Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Pablo Healthcare & Wellness Center during CMS and state inspections, most recent first.
A resident with encephalopathy, traumatic brain injury, unsteadiness of feet, and type 2 DM with kidney disease, and documented moderate cognitive decline, had a known history of elopement and goal-directed wandering with expressed desire to go home. Despite prior elopement through an emergency door and assessments identifying high elopement risk, the care plan for wandering/elopement did not include a wander guard intervention. On one morning, kitchen staff unlocked the main entrance to allow another staff member in and failed to relock it, leaving the front door unmanned while staff attended to other care tasks. The resident removed the wander guard and exited through the unlocked front door without supervision or authorization, later confirmed by CCTV. Facility policy required staff to accompany residents who exit and to complete thorough unusual occurrence investigations with staff interviews, but the investigation lacked written interviews from the staff member who had unlocked the door.
Staff failed to follow the facility’s policy for investigating injuries of unknown origin when a resident was found with a complete avulsion of the right great toenail and no one knew how it occurred. The resident had mild cognitive impairment and aphasia, limiting the ability to explain the event. A CNA discovered the missing toenail and notified an LVN, who asked other nurses but obtained no explanation. Documentation noted the resident often dangled feet off the bed and sometimes hit hard surfaces, and the LVN assumed this might be the cause. However, the DON confirmed that no formal investigation was conducted and the IDT did not review the unexplained injury, despite policy requirements for thorough investigation of such injuries.
A resident with mild cognitive impairment, aphasia, and a seizure disorder frequently dangled her feet outside the bed, sometimes striking hard parts of the bed and a nearby table, which was documented as causing damage to her skin and nails. Staff later discovered a complete avulsion of the resident’s right great toenail, with no one able to explain how it occurred, and an LVN assumed it might be related to the foot-dangling behavior. Observation showed the resident in bed with her feet near the footboard and no protective devices in place. The DON acknowledged that, despite awareness of the behavior and its effects, the IDT had not incorporated this behavior into the resident’s care plan with specific interventions.
The facility failed to follow its abuse prevention policy by hiring and retaining a CNA who had a documented finding of patient abuse on the state nurse aide registry and was listed on OIG/medical exclusion and State Board lists, without obtaining required reference checks or making reasonable efforts to uncover past criminal prosecutions. This CNA was later involved in an incident in which a cognitively intact, paraplegic resident reported verbal and physical abuse after requesting assistance with clothing and water, stating the CNA refused proper help and spilled water on the wheelchair, damaging items in the resident’s wallet, while the CNA gave a differing account of items sliding off a bedside table.
A resident with mild cognitive impairment and anxiety disorder reported that a staff member may have used their bank card for unauthorized online purchases. Although the facility assisted the resident in replacing the card and changing passwords, the administrator did not report the allegation to law enforcement or regulatory agencies as required by policy, instead handling the matter internally.
Surveyors found a reddish-brown residue inside and around the ice chute dispenser of the residents' ice machine during an inspection with the MD and RD. The residue was confirmed by wiping with a paper towel, and both the MD and DON acknowledged that the ice machine should have been clean and free of dirt to prevent foodborne illness. Facility policy and FDA Food Code require routine cleaning and sanitizing of food-contact equipment, which was not followed in this instance.
A deficiency was identified when an LVN pre-poured medications for multiple residents instead of preparing them immediately before administration, as required by facility policy. The LVN carried a tray with several pre-labeled medication cups and administered them after preparing them in advance, stating this made her medication pass faster. The DON confirmed that this practice was not permitted and posed risks for medication errors and infection control breaches, as outlined in the facility's medication administration policy.
Several residents reported that meals were consistently bland and lacked flavor, prompting them to use extra salt and pepper. During a meal observation, a resident complained to staff about the lack of taste. A test tray tasting by surveyors and dietary staff confirmed that the food was bland. The Dietary Services Supervisor acknowledged the importance of flavorful meals, and facility policy required recipe concerns to be reported for evaluation.
A staff member discussed a resident's Parkinson's diagnosis, hand tremors, and hearing impairment out loud during lunch in front of another resident and within earshot of others. This public disclosure of confidential health information violated the resident's right to privacy and dignity, as confirmed by the DON and facility policy.
A resident with Depression and PTSD was not referred for a Level II PASARR evaluation after a positive Level I screening. The MDS coordinator acknowledged missing the required follow-up, despite facility policy requiring coordination of Level II PASARR recommendations with resident assessment and care planning.
A resident with a gastrostomy tube did not receive the prescribed amount and schedule of enteral nutrition due to an LVN's lack of awareness of the physician's order, resulting in continuous feeding at an incorrect rate. Staff interviews confirmed that the enteral feeding orders were not followed, and facility policy required adherence to physician orders for tube feeding.
