Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Mateo Medical Center D/p Snf during CMS and state inspections, most recent first.
A resident with epilepsy, HTN, and brain cancer did not receive several ordered meds as prescribed. Staff documented missed or delayed doses of Phenobarbital, Olmesartan, Metoprolol, and Hydroxyzine due to pharmacy availability issues, missing documentation, and one instance where Hydroxyzine was given 4 times instead of the ordered 3 times daily. The DON and LPNs confirmed the MAR entries and noted that some doses were not given on time or were not properly documented.
Inadequate Supervision of Resident at Risk for Elopement: A resident with moderate cognitive impairment was identified as an elopement risk and wanderer, with documented exit-seeking behavior and a WanderGuard order. Staff observed the resident playing with and trying to remove the device, and the eMAR showed he refused to wear it on the night shift. The resident was later found missing after being seen in his room earlier, and the DON stated the WanderGuard was found on his bed after he removed it and got past the alarm.
A resident with recurrent acute diverticulitis reported being in severe pain for several hours, repeatedly using the call light and calling out without staff response, later discovering the call bell was unplugged and independently contacting the hospital for assistance. An LVN stated the resident never activated the call light and was found asleep during rounds, and the Unit Supervisor acknowledged conducting an investigation but failed to document interviews or details and did not interview other residents, roommates, or family members as required by policy. Subsequent testing showed the resident’s call light cord-out feature did not trigger an alarm, additional rooms had non-functioning cord-out features, and the Maintenance Director was unaware of and did not maintain this safety feature.
A resident with recurrent acute diverticulitis reported being very sick and in pain, repeatedly using the call light without staff response for several hours, with the room door closed and the call bell later found to be disconnected. The resident ultimately called the hospital emergency room and, when ambulance staff arrived, told an LVN she had been calling for hours without help. The LVN, Unit Supervisor, and DON were aware of the resident’s allegation that staff did not respond to her calls for assistance, but the Unit Supervisor considered the complaint as the resident “venting” rather than an allegation of neglect, and it was not reported or investigated as required by the facility’s abuse and neglect reporting policy.
The facility did not maintain safe water temperatures in resident bathrooms, allowed multiple residents to keep smoking materials in their possession—including in rooms where oxygen was in use—and failed to provide adequate supervision to prevent two residents from eloping, including one with severe memory impairment. Staff and resident interviews confirmed that facility policies on water temperature, smoking, and elopement prevention were not consistently implemented.
The facility did not conduct a thorough investigation after an allegation of sexual abuse between two residents. Although both residents and a staff witness were interviewed, there was no evidence that other residents in the area were assessed or interviewed, and investigation documentation was incomplete. The facility's policy required thorough investigations but lacked guidance for cases involving non-interviewable residents without family.
A resident developed a Stage III pressure ulcer due to the facility's failure to perform accurate body checks and report earlier stages of skin impairments. The resident, at moderate risk for pressure ulcers, had multiple skin impairments that were not properly documented or reported, leading to the development of in-house acquired Stage III pressure ulcers on the left heel and buttock.
The facility failed to serve food according to residents' preferences, such as Jook and various soups. Despite documented preferences, meals served did not align with these preferences, affecting residents' quality of life and nutritional satisfaction.
The facility failed to provide meals according to scheduled serving hours, with consistent delays in breakfast and lunch service. Staff confirmed the delays, and residents reported receiving cold or frozen food. The facility's policy requires specific meal times, but these were not adhered to, affecting residents' dining experience and well-being.
The facility failed to ensure food safety by not properly drying utensils, cleaning plate warmers, and storing serving trays in a sanitary manner. Additionally, undated food items and overripe grapes were found in the refrigerator, and a hand sanitizer dispenser was improperly used in the kitchen.
The facility failed to ensure dignity and respect for three residents by not adhering to proper feeding and communication protocols. Staff were observed standing over two residents while assisting them with meals, and the facility did not provide adequate communication support for a resident whose preferred language is Cantonese, relying instead on makeshift methods and family members for translation.
