical need, and that no Medicaid application had been filed. Facility records showed poor care coordination, conflicting discharge documentation, and failure to follow internal policies requiring appropriate notice, documentation, and financial assistance counseling at discharge.
Resident Council Meetings Held Without Privacy. A resident and other residents stated resident council meetings were often held in a hallway because the only other space was being used as a gym. The AD confirmed meetings were sometimes held in the hallway when the gym was busy, and council minutes did not document a meeting location. The facility policy stated the resident council group is provided with space and privacy to conduct meetings.
The facility failed to adequately monitor antipsychotic-related orthostatic BP for one resident, with staff confirming the MAR did not accurately reflect the monitoring performed. The facility also allowed PRN lorazepam and olanzapine orders to remain active beyond the usual 14-day limit without documented stop dates or clinical rationale, despite staff acknowledging the standard practice for PRN psychotropic orders.
A licensed pharmacist did not complete monthly MRRs as required, and multiple pharmacist recommendations were not timely addressed for several residents. One resident had a PRN antipsychotic order without an end date, two residents had PRN lorazepam orders missing stop dates with no documented prescriber response, one resident’s heparin recommendation was delayed, and another resident remained on multiple psychotropic medications for MDD without the pharmacist’s recommendation being acted upon.
A commode riser with affixed handrails and a toilet seat was observed in a shared bathroom with chipped paint and red/brown discolorations on the metal frame. The Mnt later verified the discoloration was rust and stated the equipment was not safe, not clean, and not sanitary; the monthly equipment checklist was also reviewed and included toilet bedside commodes and risers under Recliners/Chair.
A resident with cerebral palsy, bipolar disorder, depression, and autistic disorder did not have a PASARR re-evaluated on the 30th day after admission. The DON said the Marketing Director completes PASARRs for new admits, and the Marketing Director stated she submitted the PASARR for this resident, which remained negative as an exempted hospital discharge. Facility guidance stated that a Resident Review is required when an exempted hospital discharge exceeds 30 calendar days.
A CNA administered OCuSOFT LID SCRUB eyelid cleanser to a resident, even though the consulting pharmacist stated it is a medication that requires an active MD order, licensed nurse administration, and locked storage. The product was found in the resident’s bedside cabinet, and the ADON stated he had seen it in the med cart given by nurses and was unaware of CNAs administering medications. The facility policy stated only licensed or permitted staff may prepare, administer, and document meds in accordance with prescriber orders.
Failure to provide needed hygiene assistance: A resident who was dependent on staff for oral and personal hygiene was observed with white greasy buildup on both eyelids and thick white buildup on the gums and teeth, with difficulty opening both eyes. Staff acknowledged the resident’s eyes were dirty and delayed cleaning them, despite the care plan calling for assistance with personal hygiene every shift and as needed and the CNA role including mouth care and grooming.
Failure to Provide Individualized Activities: A resident who liked music was repeatedly observed lying in bed without music, TV, or other individualized stimulation. The AD said the facility used room visits without a set schedule, with visits lasting about 10 minutes and offered 2 to 3 times weekly, despite the resident's activity assessment showing a preference for music and group activities.
Hot Water Temperature Exceeded Safe Range in Shared Bathroom. The facility failed to identify an environmental hazard when hot water in a shared resident bathroom measured above 120 degrees F, including readings of 121.5 degrees F and about 125 degrees F during observation and interview. The Mnt stated the facility checks hot water weekly, and the DSD/IP confirmed that one resident used the bathroom independently without staff assistance. The facility policy required tap water to be kept within a temperature range to prevent scalding and for maintenance staff to conduct periodic temperature checks and document them in a safety log.
A resident with COPD, pneumonia, and shortness of breath was ordered continuous oxygen via NC at 1 L/min with a goal sat of 88% and weaning as tolerated, but was repeatedly observed on 2 L/min. The MAR showed sats from 94% to 97% with no recorded weaning, and the resident said no one told her how much oxygen she was receiving or tried to take her off oxygen. The DON confirmed the 2 L/min setting, and an LVN stated the resident had always been on oxygen despite the 1 L/min order.
A resident with diabetes and CKD requiring dialysis had a physician order that still listed the dialysis access site as the right upper chest, even though staff acknowledged the access had been surgically changed to the left upper arm. Observation and record review showed nursing documentation continued to chart the old chest site on the MAR, and the DON and LPN confirmed the order had not been updated to reflect the resident’s current access site.
A resident’s OCuSOFT LID SCRUB eyelid cleanser was found stored in an unsecured bedside cabinet drawer, where a CNA could access it. The consulting pharmacist stated the product is a medication requiring a physician order, nurse administration, and locked storage, and the ADON confirmed medications should be kept in the med room.
Failure to Use EBP During Wound Care and Maintain Clean Oxygen Tubing: A resident with a stage 3 sacral pressure injury received wound care without EBP during high-contact care, even though the care plan called for EBP. In a separate observation, another resident with a hx of stroke and pulmonary edema had oxygen tubing with debris and crust; staff noted the tubing looked dirty and there was no label showing when it had last been changed.
A resident did not receive consistent range of motion (ROM) exercises to the left lower extremity, leading to the development of contractures. Initial therapy assessments showed normal ROM, but subsequent documentation revealed a decline in knee extension and mobility that was not properly addressed or reflected in the care plan. Upon hospital transfer, the resident had contractures, multiple wounds, and poor circulation in the affected leg.
The facility failed to provide sufficient space for group activities and communal dining, conducting activities in the hallway and serving meals in residents' rooms. This arrangement disturbed residents near the activity area and limited communal dining options. The Activities Director and Administrator confirmed the lack of designated spaces, with activities held in hallways and meals served in rooms since the pandemic.