Twelve rooms with multiple beds were found to provide less than the required 80 square feet per resident, with measurements ranging from 71.54 to 79.6 square feet per bed. Despite this, observations indicated that care provision, personal space, and storage for belongings were adequate, and no complaints or safety concerns were reported.
Two residents were not protected from physical abuse by other residents, including one being struck in the head and another having lemonade thrown at her. In both cases, the aggressors had histories of behavioral issues, and lapses in supervision contributed to the incidents. Facility investigations classified these as negative interactions, and the abuse prevention policy required intervention in such situations.
A resident with mild cognitive impairment and a history of stroke alleged that a CNA hit him after refusing to wear a sock. The DON did not interview the alleged CNA or the assigned caregiver, and the alleged abuser was not suspended as required by facility policy. The CNA continued to provide care to the resident, and the investigation summary lacked documentation of necessary staff interviews.
A resident with morbid obesity and intact cognition, who required partial assistance with walking, did not receive restorative nursing services as recommended by therapy upon discharge. Although therapy staff referred the resident for RNA to maintain mobility and strength, RNA staff were unaware of the referral, and the responsible LVN did not follow up due to absence, resulting in the resident not receiving the necessary restorative care.
A resident with congestive heart failure and type 2 diabetes was not assisted in changing into a hospital gown upon request, despite expressing discomfort in street clothes. The CNA cited cold weather as a reason, and the resident reported similar refusals in the past, affecting his dignity. Staff interviews confirmed the resident should have been assisted, and the facility's policy emphasizes honoring resident preferences.
A resident in an LTC facility experienced delays in call light response, leading to feelings of neglect. Despite being at risk of falls and needing assistance, the resident's call light went unanswered for 20 minutes, with staff passing by without responding. The facility's policy requires prompt responses to call lights to ensure resident safety and well-being.
A resident's room was found with an uncovered trash bin overflowing with soiled diapers and dirty gloves, and a mesh bag of dirty laundry on the floor. The resident, with congestive heart failure and type 2 diabetes, was distressed by the unsanitary conditions. A CNA confirmed the items were left by the previous shift, and the DON stated CNAs are responsible for maintaining cleanliness. The facility's policy emphasizes a clean and homelike environment, which was not upheld, posing a potential infection risk.
Two residents did not receive showers consistently as scheduled, impacting their grooming and hygiene. One resident, with conditions including diabetes and depression, reported receiving showers only once every three weeks instead of twice weekly. Another resident needed to remind staff multiple times for showers, receiving only two in 30 days. Facility records lacked documentation for missed showers, despite a policy emphasizing regular bathing.
The facility failed to maintain a clean environment in a resident room and shared bathroom. Observations revealed a dirty bathroom with unflushed urine and a dirty trash can, while the room floor was unswept. Residents reported infrequent cleaning unless requested. A CNA and the Housekeeping Supervisor confirmed the unclean state, and the Infection Preventionist and DON emphasized the need for continuous cleanliness. Facility policies outlined the requirement for maintaining sanitary conditions.
Two residents in a facility engaged in physical altercations due to inadequate separation after an initial incident. Despite policies requiring immediate separation and supervision, staff returned one resident to the shared room, leading to further conflict. The residents involved had significant medical and cognitive conditions, and the staff's actions did not align with the facility's procedures for handling such situations.
The facility failed to follow its infection control policies, leaving COVID-19 positive resident room doors open and not maintaining ventilation systems as required. The Infection Preventionist confirmed that none of the residents were fall risks, yet doors were left open. Additionally, the portable AC unit in the COVID-designated area was turned off, and air filters were not cleaned weekly as recommended, compromising the facility's ability to control the virus spread.
A registry CNA worked at the facility without a background check or abuse prevention training, leading to a deficiency. The Staffing Coordinator failed to verify the CNA's documents, and the CNA confirmed she did not receive the necessary training. The facility's policy required these screenings and training, which were not conducted, potentially endangering residents.
A resident with multiple complex medical conditions did not receive prescribed hydromorphone for severe pain as ordered, leading to uncontrolled pain, increased agitation, and verbal aggression. The resident's request for pain medication was not properly communicated or addressed by the staff, resulting in a significant delay in pain relief.
The facility failed to accurately record the administration of hydromorphone for a resident, leading to confusion and delays in pain management. The resident, with multiple diagnoses and intact cognitive status, reported severe pain and delays in receiving medication, which was corroborated by nursing staff interviews. The facility's policy required proper documentation of administered drugs, which was not followed.