The facility failed to ensure proper coordination and communication with the hospice agency for three residents, leading to significant deficiencies in care. For one resident, there was no coordination for communication regarding changes in condition and death, and the family was not notified. Another resident's care plan did not include specific hospice interventions, and a third resident's care plan lacked documentation of hospice care interventions. Facility policies on end-of-life care and hospice care were not followed.
The facility failed to ensure that three residents were free from unnecessary psychotropic medications due to the lack of proper consent and adherence to medication protocols. Consents were not obtained for various medications, and PRN orders were not properly managed, leading to potential adverse health consequences.
The facility failed to ensure medications were not expired and stored properly. One medication cart contained expired or unlabeled eye drops, and multiple medications were stored in the garage without temperature control. Staff acknowledged these issues, and the Pharmacist confirmed the need for controlled storage temperatures and daily temperature logs.
The facility failed to develop comprehensive care plans for two residents, one with pressure ulcers and another using Lorazepam for anxiety, leading to deficiencies in addressing their specific medical needs.
The facility failed to post complete nurse staffing data daily, missing the total number and actual hours worked by each category of nursing staff from 3/11/24 to 3/15/24. Interviews revealed that the correct data was not posted as required by the facility's policy.
The facility failed to maintain accurate reconciliation for Hydromorphone for a resident. The LVN did not document the administration of the medication immediately as required, leading to a discrepancy between the documented and actual number of tablets. This was confirmed by the DON during the survey.
The facility failed to act on the pharmacy consultant's recommendation for a resident's psychotropic medication. The resident, diagnosed with dementia and anxiety, had an order for Lorazepam that was not reviewed or discontinued as recommended, leading to potential unnecessary medication use and adverse health consequences.
A facility failed to follow a physician's order for administering Hydromorphone to a resident, resulting in an excessive dose being given for moderate pain. The LVN administered two tablets instead of one, despite the resident's pain level being documented as a 7, which is considered moderate pain. The DON confirmed the medication was given outside the prescribed parameters.
The facility failed to ensure proper disposal of refuse in the kitchen, as a half-open recycle container near the food preparation area was observed. The Clinical Services Manager and Director of Food and Nutrition Services had differing opinions on when to close the lid, leading to potential contamination risks. Infection Preventionists confirmed that the facility's policy requiring close-fitting covers on waste containers was not followed.
The facility failed to maintain an effective infection control program, evidenced by an expired Biohazard Spill Kit and improper cleaning of a glucometer. The Infection Preventionist acknowledged the expired kit, and a Licensed Vocational Nurse used non-approved wipes for cleaning the glucometer, contrary to the manufacturer's instructions and facility policy.
The facility failed to ensure staff were trained on infection control practices for oral suctioning, with nurses unaware of protocols for changing tubes and cleaning canisters. Interviews revealed no specific policies or procedures for suctioning, and staff were unsure about proper maintenance of the equipment.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident with diagnoses including epilepsy, hypertension, and malignant neoplasm of the brain. The resident was cognitively intact per the MDS. During interview, the resident stated that Phenobarbital, Olmesartan Medoxomil, Metoprolol, and Hydroxyzine were sometimes not taken on time from February through April 2026 because the resident ran out of the medications, and the resident was worried about the effect on health. Record review and staff interviews showed multiple medication administration issues. The MAR documented a missed dose of Metoprolol on 3/4/26 with a chart code indicating vitals were outside parameters, but the Weights and Vitals Summary did not show BP or pulse at that time, and the nurse stated the BP and pulse may have been missed on the MAR. The MAR also showed Olmesartan Medoxomil was not given on 2/12/26, 3/7/26, and 4/9/26 because the medication was not available from the pharmacy, and staff stated the pharmacy had not delivered it on time even though refills had been requested. The DON confirmed one of these omissions and noted there were no nursing notes explaining why the medication was not given. The record also showed Phenobarbital was not given on 2/28/26 because it was not available from the pharmacy, and the nurse acknowledged there was no nursing progress note or Orders-Administration Note to explain the chart code used. Hydroxyzine was documented as given four times on 3/23/26 even though the physician order was for three times daily, and both nurses interviewed acknowledged the medication should have been administered only three times. Hydroxyzine was also not given on 3/22/26 at 1 PM because it was not available from the pharmacy. The facility policy stated that all medications shall be administered according to physician orders and in a timely, safe, and documented manner.