A facility failed to maintain the privacy of a resident's care instructions, which were posted on the resident's bedroom wall, exposing their medical condition to others. The resident, with cognitive impairment and multiple diagnoses, had their care instructions posted by a family member. The DON acknowledged the issue but noted the family's involvement. This action violated the facility's policy on treating residents with dignity and respect.
A facility failed to assess and educate a resident on the self-administration of doxycycline, an antibiotic, as required by policy. The resident was observed with doxycycline on their bedside table and stated they were taking it for a bacterial infection. The RN and ADON were unaware of a care plan for the medication, and the resident's care plan only included five other medications for self-administration. The care plan was updated after the issue was identified, but the medication orders did not reflect the resident's use of doxycycline.
A resident's POLST form was found incomplete, lacking clear signatures and the identity of the individual with whom it was discussed. The DON confirmed the absence of necessary information, which could impact honoring the resident's end-of-life choices.
A facility failed to provide a resident with the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) while receiving Medicare Part A services. The resident, who had multiple diagnoses and was responsible for his own decisions, did not receive the SNF ABN due to being out for dialysis on the day it was supposed to be issued. Although a Notification of Medicare Non-Coverage (NOMNC) was provided, the absence of the SNF ABN meant the resident was not informed about potential financial liability and the right to appeal.
A resident with multiple health issues, including moderate cognitive impairment, reported hip pain later diagnosed as a pathological fracture. Despite no falls or activities explaining the pain, the facility failed to report the injury of unknown origin to the California Department of Public Health, as confirmed by the DON and Director of Staff Development. Facility policies require such injuries to be reported and investigated, but this was not done.
The facility failed to complete MDS assessments for four residents within the required timeframe. Admission and annual assessments were not completed within 14 days of admission or the ARD, as required by the RAI User Manual. The MDS Coordinator confirmed the delays, which could result in delayed identification of residents' needs.
A resident admitted to hospice care with serious health conditions did not have a Significant Change in Status Assessment (SCSA) completed within the required 14-day period. The assessment was completed 16 days after hospice admission, potentially delaying appropriate treatment and services.
The facility failed to complete MDS quarterly assessments within the required timeframe for three residents. The assessments were not completed within 92 days following the previous OBRA assessment, as required. The MDS Coordinator acknowledged the delay, which could result in delayed identification of residents' needs.
The facility failed to implement person-centered care plans for three residents, leading to deficiencies in care. A resident with respiratory issues received incorrect oxygen levels, another resident with COPD was given more oxygen than prescribed, and a resident requiring a two-person assist for transfers was handled by one staff member, contrary to their care plan.
A facility failed to update a resident's care plan after an IDT assessment found their weight loss acceptable due to CHF. The care plan aimed to maintain the resident's weight within 5% of 195 lbs, but the resident's weight dropped to 182.8 lbs. The RD acknowledged the need to update the care plan to align with the IDT's findings, suggesting a BMI-based goal.
The facility did not follow physician's orders for oxygen administration for two residents. One resident with respiratory failure was observed with an incorrect oxygen delivery setup, while another resident with COPD received a higher oxygen flow than prescribed. These actions were inconsistent with the facility's policy and the residents' care plans.
A resident with hemiplegia and other conditions was transferred by a single RNA using a sit-to-stand lift, despite the care plan requiring two-person assistance. The sling used was frayed and missing a buckle. Staff interviews revealed a lack of recent training and inconsistencies in understanding transfer requirements.
A medication error rate of 11% was observed in an LTC facility due to improper administration practices. A nurse failed to verify a resident's identity and did not ensure full consumption of MiraLAX, while another nurse improperly administered Flonase by not following recommended guidelines.
The facility failed to ensure safe food handling practices when two kitchen staff members were observed wearing yellow bracelets on both arms during food preparation. The Certified Dietary Manager (CDM) and another staff member were seen preparing food while wearing the bracelets, which they later removed. The facility's policy specifies minimal jewelry and requires hand jewelry to be covered with gloves.
The facility's QAPI program failed to prevent medication errors, resulting in an 11% error rate during a medication pass. Errors included improper resident identification and incorrect administration of medications. The Quality Committee had only met once in the past year and lacked a project to address these errors.
The facility failed to maintain its infection control program for two residents on transmission-based precautions. A resident with MRSA had no PPE available outside their room, contrary to facility policy. Another resident on enhanced barrier precautions had their PPE cart misplaced, and an LVN handled their Foley bag without PPE. These actions were against CDC guidelines and facility policies, potentially increasing infection spread risk.
Improper Discharge to Emergency Department After Medicare Exhaustion Without Adequate Planning or Counseling
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective discharge planning process and to ensure an orderly, appropriate discharge for one of three sampled residents. The resident was admitted with multiple chronic conditions, including COPD with acute exacerbation, centrilobular emphysema, gait and mobility abnormalities, unsteadiness, dysphagia, CKD, and urinary retention. A discharge care plan was initiated but left the discharge destination preference blank and did not identify specific discharge problems, goals, or interventions. The care plan was not revised or updated to reflect any discharge preferences of the resident or the resident’s representative. As the resident’s Medicare Part A coverage approached exhaustion, the facility issued a Notice of Medicare Non-Coverage indicating the end date of coverage. Provider documentation around this time was inconsistent: a practitioner note stated the resident was medically stabilized but not strong enough to return home and that discharge planning was pending therapy progress, while a physician discharge summary documented a planned discharge home with home health services and a stable condition. A physician order later specified discharge home with RN, PT, OT, HHA, and SW services. However, the Notice of Proposed Transfer/Discharge and the facility’s Discharge Summary and Post-Care Instructions instead identified a plan to send the resident to a VA location to check benefits eligibility and assign a social worker for placement under a VA program, with transportation by a friend. On the actual day of discharge, the social worker documented that the resident would be brought to the VA emergency room so that a social worker, VA PCP, and benefits eligibility could be arranged, citing exhaustion of Medicare days at the current and previous SNFs. Nursing documentation recorded that the resident left via a transportation company but did not document the discharge destination or home health information as ordered by the physician. Interviews with the DON and ADON confirmed there was no significant change in the resident’s condition and that the resident was stable on the day of discharge, indicating no medical necessity for an emergency transfer. The social worker and VA staff confirmed that the resident was taken directly to the VA emergency department without an appointment and without an apparent medical reason, and VA staff reported telling the social worker that the resident could not be brought in “for no reason.” The resident’s representative reported not being informed about the option to apply for Medi-Cal or to pay privately to remain at the facility and described the discharge as rushed, with nothing prepared in advance, despite the social worker’s knowledge that the resident had no place to stay because his prior apartment had been demolished. VA staff further stated that no Medi-Cal application had been filed for the resident and characterized the discharge as occurring after the resident ran out of 100 Medicare days. Review of the clinical record showed a lack of documented care coordination and discharge planning discussions with the interdisciplinary team, the resident, and the representative, and the discharge documentation from medical provider, social services, and nursing contained conflicting information. These actions and omissions were inconsistent with the facility’s own transfer/discharge policies, which require that residents not be transferred unless necessary for their welfare, that appropriate notice and documentation be provided, that residents receive assistance with third-party payment applications, and that residents who continue to need LTC services be offered the option to remain privately or with Medicaid assistance.