Failure to Secure Main Entrance and Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the main entrance secured and to provide adequate supervision to prevent elopement for a resident with known elopement risk. The resident was admitted with encephalopathy, traumatic brain injury without loss of consciousness, unsteadiness of feet, and type 2 diabetes with kidney disease. An MDS dated 11/3/25 showed a BIMS score of 11/15, indicating moderate cognitive decline, and documented that the resident required supervision, verbal cues, and touching assistance for functional activities. An SBAR dated 10/31/25 documented that the resident had previously exited the facility unattended through an emergency door and was observed walking away from the facility, requiring three staff to follow and attempt to redirect him back. An elopement evaluation dated 10/31/25 indicated the resident had a history of elopement or attempts to leave without informing staff, expressed a desire to go home, and had goal-directed wandering likely to affect safety. Despite this, the care plan for risk of wandering/elopement initiated on 10/31/25 and reviewed on 12/2/25 did not include the use of a wander guard as an intervention. On 11/25/25, at approximately 6:30 a.m., staff discovered during routine rounding that the resident was not present on the unit, and there were no witnesses to the resident’s departure. Review of closed-circuit television confirmed the resident had eloped through the front main door. The facility’s investigative summary dated 11/27/25 documented that the resident had removed his wander guard and exited through the unlocked front door without supervision or authorization. The DON reported that kitchen staff had unlocked the front door to allow another kitchen staff member to enter and forgot to relock it as it was close to 7:00 a.m., leaving the front door unmanned while staff were busy with other resident care activities. A subsequent elopement evaluation dated 11/27/25 again documented the resident’s history of elopement, wandering, expressed desire to go home, and goal-directed wandering likely to affect safety, and a progress note dated 11/28/25 recorded ongoing noncompliance with wearing the assigned wander guard and a pattern of exit-seeking behaviors. Review of the facility’s policies on wandering/elopement and unusual occurrence reporting showed that staff were expected to follow or accompany residents who exit despite efforts to stop them and to conduct and document investigations including staff and witness interviews, but the DON acknowledged that written interviews from the staff who unlocked the main door were missing from the investigation summary and further attempts to interview that staff member were unsuccessful.
Failure to Investigate Injury of Unknown Origin Involving Toenail Avulsion
Penalty
Summary
Facility staff failed to follow the facility’s policy and procedure for investigating injuries of unknown origin when a resident was found with a complete avulsion of the right great toenail and the source of the injury was unknown. The resident’s MDS showed mild cognitive impairment with a BIMS score of 11, difficulty recalling the day of the week, and some difficulty communicating, including aphasia noted at the time of the injury, which prevented the resident from describing what happened. A CNA discovered the resident’s right great toenail was completely off, with the nail bed dry and red, and reported this to an LVN. The LVN asked other nurses about the cause, but no one knew how the toenail came off. The COC note documented that the resident often dangled her feet outside the bed and sometimes hit hard parts of the bed and nearby table, causing skin and nail damage. Despite the unexplained nature of the injury and the resident’s inability to explain the cause, the facility did not initiate or conduct a thorough investigation as required by its policy titled “Injury of Unknown Origin-Investigation.” The LVN stated he assumed the toenail avulsion may have occurred because the resident dangled her feet and hit hard surfaces, but this was not confirmed. The DON acknowledged that the facility did not investigate the source of the toenail injury and that the IDT did not review the injury. The facility’s policy defined an injury of unknown source as one where the source was not observed or could not be explained by the resident and was suspicious due to extent, location, number, or incidence over time, yet no formal investigation or IDT review was completed for this resident’s unexplained toenail avulsion.
Failure to Care Plan for Resident’s Repetitive Foot-Dangling Behavior and Resulting Toe Injury
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete care plan with measurable interventions to address a resident’s behavior of dangling her feet outside the bed and striking hard surfaces. The resident had a BIMS score of 11, indicating mild cognitive impairment, and had difficulty recalling the day of the week and communicating without prompting. The MDS also documented a diagnosis of seizure disorder or epilepsy. A Change in Condition Evaluation (COC) dated 2/13/26 documented that the resident often dangled her feet outside the bed and at times hit the hard parts of the bed and a nearby table, causing damage to her skin and nails. On that same date, CNA 1 reported a complete nail avulsion of the resident’s right great toe, described as dry and red in appearance, and the resident was aphasic and unable to describe what had happened. On observation on 2/19/26, the resident was seen lying in bed with the bed in a low position and a dressing on the right great toe; her feet were close to the footboard, and there were no devices in place to prevent her feet from hitting the footboard. CNA 1 stated she found the resident’s right great toenail off and did not know how it occurred. LVN 1 reported that CNA 1 informed him of the toenail avulsion, that other nurses also did not know how it happened, and that he assumed it may have been related to the resident dangling her feet outside the bed. During record review with LVN 1 and the DON, the COC and the care plan for the right great toenail avulsion were reviewed, and the DON acknowledged there was an assumption that the resident sometimes hit her leg on hard parts of the bed. The DON further stated that the interdisciplinary team had not addressed the resident’s behavior of dangling her feet outside the bed and hitting her legs on hard parts of the bed with care plan interventions.