Inadequate Supervision of Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as an elopement risk and wanderer, and the resident was able to leave the supervised area after removing his WanderGuard. The resident’s records showed a BIMS score of 8 out of 15, indicating moderate impairment in memory and reasoning abilities. His care plan identified him as an elopement risk/wanderer related to impaired safety awareness after an attempt to leave the facility, and an IDT note documented wandering behaviors and exit-seeking attempts. The eMAR for May 2026 showed that on the night shift the resident refused to wear his WanderGuard, stating he was okay and after risks and benefits were explained to him. During interviews, a CNA stated she saw the resident in his room during morning rounds, then found him missing after returning from break and notified the nurse. The CNA stated the resident was confused, was an elopement risk, and had a WanderGuard, and she believed he had it on earlier that morning. An LVN stated the resident had a recent physician order for the WanderGuard, had been observed playing with it and trying to remove it, and that night shift did not report his refusal to wear it. The DON stated staff later found the WanderGuard on the resident’s bed, indicating he had removed it and was able to get past the alarm. The facility’s policy required residents at risk for elopement to be identified upon admission and when there was a change in condition.
Failure to Thoroughly Investigate Allegation of Neglect and Call Light Malfunction
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving Resident 1, one of three sample residents. Resident 1, who had a diagnosis of recurrent acute diverticulitis and reported being very sick and in pain, stated that sometime in January she repeatedly used her call light and called out in pain for approximately four hours without staff responding. She reported that someone closed her room door and that she later discovered her call bell was not connected, although she had not initially realized it was unplugged. She stated that, after no one responded, she called the hospital emergency room herself, and when the ambulance arrived and transported her out of the room, she saw an LVN at the desk and told the LVN she had been calling for hours for help. A hospital discharge summary dated 1/15/2026 documented her diagnosis of recurrent acute diverticulitis. During interviews, LVN 1 characterized the resident as having a history of false accusations and stated that the resident never turned on the call light or called for help, and that staff found her asleep during rounds. The Unit Supervisor reported that he conducted an investigation based on the resident’s complaint that she had been in pain for four hours, had used her call light, and had been unaware that her call light was unplugged from the wall. However, the Unit Supervisor did not document any part of his investigation, including interviews with nurses or the resident, and could not provide specific dates, times, or content of those interviews. He also did not interview other residents, roommates, family members, or responsible parties as required by facility policy. When the resident’s call light was later tested, the cord-out feature did not trigger an alarm at the nursing station, and additional rooms were found with non-functioning cord-out features. The Maintenance Director stated he was unaware the call light system had a cord-out feature and did not include it in his routine maintenance checks. The facility’s Abuse-Reporting & Investigations policy required interviewing individuals who may have information relevant to the allegation, such as the resident, witnesses, other residents, roommates, family, and visitors, which was not done in this case.
Failure to Recognize and Report Resident Allegation of Neglect
Penalty
Summary
Facility staff failed to recognize and report an allegation of neglect when a resident stated she had been in pain and that staff did not respond to her calls for assistance over several hours. The resident reported that sometime in January she was very sick and in pain, repeatedly rang for the nurse, and no one came to her room. She stated that someone had closed her room door and that her call bell was not connected, which she did not initially realize. She continued to ring without response, became worried, and ultimately called the hospital emergency room herself. When ambulance staff arrived and wheeled her out of the room, she observed a LVN sitting at the desk and told the LVN she had been calling for hours for help, describing the experience as very scary. Record review showed that the resident’s hospital discharge summary dated 1/15/2026 documented a diagnosis of recurrent acute diverticulitis, a sudden onset inflammation/infection of a portion of the colon that may cause sudden intense abdominal pain. During interviews, the LVN and the Unit Supervisor both acknowledged they were aware that the resident had alleged she was in pain and that staff did not respond to her calls for assistance. The DON stated that when the Unit Supervisor spoke with the resident by phone regarding her hospitalization on 1/21/2026, the Unit Supervisor did not identify the resident’s statements as an incident of neglect, instead characterizing them as the resident “just venting.” This response was inconsistent with the facility’s Abuse-Reporting & Investigations policy, which requires the facility to promptly report and thoroughly investigate all allegations of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, injuries of unknown source, and suspicions of crimes.