Resident Council Meetings Held Without Private Space
Penalty
Summary
The facility failed to ensure residents were provided a private space to participate in resident council meetings. During a group interview on 12/03/2025 with Residents 58, 24, 26, 27, and 43, Resident 24 stated that resident council meetings were often held in a hallway because the facility had limited private spaces, and that the only available space was the old dining room, which was being used as the gym. Resident 24 stated that residents requested a private space for the meetings but were told there was no room available. Residents 26 and 27 also verified that group meetings were held in facility hallways. During an interview on 12/5/2025, the Activity Director stated that resident council meetings were sometimes held in the hallway if the gym was busy, in a small group in the corner of the hallway. Review of resident council minutes dated 9/26/2025, 10/24/2025, and 11/28/2025 showed that 22 residents attended the meetings, but no meeting location was documented. Review of the facility policy titled Resident Council stated that the resident council group is provided with space, privacy, and support to conduct meetings.
Psychotropic Monitoring and PRN Order Duration Deficiencies
Penalty
Summary
The facility failed to provide adequate monitoring for antipsychotic medications for two residents and allowed PRN medications to remain ordered beyond the 14-day limit for three residents. For one resident, the record showed an orthostatic blood pressure order related to antipsychotic use, but the documented blood pressure entries on the MAR reflected duplicate readings with no documented times, and staff confirmed that only one blood pressure had actually been documented per shift. The LVN and ADON stated the documentation did not accurately reflect orthostatic blood pressure monitoring. For two residents, the facility had current lorazepam PRN orders for anxiety or agitation with no stop date documented. A note to the prescriber indicated the order should be clarified and either limited to 14 days or supported with clinical rationale for use beyond the CMS 14-day limit, but the ADON confirmed the orders remained active without a stop date and could not locate clinical rationales supporting use beyond 14 days. For another resident admitted with a history of schizophrenia, weakness, and low blood pressure, the order summary showed olanzapine 5 mg PRN for agitation/psychosis started without an end date. Staff reviewed the order and acknowledged the facility’s usual practice that PRN medications are generally prescribed for 14 days, but stated this order had no stop date and was allowed to continue. The resident’s November MAR showed no use of the medication that month, and the pharmacist medication regimen review had not been repeated after the initial review at admission.
Pharmacist Medication Review and Follow-Up Deficiencies
Penalty
Summary
The facility did not ensure that a licensed pharmacist completed monthly medication regimen reviews and that pharmacist recommendations were timely addressed for five sampled residents. The report states that the pharmacist’s reviews were done on admission and then every quarter, despite the facility policy indicating medication regimen reviews are to be completed upon admission and at least monthly thereafter. For Resident 18, admitted with a history of schizophrenia and low blood pressure, the admission medication regimen review was completed on 8/7/25, and no additional pharmacist review was documented before the survey review. The DON stated the resident would not have been due for another review until later in the month, consistent with the facility’s quarterly practice rather than monthly review. Resident 18 also had an order for olanzapine 5 mg by mouth every 24 hours as needed for agitation/psychosis that began on 10/20/25 and did not include an end date. During interview, staff confirmed the facility policy for as-needed medications was usually for physicians to prescribe them for 14 days at a time and then renew or discontinue them. The DON stated that, in this case, the medication could be continued indefinitely without a stop date because the resident continued to have the same behaviors. The record review also noted that the medication was not administered in November 2025. For Residents 7 and 8, the pharmacist issued a note to the attending physician/prescriber on 11/06/25 regarding lorazepam 2 mg/mL, 0.5 mL every 4 hours as needed for anxiety or agitation, stating the order was missing a stop date and requesting clarification or a 14-day stop. The ADON confirmed the order remained active with no stop date and that no physician/prescriber response was documented. For Resident 2, the pharmacist noted on 11/06/25 that heparin 5,000 units twice daily for post-DVT prophylaxis had no stop date and recommended considering one if clinically appropriate; the DON stated the recommendation was not addressed until 12/03/25, when a telephone order was obtained to discontinue the medication. The DON also confirmed no attending physician/prescriber response was provided for Residents 7 and 8. Resident 5’s record showed diagnoses including pneumonia, dementia, anxiety disorder, and major depression. The medication record listed quetiapine (Seroquel) 25 mg three times daily for MDD, along with clonazepam, mirtazapine, and paroxetine also ordered for MDD. The pharmacist’s medication regimen review dated 10/27/25 stated that the current orders included clonazepam, mirtazapine, paroxetine, and quetiapine, and recommended entering orders in PCC to monitor target behavior and side effects for the listed medications. The pharmacist also noted there was no indication that the four antipsychotic drugs could be given together. During interview, the pharmacist stated the recommendation had not been acted upon, and the DON confirmed there was no order or diagnosis change for Seroquel in the medical record.