Failure to Screen and Exclude CNA with Prior Abuse Finding Leading to Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policy by hiring and continuing to employ a CNA who had a documented finding of patient abuse on the state nurse aide registry and was listed on the OIG/medical exclusion and State Board lists. The CNA’s background screening report, completed prior to hire, clearly indicated a finding of patient abuse, yet the facility proceeded with employment. The facility also failed to obtain and document reference checks from previous and/or current employers or make reasonable efforts to uncover information about any past criminal prosecutions for this CNA, despite policy requirements to screen potential employees for a history of abuse, neglect, or mistreatment. The Administrator later stated he was not aware of the CNA’s abuse finding and that the facility does not hire nursing staff with such findings. The deficiency was further evidenced by an incident involving a resident with paraplegia and intact cognition, as shown by a BIMS score of 15 and clear communication abilities. According to an SBAR progress note, the resident reported that the CNA verbally and physically abused him, and the resident appeared anxious, intimidated, and uncomfortable with care. In an interview, the resident stated he had asked the CNA for help with clothing and water, and the CNA told him to stand up and help himself, then spilled water on the resident’s wheelchair and damaged items in his wallet, leaving the resident upset and anxious. In a separate interview, the CNA described an event in which a bottle of hot sauce and water slid from a bedside table and broke while the CNA was moving the table. These events, combined with the documented abuse finding on the CNA’s background screening and the lack of reference checks, demonstrate the facility’s failure to implement its abuse prevention policy not to employ or continue to employ anyone found guilty of abuse.
Failure to Report Alleged Financial Abuse to Authorities
Penalty
Summary
The facility failed to follow its policy and regulatory requirements to report an allegation of financial abuse and misappropriation of resident property to the appropriate agencies. Specifically, a resident with mild cognitive impairment and a history of anxiety disorder reported concerns that a staff member who assisted with online purchases may have used the resident's bank card for unauthorized transactions. The facility assisted the resident in replacing the debit card and changing online account passwords but did not notify law enforcement or the licensing department as required. Interviews with staff confirmed that the incident was not reported to authorities because the facility believed there was no missing money from the resident's account. Documentation showed that the resident had difficulty recalling certain information and required assistance with online purchases due to vision and communication challenges. The staff member involved admitted to helping the resident with online purchases and receiving items on the resident's behalf. The facility's own policy required reporting all allegations of abuse and criminal activity, but the administrator assigned the investigation to social services and limited the response to internal actions, failing to meet mandatory reporting obligations.
Unsanitary Ice Machine with Residue Found During Inspection
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the storage and preparation of ice supplied to residents. During an inspection, the Maintenance Director (MD) and Registered Dietician (RD) opened the residents' ice machine and found a reddish-brown residue inside the back part of the ice container and around the ice chute dispenser. The RD wiped the residue with a paper towel, confirming its presence. Both the RD and MD acknowledged that the residue should not have been present, and the MD stated that the ice machine should have been maintained and cleaned to prevent any residue. The DON also confirmed that the ice machine should always be clean to prevent foodborne illnesses and acknowledged that the residue could have caused food poisoning. A review of the facility's policy and procedure for ice machine operation and cleaning indicated that the machine should be cleaned routinely, with the inside washed and sanitized at least monthly. Additionally, the FDA Food Code requires that equipment food-contact surfaces and utensils be clean to sight and touch. The presence of residue in the ice machine demonstrated a failure to follow these established cleaning protocols and professional standards, resulting in unsanitary conditions for the ice supplied to residents.
Failure to Follow Medication Administration Standards Due to Pre-Pouring by LVN
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to adhere to professional standards during medication administration for four residents. The LVN was observed carrying a medication tray containing multiple pre-poured medication cups labeled with room numbers, rather than preparing medications immediately before administration as required by facility policy. The LVN administered medications to residents after preparing them in advance, a practice known as pre-pouring, which is not permitted according to the facility's guidelines. The LVN stated during interviews that she routinely prepared medications ahead of time to expedite her medication pass and was unaware of the facility's policy prohibiting pre-pouring. She also indicated that she memorized the medications for each resident and did not perceive any risk of medication errors with this method. The LVN further explained that if medication cups were mixed up, she would discard the medications and start over, but did not acknowledge the potential for error inherent in this process. The Director of Nursing (DON) confirmed that the facility's policy requires medications to be prepared and administered to one resident at a time, with verification of the resident's identity prior to administration. The DON emphasized that pre-pouring medications is not allowed due to the risk of medication errors and infection control breaches. The facility's written policy also specifies that medications are to be administered at the time they are prepared and not pre-poured, and that documentation should occur immediately after administration.