Failure to Prevent Accident Hazards, Unsafe Smoking Practices, and Inadequate Elopement Supervision
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for its residents. Specifically, hot water temperatures in six out of eight resident bathroom sinks were found to be excessively high, ranging from 121.6°F to 136.7°F, which exceeded the facility's policy limit of 120°F. Residents affected included individuals with severe cognitive and visual impairments, such as schizoaffective disorder, dementia, and Alzheimer's disease, who were able to access the bathrooms independently. Staff confirmed that daily random water temperature checks were performed, but the temperatures remained above the safe threshold, and the facility's policy on water temperature was not effectively implemented. The facility also failed to ensure safe smoking practices and did not enforce its smoking policy. Multiple residents were allowed to keep lighters and cigarettes in their possession within the resident care areas, despite facility policy requiring all smoking materials to be stored at the nursing stations. One resident was observed igniting a lighter in her room while her roommate was actively receiving continuous supplemental oxygen, directly violating the facility's oxygen therapy and smoking policies. Interviews with residents and staff confirmed that several residents routinely kept smoking materials in their rooms or on their person, and staff were aware of this practice. Additionally, the facility did not provide adequate supervision to prevent elopement for two residents identified as high risk. One resident with a history of wandering and severe memory impairment eloped from the facility and was found over a mile away after more than two hours. Documentation and investigation of the incident were lacking, and the resident's care plan was not updated with effective interventions. Another resident also eloped, and staff interviews revealed that supervision and documentation were insufficient to prevent or address the incident. The facility's policy on wandering and elopement was not consistently followed, as required assessments, notifications, and care plan updates were not completed.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving two residents. According to the documentation, one resident reported to the receptionist that another resident exposed himself and requested inappropriate contact. The facility's investigation included interviews and assessments of both residents and a statement from an activity staff member who witnessed part of the incident. The staff member reported seeing one resident attempting to pull his zipper down but did not observe any exposure of genitals. The investigation documents were not titled or dated, and there was no evidence that the facility assessed or interviewed other residents in the area who may have been affected or had information about the incident. During interviews, the Administrator and DON described their general process for investigating abuse allegations, including interviewing staff, residents, and family, as well as checking the environment and conducting body checks for non-interviewable residents. However, in this case, there was no documentation that these steps were followed for other potentially affected residents. The facility's abuse policy required prompt and thorough investigations, including interviewing witnesses and other residents under the care of the staff member involved, but did not provide specific guidance for situations where a resident was not interviewable and had no family. This lack of thorough investigation did not ensure that other residents were protected from abuse.
Failure to Prevent Development of Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of a preventable pressure ulcer for a resident when staff did not perform an accurate body check that reflected and identified the resident's skin condition. The resident, who was readmitted with diagnoses including diabetes, congestive heart failure, and malnutrition, was assessed as moderate risk for developing pressure ulcers. Despite this, the resident developed a Stage III pressure ulcer on the left heel and left buttock, which were in-house acquired and not reported in earlier stages by the staff. The facility's records indicated that the resident had no pressure injuries on readmission, but subsequent assessments revealed multiple skin impairments, including a Stage III pressure ulcer on the sacrum and upper back, which were present on admission, and a new Stage III pressure ulcer on the left heel and left buttock that developed in-house. The facility's documentation and staff interviews revealed that the pressure ulcers were not reported in their earlier stages, and the physician was not notified of the identified skin impairments. The facility's policies on skin integrity management and pressure injury prevention did not provide clear procedures for risk assessment, skin inspection, interventions, and documentation, contributing to the deficiency.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to serve food and substitutes according to residents' preferences, specifically for those who preferred Jook (rice soup) and various types of soups. During an observation and interview with a cook, it was noted that the meal being prepared was meatballs, pasta, and spinach, with no Jook or soup available. Several residents' meal tickets indicated preferences for Jook or soup, but these preferences were not honored. For example, Resident 90's meal ticket indicated a preference for hamburgers and a dislike for pasta, yet no hamburger was served when the menu included meatballs. This discrepancy was confirmed by the kitchen aide and the cook, who acknowledged that Jook was not available on the tray line that day. The Dietary Manager (DM) and the Consultant Registered Dietician (CRD) were also interviewed and confirmed the absence of Jook and soup on the menu. A review of the facility's policy and procedure for dietary profiles and resident preferences revealed that the DM is responsible for meeting with residents within 72 hours of admission to capture and update their nutritional needs and preferences. Despite this policy, the facility failed to provide meals that aligned with the documented preferences of several residents, affecting their quality of life and nutritional satisfaction.