Unsanitary Commode Riser Observed in Shared Bathroom
Penalty
Summary
The facility failed to maintain sanitary durable medical equipment used for activities of daily living for one sampled resident. During an observation in the shared bathroom of rooms [ROOM NUMBERS], a white metal commode riser with affixed handrails and a toilet seat was seen placed over the toilet. The equipment had one dime-sized area of chipped paint and red/brown discolorations on the middle of the horizontal metal back bar and multiple locations on the right posterior leg post. During interview and record review with the Maintenance Director, the monthly equipment checklist was reviewed and the director stated that all areas on the sheet are checked and that the equipment titled Recliners/Chair includes all toilet bedside commodes and risers. When the commode riser was re-observed with the Maintenance Director, he verified the chipped paint and red/brown discolorations and stated that it should be replaced, identifying the discoloration as rust. He stated that the equipment was not safe, not clean, and not sanitary, and that it should be replaced rather than painted.
PASARR Resident Review Not Re-evaluated on Time
Penalty
Summary
The facility did not ensure that one resident, identified in the report as Resident 40, had a PASARR re-evaluated on the 30th day after admission. The resident’s admission record dated 12/5/25 showed diagnoses including cerebral palsy, bipolar disorder, depression, and autistic disorder. A PASARR Level 1 screening submitted on 10/30/25 was negative with a reason of exempted hospital discharge. During interviews, the DON stated that the Marketing Director completes and submits PASARRs for all new admissions, and the Marketing Director stated that she completed and submitted the PASARR for this resident on 12/3/25. The new Level 1 screening was also negative with a reason of exempted hospital discharge, and the Level II mental health evaluation indicated referral was not required. The report stated that if the individual remains in the NF longer than 30 days, the facility must resubmit a new Level 1 screening as a Resident Review on the 31st day. Facility guidance also identified Resident Review as the screening type for an individual who is an exempted hospital discharge and exceeds a stay of 30 calendar days.
CNA Administered Eyelid Cleanser Without Licensed Nurse Oversight
Penalty
Summary
The facility failed to provide services that maintained professional standards of quality for one resident when a CNA administered an eyelid cleanser product. During an interview in the resident’s room, the CNA stated the resident had her own eye wipes for eye buildup and that staff used them on the eyes, adding that towels were not used. The CNA then retrieved an individually wrapped pre-moistened packet of OCuSOFT LID SCRUB eyelid cleanser from the resident’s bedside cabinet drawer. During a phone interview, the consulting pharmacist stated that because of the active ingredients in OCuSOFT LID SCRUB eyelid cleanser, it is a medication that requires an active physician order, must be administered by a licensed nurse, and must be stored in a locked location. In a later observation in the resident’s room, a blue box containing the OCuSOFT LID SCRUB eyelid cleanser wipes was found in the bedside cabinet. The ADON stated he had seen the product in the medication cart given by nurses, that he would remove it and obtain an MD order, and that he was unaware of medication being administered by CNAs. The facility policy stated that only persons licensed or permitted by the state to prepare, administer, and document medications may do so, and that medications are administered in accordance with prescriber orders.
Failure to Provide Needed Hygiene Assistance
Penalty
Summary
The facility failed to provide the necessary services to maintain good grooming, personal hygiene, and oral hygiene for one resident who was unable to perform these activities independently. Resident 8’s MDS dated 09/23/2025 indicated limited range of motion and impairments in both upper and lower extremities that interfered with daily functions, and that the resident was dependent on staff for oral hygiene and personal hygiene, including washing and drying the face. The care plan directed staff to assist with maintaining good personal hygiene every shift and as needed, and to provide assistance with care and ADLs. During observation on 12/02/2025, Resident 8 was lying flat in bed with the television on and was observed having difficulty opening both eyes due to white greasy buildup on the bilateral upper and lower lash lines, along with thick white buildup on the base of the lower gums and bottom row of natural teeth. During a later observation and interview, a CNA stated the resident’s eyes were dirty and said she would clean them after finishing with another resident, while also stating the resident had her own eye wipes due to eye buildup. The CNA retrieved a box of pre-moistened eyelid cleaner pads from the resident’s bedside drawer. The CNA job description included providing routine daily nursing care and assisting residents with dental and mouth care, bathing, grooming, and dressing.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized and ongoing activities and stimulation for one of three residents, Resident 7. During observations on 12/02/2025, 12/04/2025, and 12/05/2025, Resident 7 was repeatedly found lying in bed, arousable to voice, with no music or television playing at the bedside and no individualized activities or stimulation observed. During interview, the Activities Director stated the facility goes room to room without a set schedule, that bedbound residents should have TV and music on continuously, and that room visits last about 10 minutes and are offered 2 to 3 times per week. The activity assessment dated 12/05/2025 indicated Resident 7 likes music and that it was somewhat important for her to do her favorite activities and do things with groups of people. The facility policy stated activity programs are designed to meet residents' interests and support their physical, mental, and psychosocial well-being, and that individualized and group activities reflect residents' cultural and religious interests, hobbies, life experiences, and personal preferences.
Hot Water Temperature Exceeded Safe Range in Shared Bathroom
Penalty
Summary
The facility failed to identify an environmental hazard for one of four residents when the hot water temperature in a shared resident bathroom was greater than 120 degrees Fahrenheit. During observation on 12/02/2025 at 10:07 AM, the hot water in the resident's face bowl measured 121.5 degrees Fahrenheit on a calibrated thermometer. During a later observation and interview on 12/03/2025 at 11:47 AM with the Maintenance Director and the Director of Staff Development/Infection Preventionist, the hot water in the shared resident bathroom was intolerable to touch after five minutes of continuous running, and the calibrated thermometer recorded the water temperature at between 124 and 126 degrees Fahrenheit. The Maintenance Director stated that the facility checks hot water every week, and the DSD/IP confirmed that Resident 2 was the only resident who used the bathroom independently without staff assistance. The facility policy titled Water Temperatures, Safety of, dated 12/2009, stated that tap water shall be kept within a temperature range to prevent scalding of residents and that maintenance staff shall conduct periodic tap water temperature checks and record the temperatures in a safety log.