Failure to Provide Palatable and Flavorful Meals
Penalty
Summary
Surveyors identified that the facility failed to provide palatable and flavorful food to four sampled residents. Multiple residents reported that the food served was consistently bland and lacked taste, with one resident keeping extra salt and pepper on hand to compensate. During interviews, residents expressed dissatisfaction with the taste of the meals, describing them as flavorless and unappetizing. These observations were corroborated during a dining observation, where a resident was seen complaining to staff about the lack of flavor in their meal. A review of the facility's menu confirmed the items served, and a test tray tasting conducted by surveyors, the Registered Dietician, and the Dietary Services Supervisor found that the food, specifically the fish and scalloped potatoes, was bland and lacked flavor. The Dietary Services Supervisor acknowledged the importance of providing flavorful meals to support residents' food preferences and dignity. The facility's policy indicated that recipe accuracy concerns should be reported to the Dietician for evaluation and modification as necessary.
Staff Disclosed Resident's Diagnosis in Presence of Others, Violating Privacy and Dignity
Penalty
Summary
A staff member failed to treat a resident with dignity and respect by disclosing the resident's medical diagnosis and condition in the presence of another resident and within earshot of others during a mealtime. Specifically, the Activity Assistant (AA) stated out loud that the resident had Parkinson's disease, pointed out the resident's hand tremors, and mentioned the resident's hearing impairment while feeding the resident lunch. This disclosure was made without being prompted and occurred in a public setting where other residents were present. The resident involved had been admitted with diagnoses of Parkinsonism and dementia. The AA later acknowledged that sharing the resident's medical information in this manner was inappropriate and recognized it as a violation of privacy. The Director of Nursing confirmed that staff are not permitted to disclose residents' diagnoses or personal information in public areas, as this could affect the resident's dignity and self-esteem. Facility policy also requires that confidential clinical information be protected and that communication about residents be conducted outside the hearing range of others.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR evaluation after the resident was identified as positive during the Level I PASARR screening. The resident was admitted with diagnoses of Depression and Post Traumatic Stress Disorder (PTSD), both of which are considered serious mental health conditions. The Level I PASARR screening indicated a positive result, which should have triggered a referral for a Level II evaluation to determine the need for specialized mental health services or a higher level of care. During an interview and record review, the Minimum Data Set Coordinator (MDSC) confirmed responsibility for reviewing PASARR results and following up with Level II evaluations as needed. The MDSC acknowledged that the Level II evaluation was not completed for this resident, stating it was missed. The facility's policy requires coordination of recommendations from Level II PASARR determinations with resident assessment and care planning, but this process was not followed in this case.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic subarachnoid hemorrhage and gastrostomy status did not receive the prescribed amount of enteral nutrition as ordered by the physician. The physician's order specified that the resident should receive Jevity 1.5 at 75 ml/hour for 20 hours daily, with the feeding paused from 8:00 a.m. to 12:00 p.m. However, observation revealed that the resident was receiving tube feeding at a rate of 60 ml/hour continuously over 24 hours, and the feeding was not stopped during the specified time frame. The nurse responsible for the resident was unaware of the correct order and believed the feeding was to be administered at 60 ml/hour without interruption. Interviews with facility staff, including the LVN, Registered Dietician, and DON, confirmed that the prescribed enteral feeding orders were not followed. The LVN admitted to not knowing the correct rate or schedule and only replaced the formula bottle when it was nearly empty. The Registered Dietician and DON both stated that the resident was at risk for inadequate nutrition due to not receiving the recommended amount of enteral feeding. Review of facility policy indicated that enteral feeding should be administered as ordered by the physician, with careful calculation and verification of the amount to be given per shift.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility was found to have 12 resident rooms with multiple beds that did not meet the required minimum of 80 square feet per resident. During an observation, specific rooms were measured and found to provide between 71.54 and 79.6 square feet per bed, which is below the regulatory standard. Despite these measurements, observations conducted over several days indicated that there was sufficient space for care provision, no heavy equipment obstructed care, and each resident had adequate personal space and privacy. There were no complaints from residents regarding space for belongings, and no negative consequences or safety concerns were observed or reported during the survey period.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents. In the first incident, a resident with heart failure and generalized weakness was struck twice in the head by her roommate after waiting outside the bathroom. The resident reported pain and distress following the incident. Documentation and interviews revealed that the aggressor had previously been on 1:1 observation for behavioral concerns, but this supervision was not provided during the night shift when the incident occurred. The Director of Nursing confirmed that 1:1 observation was not guaranteed during night shifts, and the aggressor did not have a sitter at the time of the event. In the second incident, a resident with respiratory failure and chronic pain syndrome had lemonade thrown at her by her roommate, who exhibited ongoing verbal and physical aggression. Staff responded to the altercation after hearing screaming and separated the residents. Documentation indicated that the aggressor continued to display aggressive behaviors in the days following the incident, ultimately resulting in a psychiatric hold. In both cases, the facility's investigations concluded the events as negative interactions between residents, and the facility's abuse prevention policy required the identification and intervention in situations where abuse was more likely to occur.