Failure to Adhere to Scheduled Meal Times
Penalty
Summary
The facility failed to provide meals according to the scheduled serving hours, particularly for breakfast and lunch. Observations and interviews revealed that the meal cart consistently arrived late on the second floor, with breakfast being served as late as 10:15 AM. Staff, including a certified nursing assistant and the Dietary Manager, confirmed the delays. The Registered Dietitian Consultant and the facility's Consultant were informed of the issue but did not provide immediate solutions. On one occasion, the last meal cart left the kitchen at 2:30 PM, well past the scheduled lunch hours. Residents reported receiving cold or frozen food, and some were observed waiting for their meals in the hallways or by their doors, indicating a significant delay in meal service. The facility's policy requires that meals be served within specific time frames, with breakfast scheduled between 7:00 AM and 9:00 AM, lunch between 11:30 AM and 1:30 PM, and dinner between 5:00 PM and 7:00 PM. The failure to adhere to these schedules, especially the 14-hour rule between dinner and breakfast, was evident. Residents expressed dissatisfaction with the meal service, citing issues such as cold eggs and frozen foods. The Dietary Manager, who had recently started the job, acknowledged the problems but did not provide immediate corrective actions. The Dietary Supervisor also mentioned managing the employees to ensure efficiency, but the delays persisted, affecting the residents' overall dining experience and well-being.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure food safety requirements in accordance with professional standards for food service. During an observation, multiple stacks of small plastic bowls, large plastic food containers, and baking pans were found to be moist and wet, indicating they were not dried appropriately before storage. This was confirmed by the facility's Consultant and the Regional Registered Dietician (RD). Additionally, three plate warmers were found to be dirty with dust, pebbles, straws, stained papers, and other dried substances, despite the RD stating they were cleaned. The facility lacked a specific policy and procedure for the maintenance of plate warmers, further contributing to the deficiency. Serving trays were observed stacked and stored on a dusty cart outside the kitchen door, surrounded by opened packets of salt and pepper, and a box of hair caps. The Regional RD acknowledged the trays were clean but the surrounding environment was not sanitary. Furthermore, a hand sanitizer dispenser was found in the kitchen, which is not a replacement for proper handwashing. Despite the RD's claim that the dispenser was not in use, it was found to be functional and was later removed after being pointed out. In the refrigerator, 63 bowls of cream of rice and 40 bowls of oatmeal were found undated, which the Director of Food and Nutrition Services (DoFNS) acknowledged should have been labeled with preparation and use-by dates. Additionally, two packs of grapes were found to be overripe and mushy, with received dates indicating they were 13 and 16 days old. The Clinical Services Manager (CSM) confirmed the grapes were overripe and should have been discarded. The facility's Standard Operating Procedures and Shelf Life Chart for Produce were not followed, leading to the deficiency in food safety and storage practices.
Failure to Maintain Resident Dignity and Provide Adequate Communication Support
Penalty
Summary
The facility failed to ensure dignity and respect for three residents by not adhering to proper feeding and communication protocols. Staff were observed standing over two residents while assisting them with meals, which is against the recommended practice of sitting at eye level to make residents feel more comfortable. Both Certified Nursing Assistants (CNAs) involved admitted to standing because it was easier for them, and Licensed Vocational Nurses (LVNs) acknowledged that this practice was incorrect and not in line with facility guidelines. Additionally, the facility did not provide adequate communication support for a resident whose preferred language is Cantonese. The resident's care plan indicated a need for an interpreter, but staff were observed using makeshift methods such as hand gestures, picture boards, and Google Translate to communicate. Interviews with various staff members revealed that the facility lacked a reliable interpreter service, and staff often had to rely on other bilingual staff members or family members to translate, which is against the facility's policy. The facility's policy on translation and interpretation services was not followed, as it mandates the provision of competent oral translation services free of charge and discourages reliance on family members for interpretation. The Social Services Director and other staff confirmed that while some resources like picture boards and Google Translate were available, there was no formal interpreter service in place, leading to potential communication barriers for residents with limited English proficiency.