Incorrect Oxygen Flow Rate
Penalty
Summary
The facility did not ensure that one of two sampled residents, Resident 5, received oxygen at the correct flow rate according to the physician’s order. Resident 5 was admitted with diagnoses including COPD, pneumonia, shortness of breath, anxiety disorder, and major depression. The order summary dated 10/25-12/5/25 directed continuous oxygen via nasal cannula at 1 L/min with a goal saturation of 88%, and to begin weaning from oxygen as tolerated every shift starting 11/5/25. However, the medication administration record showed oxygen saturation readings from 94% to 97% and no recorded weaning of oxygen was done. During observations on 12/1/25, 12/2/25, and 12/3/25, Resident 5 was observed in bed or sitting up with oxygen via nasal cannula at 2 L/min. The resident stated she did not know how much oxygen she was receiving and said no one told her about activities or whether nurses ever tried to take her off oxygen as a trial. The DON confirmed the oxygen level was 2 L/min during one observation. During a concurrent interview and record review, LVN 2 stated the resident had always been on oxygen, that the order was 1 L/min, and that oxygen saturation ranged from 92% to 97%, with oxygen given continuously. The facility policy and procedure for oxygen administration stated to verify there is a physician’s order and to review the physician’s order or facility protocol for oxygen administration.
Dialysis Access Site Documentation Was Not Updated
Penalty
Summary
The facility did not ensure safe, appropriate dialysis care for a resident who required hemodialysis. Resident 11 was admitted with a history of diabetes and chronic kidney disease requiring dialysis treatment. The physician order in the record directed nursing staff to check the A.V. site to the right upper chest dressing every shift, leave it intact for 4 to 6 hours following dialysis, change it if soiled or fallen off, and apply pressure immediately if bleeding was noted from the dialysis access site. These orders remained active in the record when the surveyor reviewed the chart. During observation and interview, Resident 11 pointed to a left upper arm bandage when asked where the dialysis access was located and stated there was nothing on the chest. However, the order summary and MAR for November and December documented the dialysis access site as the right upper chest, and nurses charted each day that the access site was on the chest. The DON acknowledged that Resident 11’s current dialysis access site had been changed in November and was actually on the left upper arm, but the physician order had not been updated. The DON also stated it was strange that the site had not been changed in the orders and could not explain why the update had not been made. Licensed staff reviewed the same order and MAR and stated the charting location was the only place nursing could document the dialysis access site, even though the resident no longer had a chest access. The facility policy required nurses to document the location of the catheter, the condition of the dressing, whether dialysis was done during the shift, any post-dialysis report, and post-dialysis observation. The charting documentation policy also required entries to be objective, completed, and accurate. Despite this, the record continued to reflect the old chest access site rather than the resident’s current left upper arm access site.
Unsecured Storage of Resident Medication
Penalty
Summary
The facility failed to secure medications for one of three residents, Resident 8, by storing OCuSOFT LID SCRUB eyelid cleanser in an unsecured bedside cabinet drawer rather than in a locked medication storage area. During observation, a CNA reached into Resident 8’s top drawer and removed an individually wrapped pre-moistened packet of the eyelid cleanser from a blue box. The consulting pharmacist stated that, because of the active ingredients, the product is a medication that requires an active physician order, administration by a licensed nurse, and storage in a locked location. During a later observation, the blue box containing the eyelid cleanser wipes was still found in Resident 8’s bedside cabinet, and the ADON confirmed that medications should be stored in the medication room. The facility policy also stated that medications and biologicals are to be stored in locked compartments with access limited to authorized personnel.
Failure to Use EBP During Wound Care and Maintain Clean Oxygen Tubing
Penalty
Summary
Enhanced barrier precautions were not implemented during high-contact wound care for a resident with a stage 3 pressure injury on the sacrum. During a concurrent observation, a CNA stated she was going to get the nurse to change the resident’s dressing because it was dirty, and the ADON then provided wound care. No enhanced barrier precautions were observed during the wound care. The resident’s care plan, initiated on 07/22/2025, indicated interventions to utilize enhanced barrier precautions during high-contact resident care, and the ADON later confirmed that no EBP was used during the observed wound care. The DSD/IP reviewed the care plan and stated that EBP should be in place for infection control measures to protect the resident from infections in her wounds and for her safety. One resident admitted on 12/23/24 with a history of stroke and pulmonary edema had oxygen tubing that was observed with flecks of debris and crust. During the observation, the tubing from the oxygen concentrator was seen going to the resident’s nostrils, and a licensed staff member stated the tubing was usually changed every day and on the night shift, but did not know when it was last changed because there was no label showing the date, time, and initials. After closer inspection, the staff member noted a brown, crusty beige area on the tubing, stated it looked dirty, and removed the debris with gloved fingers. The facility policy titled Departmental (Respiratory Therapy)- Prevention of Infection stated the oxygen cannula and tubing should be changed every seven days or as needed.