Failure to Investigate and Suspend Staff Following Abuse Allegation
Penalty
Summary
The facility failed to follow its policy and procedure for investigating an allegation of abuse involving a resident with mild cognitive impairment and a history of cerebrovascular accident. The resident, who was dependent on staff for assistance with socks, alleged that a CNA hit him on the right leg after he refused to wear a sock. The care plan for the resident specified that the alleged abuser should be suspended during the investigation, but this intervention was not implemented. The Director of Nursing did not interview the alleged CNA or the staff member assigned to the resident's care, nor was the alleged abuser suspended from duty. The CNA continued to provide care to the resident and was not informed of the allegation. The investigation summary lacked documentation of interviews with the involved staff, and the DON stated that these steps were not taken because the resident was considered a poor historian. The facility's policy required suspension and removal of the staff member from the premises during the investigation, which was not followed.
Failure to Provide Restorative Nursing Services After Therapy Discharge
Penalty
Summary
A deficiency occurred when a resident with morbid obesity and intact cognitive status, who required partial assistance with ambulation, did not receive restorative nursing services as recommended by occupational and physical therapy upon discharge. The resident's Minimum Data Set indicated a need for partial assistance with walking, and therapy discharge summaries recommended restorative nursing assistance (RNA) for bilateral upper extremity exercises and walking with a front wheel walker to maintain mobility and strength. However, the resident reported not receiving any restorative nursing interventions to help with walking. Interviews with staff revealed that the process for transitioning residents from therapy to restorative nursing involved a referral to the nursing department, but the RNA staff were unaware of the referral for this resident. The Licensed Vocational Nurse responsible for following up on the RNA referral acknowledged that the follow-up did not occur due to her absence from work. The facility's policy indicated that the DON or a licensed nurse designee manages the restorative nursing program, but the referral was not acted upon, resulting in the resident not receiving the necessary restorative care.
Failure to Honor Resident's Choice in Dressing
Penalty
Summary
The facility failed to honor a resident's right to self-determination and choice, as evidenced by the incident involving a resident who was not assisted in changing into a hospital gown upon request. The resident, who had been admitted with multiple diagnoses including congestive heart failure and type 2 diabetes, expressed a preference to change into a hospital gown for comfort at night. However, a Certified Nurse Assistant (CNA) from the night shift did not assist the resident, citing the cold weather as a reason to remain in street clothes. This lack of assistance was not an isolated incident, as the resident reported similar refusals in the past, which affected his self-esteem and dignity. Interviews with facility staff, including a CNA and a Registered Nurse (RN), confirmed that the resident should have been assisted with changing clothes to ensure comfort and to allow for skin checks. The RN noted that if the resident had refused assistance, it should have been documented, but there was no indication that the resident had a history of refusing activities of daily living (ADLs). The Director of Nursing (DON) acknowledged that changing into a hospital gown was a resident preference and should have been honored, emphasizing the importance of documentation if a resident refuses ADLs. The facility's policy and procedure on Residents Rights - Quality of Life, revised in March 2017, states that each resident should be cared for in a manner that promotes dignity, respect, and individuality. The policy emphasizes that residents should be groomed according to their wishes, including dressing preferences. The lack of documentation and failure to assist the resident in changing clothes as requested highlights a deficiency in adhering to these policies, potentially causing physical discomfort and emotional distress to the resident.
Delayed Response to Call Light in LTC Facility
Penalty
Summary
The facility failed to provide timely response to a resident's call light, which is a deficiency in providing care according to professional standards. The resident, who was admitted with diagnoses including congestive heart failure and type 2 diabetes, expressed concerns about the slow response to call lights, particularly during the PM shift. The resident, who was at risk of falls and required assistance with activities of daily living, reported feeling neglected due to the delayed responses. On the day of observation, the resident's call light was activated and remained unanswered for 20 minutes, despite being located across from the nurse's station and within view of staff. During this time, multiple staff members, including a licensed nurse, were observed passing by the room without responding to the call light. This delay in response was confirmed by a CNA who eventually attended to the resident, stating that she was not informed of the call light being on. The facility's policy requires call lights to be answered promptly, ideally within 15 minutes, to ensure residents' needs are met and to prevent potential emergencies. The Director of Nursing acknowledged the failure to adhere to this policy, emphasizing the importance of prompt responses to avoid emergencies or worsening conditions. The facility's policy and procedure documents also highlight the importance of maintaining residents' quality of life and dignity, which was compromised in this instance.