Lack of Coordination and Communication with Hospice Agency
Penalty
Summary
The facility failed to ensure proper coordination and communication with the hospice agency for three residents, leading to significant deficiencies in care. For Resident A, there was no coordination for communication between the facility and the hospice agency regarding changes in the resident's condition and death. The staff were not trained on the protocol for notifying the family, MD, and hospice. This resulted in the family not being notified of the resident's change in condition and death. Additionally, there were no progress notes or notifications made by the facility staff on the day of the resident's death. For Resident 155, the care plan did not include specific interventions for coordination of care between the facility and the hospice agency. The facility's care plan only mentioned the name of the hospice agency and contact number, without detailing the hospice services or interventions. Interviews with staff revealed that the hospice nurse visits and charts in a separate binder, but this information was not integrated into the facility's care plan. Resident B's care plan also lacked documentation of hospice care interventions. The facility's policies on end-of-life care and hospice care were not followed, as the care plans did not reflect hospice interventions, and there was no collaboration between the facility and hospice staff. This lack of coordination and communication had the potential to result in inadequate treatment and care for the residents involved.
Failure to Obtain Consent and Adhere to Psychotropic Medication Protocols
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications due to the lack of proper consent and adherence to medication protocols. For Resident 66, the facility did not obtain consent for the use of Mirtazapine at the increased dosage of 15 mg, despite the medication being administered regularly. The Licensed Vocational Nurse (LVN) confirmed that the consent was not updated to reflect the current order, and the Pharmacist stated that a new consent is required when the dosage is increased. For Resident 118, the facility did not obtain consents for the use of Aripiprazole, Buspirone, and Haloperidol. The LVN and Resident Care Coordinator (RCC) both confirmed that there were no consents on file for these medications. The LVN acknowledged the responsibility of obtaining these consents but failed to do so. Resident 255 was administered Lorazepam and Trazodone without the necessary consents. Additionally, the PRN order for Lorazepam did not have a stop date and was administered beyond the recommended 14-day period. The LVN confirmed the absence of consents and the Pharmacist highlighted the requirement for PRN psychotropic medications to be limited to 14 days unless renewed. The facility's policy also mandates that PRN orders should not exceed 14 days without proper documentation and renewal, which was not followed in this case.
Expired and Improperly Stored Medications
Penalty
Summary
The facility failed to ensure medications were not expired and stored properly. One out of six sampled medication carts contained two prescription eye drops that were either expired or not labeled after opening. During an observation and interview, an opened Latanoprost Ophthalmic solution was found in the medication cart drawer with an expiration date that had passed. Another Latanoprost Ophthalmic solution was found without an open date or expiration date after opening. The Licensed Vocational Nurse acknowledged that these medications should have been discarded. Additionally, multiple medications were found to be stored in the garage without temperature control. Bottles of Hydrogen Peroxide 3%, Milk of Magnesia, ClearLax, and Stomach Relief were observed on the shelves in the garage storage. The Infection Preventionist and Central Supply Coordinator acknowledged that these over-the-counter drugs should not be stored in the garage and should be kept in the medication room in the nursing station. There was no thermometer or temperature log in the garage storage to ensure that medications were stored at room temperature. The Pharmacist confirmed that over-the-counter drugs should be stored at controlled temperatures and that temperature logs should be maintained daily.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in addressing their specific medical needs. Resident 111, who was readmitted with diagnoses including diabetes, congestive heart failure, and malnutrition, had two Stage 3 pressure ulcers. Despite the presence of these ulcers, the care plan for Resident 111 did not include specific interventions for the newly identified pressure ulcer on the left buttock, and the existing care plan for the left heel ulcer was not detailed enough to reflect the physician's orders. This lack of specificity and comprehensiveness in the care plan was acknowledged by the LVN during the review. Similarly, Resident 66, who was admitted with diagnoses including dementia, anxiety, and major depressive disorder, had an order for Lorazepam to treat anxiety. However, there was no care plan developed to address the use of this antianxiety medication. The LVN confirmed the absence of a care plan for Lorazepam during the review. The facility's policy on comprehensive person-centered care planning requires that care plans be periodically reviewed and revised, especially upon the onset of new problems, which was not adhered to in these cases.