Failure to Provide Consistent ROM Interventions Resulting in Contractures
Penalty
Summary
A facility failed to provide consistent range of motion (ROM) exercises to a resident's left lower extremity (LLE) from admission until hospital transfer, resulting in the development of contractures. Initial assessments and therapy evaluations indicated that the resident had normal ROM in both lower extremities, with no contractures present. However, subsequent therapy notes and evaluations documented a progressive decline in the resident's left knee extension, with increasing difficulty in straightening the knee and performing transfers. Despite these changes, there was no documented change-of-condition evaluation or timely revision of the resident's care plan to address the decline in mobility. Therapy documentation showed that while some improvement in left knee extension was recorded over a short period, there were also periods with no improvement or worsening of the condition. The care plan addressing physical therapy and restorative nursing ROM was not updated to reflect the resident's declining ROM in the LLE, and there was a lack of documentation indicating that lower extremity ROM exercises were consistently provided. Interviews with facility staff confirmed that changes in the resident's mobility were not properly assessed or documented, and that contractures were not initially recognized or addressed in a timely manner. Upon hospital admission, the resident was found to have contractures in the LLE, along with multiple serious wounds, poor blood flow, and signs of infection and tissue death in the affected leg. The hospital team noted that the resident's poor nutrition, tight leg muscles, and compromised circulation would make wound healing difficult. The failure to provide consistent ROM interventions and to update care plans in response to the resident's declining mobility directly contributed to the development of contractures and associated complications.
Inadequate Space for Activities and Dining
Penalty
Summary
The facility failed to provide adequate space for group activities and communal dining for its 43 residents, as observed during a survey. The facility, licensed for 45 beds, conducted activities in the hallway due to the absence of a designated activity or dining room. This arrangement caused inconvenience to residents whose rooms were near the activity area, as they were disturbed by the noise. Resident 32 expressed discomfort with the noise from activities such as music and karaoke held in the hallway outside his room. The Activities Director confirmed that activities were held in the hallway, and residents in nearby rooms often closed their doors to minimize the noise. Additionally, the facility did not have a designated dining room, resulting in residents eating meals in their rooms. The Certified Dietary Manager stated that all meals were served in residents' rooms since the pandemic, and the previous dining room was repurposed as a rehab room. Resident 20 mentioned a preference for eating in a dining room rather than in his room, highlighting the lack of communal dining space. The Administrator acknowledged that activities and dining were conducted in the therapy room, hallway, or patio, depending on the weather, but noted that residents preferred eating in their rooms or the hallway.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the privacy of a resident's unique care instructions, which were posted in two places on the resident's bedroom wall. This action exposed the resident's medical condition to other residents and visitors. The resident, admitted to the skilled nursing facility with diagnoses including Parkinson's Disease, Diabetes Mellitus, and Major Depressive Disorder, was found to have a cognitive impairment with a BIMS score of 8. During interviews, a CNA mentioned that the resident's daughter posted the care instructions, and the DON acknowledged the posting but suggested that the resident's name should not be included. The facility's policy on Resident's Rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in this instance.
Failure to Assess and Educate Resident on Self-Administration of Doxycycline
Penalty
Summary
The facility failed to ensure that a resident could safely self-administer doxycycline, an antibiotic, as there was no assessment or education provided to the resident regarding its self-administration. The facility's policy requires the interdisciplinary team to assess a resident's cognitive and physical abilities to determine if self-administration is safe and appropriate. However, this was not done for the resident in question, who was observed with a bottle of doxycycline on their bedside table and stated they were taking it for a bacterial infection. The registered nurse was unaware of a care plan for the doxycycline, and the case manager confirmed that a self-medication assessment and care plan should be in place for residents self-administering medications. Further investigation revealed that the resident's care plan, dated several months prior, only included five other medications for self-administration, none of which were doxycycline. The assistant director of nursing was also unaware of the resident taking doxycycline and expressed concern about the risk of overdose. The care plan was updated to include doxycycline only after the issue was identified, but the medication orders still did not reflect that the resident was taking doxycycline. This oversight could lead to potential risks such as overdose, drug interactions, or unrecognized side effects.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to maintain a valid Physician Orders for Life-Sustaining Treatment (POLST) for one of the residents, identified as Resident 47. The POLST, which is a critical document for guiding medical treatment decisions during end-of-life care, was found to be incomplete. Specifically, the POLST lacked a clear signature or identity of the individual with whom the POLST was discussed, which is a requirement for its validity. This deficiency was identified during a review of Resident 47's records, which showed that the POLST form did not have the necessary signatures or printed names of either the patient or a legally recognized decision maker. During an interview and record review with the Director of Nursing (DON), it was confirmed that the section of the POLST indicating whether the information was discussed with the patient or a legally recognized decision maker was left blank. The DON acknowledged the absence of a clear signature and printed name, stating that the form was incomplete. Resident 47, who was admitted in April 2024, had a cognitive status indicating intact cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. The lack of a valid POLST form has the potential to result in the resident's end-of-life choices not being honored.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN, Form CMS-10055) to a resident receiving Medicare Part A services. This notice is essential to inform residents of potential financial liability for non-covered stays and their right to appeal. The deficiency was identified for a resident who was admitted with multiple diagnoses, including orthopedic aftercare following surgical amputation, a non-pressure wound, type 2 diabetes mellitus, and end-stage kidney disease. The resident was responsible for his own decisions and was receiving Medicare Part A skilled services, which started on May 12, 2024, and the last covered day was May 31, 2024. The case manager stated that the resident had reached his maximum potential and was saving the remaining Part A days for an upcoming surgery. Although a Notification of Medicare Non-Coverage (NOMNC) was provided to the resident before the last covered day, the SNF ABN was not issued because the resident was out for dialysis on the day it was supposed to be given. The previous Social Services Director confirmed that the SNF ABN was not issued due to the resident's absence for dialysis. The facility's failure to provide the SNF ABN meant the resident was not informed about the potential financial liability and the right to appeal the termination of Medicare Part A services.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required timeframes for a resident who reported hip pain, which was later diagnosed as a pathological fracture. The resident, who had multiple diagnoses including end-stage renal disease, anemia, and muscle wasting and atrophy, was admitted in January 2024. The resident had a Brief Interview for Mental Status score indicating moderate cognitive impairment. On a specific date, the Director of Nursing (DON) noted the resident's complaint of right hip pain and an X-ray revealed a right distal femoral fracture. Despite the absence of any reported falls or activities that could explain the pain, the incident was not reported to the California Department of Public Health as required. Interviews with the DON and the Director of Staff Development confirmed that the injury should have been reported as an injury of unknown origin. The facility's policies on investigating resident injuries and recognizing signs of abuse/neglect indicate that such injuries should be reported and investigated according to established guidelines. However, the interdisciplinary team deemed the injury as likely a spontaneous pathological fracture, and no report was made to the authorities. This oversight in reporting the injury of unknown origin could lead to delayed identification and investigation of possible harm from abuse.