Unsanitary Conditions in Resident's Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident, identified as Resident 1, whose room was found to have an uncovered trash bin overflowing with soiled diapers and dirty gloves. This trash bin was located under the edge of Resident 1's bed, and a mesh bag containing Resident 1's dirty laundry was found on the floor next to the overflowing trash. Resident 1, who was admitted to the facility with diagnoses including congestive heart failure and type 2 diabetes, expressed distress upon discovering the unsanitary conditions in his room, stating that it made him feel sick to his stomach and upset. During an interview, a Certified Nurse Assistant (CNA) acknowledged that the uncovered and overflowing trash, along with the mesh bag of clothes, were present when she arrived for her shift. The CNA indicated that the previous shift's CNAs likely left the items in Resident 1's room. She confirmed that the trash bin should not have been left exposed and overflowing, and that the soiled diapers should have been disposed of immediately after care was provided. Additionally, the CNA stated that Resident 1's clothes should have been placed in a plastic bag and taken to the laundry room, as leaving them on the floor could contribute to the spread of infection. The Director of Nursing (DON) confirmed that CNAs are responsible for ensuring rooms are clean and sanitary. The DON stated that the CNA assigned to Resident 1 should have disposed of the trash with soiled diapers before leaving the room and should have placed the resident's laundry in a plastic bag rather than leaving it on the floor. The facility's policy and procedure, titled 'Resident Rooms and Environment,' emphasizes providing a safe, clean, comfortable, and homelike environment, with a focus on cleanliness and order. The failure to adhere to these procedures resulted in a potential risk of infection due to the unsanitary conditions in Resident 1's room.
Inconsistent Shower Schedule for Residents
Penalty
Summary
The facility failed to ensure that two residents received the necessary services to maintain good grooming and personal hygiene, as they were not receiving showers consistently and as scheduled. Resident 1, who was admitted with diagnoses including diabetes, severe obesity, generalized weakness, and depression, required substantial assistance for bathing. Despite being scheduled for showers twice a week, Resident 1 reported receiving a shower only once every three weeks, which was upsetting to him. The facility's records confirmed that Resident 1 missed several scheduled showers without any documented reason for refusal or unavailability. Similarly, Resident 3, who also required assistance for bathing, reported needing to remind staff multiple times to receive his showers. The facility's records indicated that Resident 3 only received two showers in a 30-day period, despite being scheduled for twice-weekly showers. Interviews with staff, including a CNA and the DON, revealed that while there was a shower schedule in place, there was no documentation to explain the missed showers for these residents. The facility's policy emphasized the importance of regular bathing for cleanliness and comfort, yet the facility did not adhere to this policy for the residents in question.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in one resident room and a shared bathroom used by five residents. During an observation, the bathroom was found to be dirty, with a raised toilet seat over the toilet bowl that had dried brown/black substances and yellowish liquid resembling urine. The trash can in the bathroom was without a liner and appeared dirty, and the bathroom floor was also unclean. Interviews with residents revealed that the bathroom was not cleaned regularly unless housekeeping was specifically called to do so. One resident mentioned having to clean the bathroom themselves before use due to its persistent uncleanliness. Further observations noted that the resident room floor was dirty, unswept, and had scratches or marks. A CNA acknowledged the bathroom's dirtiness, noting that the dirt around the toilet bowl seemed old. The Housekeeping Supervisor confirmed the bathroom's unclean state and that the room had not been mopped. The Infection Preventionist stated that bathrooms and rooms should be cleaned and sanitized continuously. The Director of Nursing emphasized the expectation for all staff to ensure cleanliness to prevent any risk to residents. The facility's policy and procedure documents outlined the need for maintaining a clean and sanitary environment, including specific cleaning tasks for restrooms and resident rooms.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in altercations between them. Resident 1, who has a history of chronic obstructive pulmonary disease, major depressive disorder, and cerebrovascular disease, hit Resident 2 on the leg while Resident 2 was sleeping. Resident 2, diagnosed with encephalopathy and cognitive communication deficit, retaliated by punching Resident 1 on the chest during a second altercation. The incidents occurred because the staff did not adequately separate the residents after the initial altercation, despite the facility's policy requiring immediate separation and supervision for safety. The staff, including CNAs and the Director of Nursing, acknowledged that Resident 1 should not have been returned to the same room as Resident 2 after the first incident. The CNAs moved Resident 1 to the nurse's station for monitoring but later returned him to the room due to a lack of available beds and the need to provide personal care. This decision led to a second altercation, highlighting a failure to adhere to the facility's policies on resident-to-resident altercations and emergency room changes for health and safety.