Failure to Post Complete Nurse Staffing Data Daily
Penalty
Summary
The facility failed to post complete nurse staffing data daily from 3/11/24 to 3/15/24. During observations on 3/11/24, 3/12/24, and 3/13/24, the posted nurse staffing information was found to be incomplete, missing the total number and actual hours worked by each category of nursing staff. The posted data only included the facility name, date, number of employees for all shifts, and census. This incomplete posting remained unchanged until 3/15/24. Interviews with the Administrator and Staffing Coordinator revealed that the staffing data was prepared by the Staffing Coordinator and left for the NOC shift supervisor to update at midnight, but the correct data was not posted for the specified dates. The facility's policy and procedure, dated 7/2018, requires the posting of specific nurse staffing data daily at the beginning of each shift. This includes the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides, along with the resident census. The failure to comply with this policy was confirmed through interviews and record reviews, indicating a lapse in the facility's adherence to its own staffing posting requirements.
Inaccurate Reconciliation of Controlled Substance
Penalty
Summary
The facility failed to maintain accurate reconciliation for a controlled substance, specifically Hydromorphone, for one of the residents. The policy for controlled medications required that the licensed nurse administering the medication immediately document the date and time of administration, the amount administered, and the signature of the nurse. However, a review of Resident 233's medication administration record indicated discrepancies. The record showed that 2mg of Hydromorphone was administered at 9:00 AM, but during an interview, the LVN stated that she had given two tablets that day. An observation confirmed that the supply contained 24 tablets, while the narcotic record indicated there should be 26 tablets remaining. This discrepancy was acknowledged by the LVN and later confirmed by the Director of Nursing, who reiterated that documentation should be done immediately after administration. The failure to accurately document and reconcile the controlled substance could lead to medication diversion. The inconsistency between the documented number of tablets and the actual count was evident during the surveyor's review and interviews. The Director of Nursing confirmed that the LVN did not follow the policy of immediate documentation after administering the medication. This lapse in proper recordkeeping and adherence to policy was identified as a deficiency during the survey.
Failure to Act on Pharmacy Consultant's Recommendation for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the pharmacy consultant's recommendation for the use of psychotropic medication was acted upon for Resident 255. Resident 255, who was admitted with diagnoses including dementia and anxiety, had an order for Lorazepam 0.5 mg to be taken as needed for anxiety. The Consultant Pharmacist's Medication Regimen Review (MRR) dated 12/30/23 recommended evaluating the necessity of continuing the PRN psychotropic medication and suggested that if continued, the order should be written for a maximum of 14 days with no refills. However, there was no response from the physician to this recommendation in January 2024, and the medication was not discontinued until 3/1/24, well beyond the recommended 14-day period. During an interview, the Licensed Vocational Nurse (LVN) confirmed that the order for Lorazepam was still active until 3/1/24. The Pharmacist acknowledged that the MRR is conducted monthly and that irregularities are communicated to the nurse and physician, but there was no documented response from the physician regarding the recommendation made in December 2023. The facility's policy requires the attending physician to document any action taken in response to identified irregularities, which was not done in this case. This failure had the potential to expose Resident 255 to unnecessary psychotropic medications and adverse health consequences.