Failure to Timely Complete MDS Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessments for four residents within the required timeframe, as mandated by the Resident Assessment Instrument (RAI) User Manual. Specifically, the admission and annual MDS assessments for Residents 29, 16, 17, and 8 were not completed within 14 days of admission or the Assessment Reference Date (ARD). For Resident 29, the admission MDS assessment was completed 16 days after admission. Resident 16's annual MDS assessment was completed 16 days after the ARD, while Resident 17's annual MDS assessment was completed 17 days after the ARD. Resident 8's admission MDS assessment was completed 29 days after admission. The MDS Coordinator confirmed during interviews that the assessments were completed late and acknowledged the requirement for the admission MDS assessment to be completed by the 14th day of admission and the annual MDS assessment to be completed 14 days after the ARD. The facility's policy and procedure on comprehensive assessments, as well as the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, were reviewed and indicated the necessity for timely completion of these assessments to assist in developing person-centered care plans. The failure to adhere to these timelines could result in delayed identification of residents' needs and significant issues affecting their well-being.
Failure to Timely Complete SCSA for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice care. The resident, who had diagnoses including stroke, respiratory failure, pulmonary fibrosis, and lung involvement in systemic lupus erythematosus, was admitted to hospice on November 11, 2023. According to the facility's records, the SCSA was completed on November 26, 2023, which was 16 days after the resident's admission to hospice care, exceeding the required 14-day timeframe. Interviews and record reviews revealed that the Licensed Vocational Nurse (LVN) and the MDS Coordinator were aware of the resident's hospice admission. The MDS Coordinator confirmed that the SCSA should have been completed within 14 days of the hospice admission. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that an SCSA is required when a terminally ill resident enrolls in a hospice program, and the assessment must be completed within the specified timeframe. The delay in completing the SCSA could potentially delay the provision of appropriate treatment and services for the resident.
Failure to Complete MDS Quarterly Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) quarterly assessments were completed within the required timeframe for three residents. Specifically, the assessments were not completed within 92 days following the previous OBRA assessment, as mandated by regulations. For Resident 20, the quarterly MDS with an Assessment Reference Date (ARD) of May 9, 2024, was completed 26 days after the ARD, instead of the required 14 days. Similarly, Resident 3's quarterly MDS with an ARD of May 14, 2024, was completed 21 days after the ARD, and Resident 17's quarterly MDS with an ARD of May 16, 2024, was completed 17 days after the ARD. The MDS Coordinator acknowledged during interviews that the assessments were not completed within the required timeframe. The facility's policy and procedure, as well as the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, require that the MDS completion date must be no later than 14 days after the ARD. The failure to adhere to these timelines could result in delayed identification of needs and significant issues affecting the residents' well-being.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement a person-centered care plan for three residents, leading to deficiencies in their care. Resident 3, who was readmitted with diagnoses including stroke and respiratory failure, was observed with an ill-fitting non-rebreather mask on top of a nasal cannula. The Licensed Vocational Nurse (LVN) noted that Resident 3 was receiving oxygen at 2 liters per minute (LPM) via nasal cannula, contrary to the active order which required 5 LPM. This discrepancy in oxygen administration was not aligned with the resident's care plan, which specified the need for continuous oxygen at 3-5 LPM. Resident 29, admitted with conditions such as heart failure and chronic obstructive pulmonary disease (COPD), was found to be receiving oxygen at 3 LPM instead of the prescribed 2 LPM. The LVN confirmed the error upon reviewing the active orders and adjusted the oxygen flow accordingly. The care plan for Resident 29 indicated the necessity for continuous oxygen at 2 LPM, highlighting a failure to adhere to the prescribed oxygen settings. Resident 16, who has hemiplegia and vascular dementia, required a two-person assist for transfers using a standing lift. However, during an observation, a Restorative Nursing Assistant (RNA) attempted to transfer the resident alone, stating familiarity with the resident's needs. This was contrary to the care plan, which mandated a two-person assist to ensure safety during transfers. The discrepancy between the care plan and the actual practice posed a risk of falls or injury to the resident.
Failure to Update Care Plan After IDT Assessment
Penalty
Summary
The facility failed to update a care plan following an interdisciplinary team (IDT) assessment for a resident whose body weight was beyond the recommended range specified in their care plan. The care plan, initiated on May 14, 2024, aimed to maintain the resident's body weight within 5% of 195 pounds. However, a review on June 4, 2024, showed the resident's weight had dropped to 182.8 pounds, which was below the 5% threshold. Despite this significant weight loss, the care plan was not updated to reflect the IDT's assessment, which considered the weight loss acceptable due to the resident's diagnosis of congestive heart failure (CHF). During interviews and record reviews, both the Director of Nursing (DON) and the Consultant Registered Dietician (RD) acknowledged the discrepancy between the care plan's weight goals and the IDT's assessment. The RD noted that the care plan should have been updated to align with the IDT's findings, suggesting that a goal based on body mass index (BMI) might be more appropriate for the resident. This oversight in updating the care plan could lead to clinical staff not recognizing significant changes in the resident's weight, potentially impacting their care.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to professional standards of care by not following the physician's orders for oxygen administration for two residents. Resident 3, who was readmitted with conditions including stroke, respiratory failure, and pulmonary fibrosis, was observed wearing an ill-fitting non-rebreather mask over a nasal cannula, contrary to the physician's order of 5 LPM via nasal cannula. The care plan indicated the need for continuous oxygen due to acute respiratory failure, but the observed practice did not align with the prescribed treatment. Similarly, Resident 29, admitted with diagnoses such as heart failure and COPD, was found receiving oxygen at 3 LPM instead of the ordered 2 LPM via nasal cannula. The active orders specified continuous oxygen at 2 LPM, with adjustments only if oxygen saturation fell below 92% or if there was shortness of breath. The facility's policy on oxygen administration emphasized verifying physician orders and ensuring the correct flow of oxygen, which was not followed in these instances.