Inadequate Infection Control and Ventilation Management
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically in managing the spread of COVID-19. Observations revealed that resident room doors in the COVID-19 positive wing were left open, contrary to the facility's policy which required these doors to remain closed unless the resident was a fall risk. Interviews with the Infection Preventionist (IP) confirmed that none of the COVID-positive residents were fall risks, yet multiple room doors were observed open. Additionally, a Housekeeping Aide reported finding doors open at various times, indicating a lack of consistent enforcement of the policy. Further deficiencies were noted in the management of ventilation measures within the COVID-designated area. The facility's policy required the use of portable air conditioning units with air filters to prevent virus transmission. However, the unit in the COVID-designated area was found turned off, and the air filters had not been cleaned according to the manufacturer's recommendation of weekly maintenance. The Maintenance Manager admitted to cleaning the filters only monthly and lacked a maintenance log or specific policy for the AC units. This oversight in maintaining proper ventilation measures contributed to the facility's failure to control the spread of COVID-19 effectively.
Failure to Screen and Train Registry CNA on Abuse Prevention
Penalty
Summary
The facility failed to ensure that all registry employees were properly screened for background checks and trained on abuse prevention. This deficiency was identified when a registry Certified Nurse Assistant (CNA) was found to have worked at the facility without a background check or abuse prevention training. The Director of Nursing (DON) confirmed that the CNA was involved in an alleged employee-to-resident abuse incident. Despite requests, the facility could not produce the CNA's certification or evidence of abuse prevention training. Interviews revealed that the Staffing Coordinator (SC) was responsible for screening and scheduling registry CNAs but admitted to not checking the required documents for the CNA in question. The CNA confirmed that she worked at the facility for one day without receiving abuse prevention training or undergoing a background check. The facility's policy required such screenings and training, but these procedures were not followed, potentially putting residents at risk.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 1, who was admitted with multiple complex medical conditions including peripheral vascular disease, chronic kidney disease, polyneuropathy, cellulitis, depression, and angina pectoris. Despite having a care plan that included administering hydromorphone for severe pain, the resident did not receive the medication as ordered on the evening of 4/18/24. The resident requested pain medication around 9-9:30 p.m., but the medication was not administered until 3:45 a.m. the following day, resulting in uncontrolled pain, increased agitation, and verbal aggression. The resident's care plan, initiated on 3/25/24, aimed for satisfactory pain control through both non-medication interventions and prn medications. However, on the evening of 4/18/24, the resident's request for pain medication was communicated by a CNA to LVN 1, who did not enter the resident's room or speak to the resident but instead assessed from a distance and concluded that the resident was not in pain. LVN 1 did not inform LVN 2, who was responsible for administering medications to the resident, about the pain medication request. As a result, the resident did not receive the hydromorphone dose from 9:30 p.m. to 12 midnight, with the last dose being administered at 5:49 p.m. The resident's pain escalated, leading to agitation and verbal aggression, and the resident eventually called 911 multiple times. The night shift nurse, LVN 3, noted that the resident usually received hydromorphone every four hours and had only received one dose that evening. LVN 3 had to request the RN to administer the medication due to the resident's severe agitation and aggression.
Failure to Accurately Record Administration of Controlled Drugs
Penalty
Summary
The facility failed to provide pharmaceutical services and procedures that assure accurate dispensing and administration of controlled drugs for one resident. Specifically, the administration of hydromorphone, a controlled opioid medication, was not accurately recorded in the Medication Administration Record (MAR). This discrepancy was identified during a review of the resident's records, which showed that doses of hydromorphone were popped from the bubble pack on several dates and times but were not signed off as administered in the MAR. The resident reported severe pain and delays in receiving pain medication, which was corroborated by interviews with nursing staff who indicated that the medication was removed from the bubble pack but not properly documented in the MAR by the administering nurse. The resident involved had multiple diagnoses, including peripheral vascular disease, chronic kidney disease, polyneuropathy, cellulitis, depression, acquired absence of the right toe, and angina pectoris. The resident's cognitive status was intact, as indicated by a BIMS score of 15. The failure to accurately record the administration of hydromorphone led to confusion and delays in pain management, as the resident reported waiting several hours and even calling the police multiple times before receiving the medication. The facility's policy and procedure required that the time and dosage of administered drugs be recorded by the person who administered them, which was not followed in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Pablo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vale Healthcare Center | 0.5 mi | ★★★★★ | 5 | 0 |
| Creekside Healthcare Center | 0.6 mi | ★★★★★ | 3 | 0 |
| Richmond Post Acute Care | 1.2 mi | ★★★★★ | 0 | 0 |
| Greenridge Post Acute | 1.7 mi | ★★★★★ | 0 | 0 |
| Shields Richmond Nursing Center | 2.3 mi | ★★★★★ | 3 | 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.