Failure to Follow Physician's Order for Pain Medication Administration
Penalty
Summary
The facility failed to follow the physician's order regarding the administration of Hydromorphone for a resident. Specifically, the Licensed Vocational Nurse (LVN) administered an excessive dose of Hydromorphone to Resident 233, who was prescribed 2 mg every four hours as needed for severe pain. The LVN gave two tablets instead of one, despite the resident's pain level being documented as a 7, which is considered moderate pain according to the facility's pain assessment order. The policy required the nurse to document the pain score prior to administering the medication and to adhere to the seven 'rights' of medication administration, including the right dose. The discrepancy between the documented number of tablets in the narcotic record and the actual number of tablets available further indicated a failure in proper medication management. During the review, it was confirmed that the LVN did not follow the physician's order and administered the medication outside the specified parameters. The Director of Nursing (DON) acknowledged that the LVN gave the pain medication outside the prescribed parameters and administered the wrong dose. This failure to adhere to the physician's order and the facility's medication administration policy had the potential to result in an adverse reaction, such as respiratory depression, for the resident.
Improper Disposal of Refuse in Kitchen
Penalty
Summary
The facility failed to ensure proper disposal of refuse in the kitchen, as observed during a survey. A blue-colored recycle container near the flat top griddle was found half-open and almost full of empty chocolate pudding cans with small pudding residue. During the observation, the Clinical Services Manager (CSM) stated that the lid should be closed, while the Director of Food and Nutrition Services (DoFNS) disagreed, indicating that the lid could be closed at the end of the day. This discrepancy in handling the refuse container was noted during an interview with the Infection Preventionists (IP) 2 and 3, who agreed that the half-open container could contaminate food in the preparation area. The facility's policy and procedure (P&P) on infection control in food and nutrition services, which mandates that waste containers should have close-fitting covers, was not followed in this instance. The U.S. Food and Drug Administration's 2022 Food Code also requires that refuse containers containing food residue be kept covered to prevent contamination and attract pests. Both IP 2 and IP 3 verified that the facility's P&P was applicable to the situation observed in the kitchen.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two key deficiencies. First, an unopened Biohazard Spill Kit with an expiration date of four years ago was found in the garage storage. The Infection Preventionist (IP) acknowledged the expired kit and admitted that it should have been discarded. Additionally, there was no specific policy regarding the expiration dates for supplies, although the facility's policy on medication storage could be applied to cleaning supplies like the Biohazard Spill Kit. This oversight indicates a lapse in the facility's protocol for managing expired supplies, which could compromise infection control measures. Second, the facility did not implement the correct cleaning and disinfecting practices for a glucometer used to test a resident's blood sugar. A Licensed Vocational Nurse (LVN) was observed cleaning the glucometer with a green non-bleach Clorox wipe, which is not approved for use on the device. The glucometer manufacturer’s manual and the facility's policy both specify the use of specific germicidal wipes for cleaning the glucometer. The IP confirmed that the green non-bleach Clorox wipes should not be used on the glucometer, highlighting a failure to adhere to proper disinfection protocols for critical medical equipment.
Lack of Training and Protocols for Oral Suctioning
Penalty
Summary
The facility did not ensure staff were trained on infection control practices for oral suctioning, as evidenced by the lack of knowledge among nurses regarding the protocol for changing tubes and cleaning the canister. During observations, a resident's bedside table was found with a suction machine and a suction tip that was not dated, mixed with other personal hygiene items. Interviews with various staff members, including CNAs, LVNs, and the Infection Preventionist, revealed that there was no specific policy or procedure for oral suctioning, and staff were unsure about the proper protocols for using and maintaining the suction equipment. The resident's son, who is the responsible party, preferred to handle the suctioning himself, but there was no documentation or clear communication about the maintenance of the equipment. Interviews with multiple LVNs indicated that they either had never used the suction machine or were unsure about the facility's protocol for its use and maintenance. Some staff mentioned that they would refer to the facility's policy, but no such policy was found. The Infection Preventionist confirmed that the responsibility for cleaning and changing the suction machine's tubing lies with the licensed nurse, but acknowledged the absence of specific policies and procedures for suctioning. This lack of training and clear guidelines could lead to breaks in infection control practices, potentially spreading infections among residents.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 876 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Mateo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookside Skilled Nursing Hospital | 1 mi | ★★★★★ | 10 | 0 |
| Belmont Healthcare Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Devonshire Oaks Nursing Center | 5.3 mi | ★★★★★ | 0 | 0 |
| Peninsula Post-acute | 6.2 mi | ★★★★★ | 12 | 0 |
| Millbrae Care Center | 7.2 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.