Inadequate Supervision and Unsafe Transfer Technique
Penalty
Summary
The facility failed to provide adequate supervision and safe transfer techniques for a resident, identified as Resident 16, who required assistance due to medical conditions including hemiplegia, hemiparesis, aphasia, and vascular dementia. The resident's care plan specified the need for two-person assistance during transfers using a sit-to-stand lift. However, a Restorative Nursing Assistant (RNA) conducted the transfer alone, contrary to the care plan instructions. The RNA justified her actions by stating familiarity with the resident, despite acknowledging the requirement for two-person assistance. Additionally, the equipment used for the transfer was found to be in poor condition. The sling used was frayed, torn, and had a missing buckle, which the RNA admitted needed replacement. Interviews with other staff, including a Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON), revealed inconsistencies in understanding the transfer requirements and a lack of recent training on the use of mechanical lifts. The facility's policy and user manuals clearly stated the need for two-person assistance and the importance of using equipment in good condition, which was not adhered to in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of 11% during a medication pass. This was due to three medication errors out of twenty-six opportunities involving two residents. One incident involved a registered nurse who administered medication to a resident without verifying their identity, as the resident did not speak English and no photo identification was available. Additionally, the nurse did not ensure the resident consumed the entire dose of MiraLAX, leaving half of the mixture at the bedside, contrary to the manufacturer's instructions. Another error involved a licensed vocational nurse who improperly administered Flonase to a resident. The resident did not blow their nose before administration, and both nostrils were sprayed simultaneously without closing one nostril as recommended. The nurse did not instruct the resident to exhale through their mouth after administration, failing to adhere to the proper technique for optimal delivery and absorption of the medication.
Unsafe Food Handling Practices Due to Jewelry
Penalty
Summary
The facility failed to ensure safe food handling practices when two kitchen staff members were observed wearing yellow bracelets on both arms during food preparation and handling. This was noted during an initial tour of the kitchen, where the Certified Dietary Manager (CDM) and another kitchen staff member were seen preparing food for lunch while wearing the bracelets. During an interview, the CDM acknowledged the oversight and mentioned that the bracelets had been removed. The staff explained that wearing bracelets is a cultural practice for Indians, signifying marriage. The facility's policy on food preparation and service, dated November 2022, specifies that jewelry should be worn minimally, and hand jewelry should be covered with gloves.
Ineffective QAPI Program Leads to High Medication Error Rate
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) program was found to be ineffective in preventing medication administration errors, as evidenced by a medication pass observation revealing an 11% error rate, which exceeds the acceptable threshold of 5%. During the observation, three errors were identified out of twenty-six medication administration opportunities involving two residents. The first error involved a failure to properly identify a resident before administering medication, as the nurse did not verify the resident's identity due to a language barrier and did not follow the facility's policy for identification. The second error occurred when the same nurse administered MiraLAX to the same resident, who did not consume the entire dose, leaving the medication to settle on the bedside table. The third error involved the improper administration of Flonase to another resident, where the nurse did not follow the correct procedure, resulting in the resident inhaling the medication incorrectly. An interview with the Quality Committee members revealed that they had only attended one meeting in the past year and could not recall any discussions on medication errors. They also lacked an ongoing performance improvement project specifically aimed at reducing medication errors, acknowledging the need for improvements in the medication administration process.
Inadequate Implementation of Infection Control Protocols
Penalty
Summary
The facility failed to implement and maintain its infection control program for two residents on transmission-based precautions. Resident 32, who was admitted with multiple diagnoses including an infection of an amputation stump and MRSA, was supposed to be under contact single room isolation precautions. However, during multiple observations, there was no personal protective equipment (PPE) available outside of Resident 32's room, which was necessary for staff and visitors to wear before entering. Licensed Vocational Nurses (LVNs) confirmed the absence of PPE and expressed uncertainty about its removal, which was against the facility's policy requiring PPE to be available directly outside the room. For Resident 34, who was on enhanced barrier precautions due to a Foley catheter, the facility also failed to adhere to infection control protocols. The PPE cart intended for Resident 34 was incorrectly placed next to his roommate's area instead of his care area. Additionally, during an observation, LVN 1 handled Resident 34's Foley bag without wearing the required PPE, which included a gown, gloves, and mask. The Infection Preventionist confirmed that these precautions were necessary during direct contact with the resident, including touching the Foley bag. The facility's policy and procedure, as well as guidelines from the Centers for Disease Control and Prevention (CDC), emphasize the importance of using PPE during high-contact resident care activities to prevent the spread of multidrug-resistant organisms. Despite these guidelines, the facility did not ensure the proper placement and use of PPE for residents on transmission-based and enhanced barrier precautions, potentially increasing the risk of infection spread among staff and residents.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 759 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Bruno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Millbrae Care Center | 2.4 mi | ★★★★★ | 24 | 0 |
| Peninsula Post-acute | 3.4 mi | ★★★★★ | 12 | 0 |
| Pacifica Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 4 | 0 |
| Golden Pavilion Healthcare | 4.5 mi | ★★★★★ | 2 | 0 |
| Golden Heights Healthcare | 4.5 mi | ★★★★★ | 0 | 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.