San Bruno Skilled Nursing

Inspectors wroteBased on interviews and record reviews, the facility failed to follow transfer and discharge requirements related to transfer and discharge for 7 out of 14 residents (Residents 1, 2, 3, 4, 5, 6, and 7). This failure resulted in or had the potential to result in residents experiencing inappropriate or unsafe transfer or discharge decisions, and increased risk of unmet care needs or disruption in continuity of care. During an interview on 07/02/2026 at 10:12 AM with Family Member 1 (FM 1) of Resident 6), FM 1 stated the Social Worker (SW) informed FM 1 that Resident 6 would have to move out because the facility is no longer a long term care facility and is converting to short term care only. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process and ensure an orderly discharge for one of three sampled residents (Resident 1). The facility discharged Resident 1 to the emergency department solely due to exhaustion of Medicare benefits, despite no documented change in condition. The facility did not assist Resident 1 and/or their representative in applying for Medical Assistance or offered the option to pay privately to continue residing at the facility. The facility failed to provide and document adequate preparation and orientation prior to Resident 1's discharge. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure residents were provided a private space to participate in resident council meetings (regular gatherings where residents meet to discuss concerns or suggest improvements for their living environment). This failure resulted in residents not receiving adequate privacy during their group meetings.

Inspectors wroteBased on interview and record review the facility failed to provide adequate monitoring for antipsychotic medications (a class of psychiatric drugs that helps manage severe mental health symptoms) for two out of five sampled residents (Residents 2 and 5) and PRN (as needed) medications were ordered beyond 14 days for three out of five sampled residents (Residents 7,8,18). This failure had the potential to result in adverse consequences ranging from functional decline, hospitalization, permanent injury, or death.

Inspectors wroteBased upon interview and record review the facility did not provide adequate medication review for five out of five sampled residents (Residents 2,5,7,8,18) when: 1) One out of five sampled residents (Resident 18)'s as needed antipsychotic orders, did not include end dates or rationales were not addressed in the medical record. 2) One out of five sampled residents (Resident 18)'s medication profile was not reviewed monthly after admission. 3) Four out of five sampled residents (Resident 2,5,7,8 )'s recommendations made by the pharmacist were not followed up, implemented, or addressed. 4) One out of five sampled residents (Resident 5)'s is on multiple antipsychotic medications for same diagnosis of MDD. These failures had the potential to cause harm from adverse consequences related to medication therapy, due to lack of timely implementation of pharmacy recommendations. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed maintain sanitary (hygienic and clean) durable medical equipment (medical equipment prescribed by a doctor for home use) used for the completion of activities of daily living (fundamental self-care tasks done daily) for one out of three sampled residents (Resident 2). This failure had the potential to result in the spread of disease-causing organisms due to ineffective cleaning and sanitation.

Inspectors wroteNumber of residents sampled: 2Number of residents cited: 1Based on observation, interview and record review, the facility did not ensure, one resident, (Resident 40) of 2 residents, have his Preadmission Screening and Resident Review( PASARR) re-evaluated on the 30th day. This failure has potential for further screening and referrals for needed services will not be provided. Review of admission Record, dated, 12/5/25, indicated, admitted on [DATE], with diagnoses including: Cerebral Palsy ( a neurologic disorder caused by abnormal development or damage to the developing brain), Bipolar Disorder (a serious mental illness causing extreme mood swings), Depression (condition with persistent sadness, hopelessness and loss of interest), Autistic Disorder (a complex neurodevelopmental condition that affects communication and social interaction). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services that maintained professional standards of quality for one out of three residents (Resident 8), when a certified nursing assistance administered a medication. This failure resulted in Resident 8 being administered medication by non-licensed staff that had the potential for clinically significant adverse consequences.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services to maintain good grooming, personal, and oral hygiene for one out of three residents (Resident 8). This failure resulted in Resident 8 having difficulty opening both eyes due to white greasy build up on her bilateral (left and right) upper and lower lash line and thick white build up on the base of her lower gums and bottom row of her natural teeth.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide received individualized and ongoing activities and stimulation for one of three residents (Resident 7). This failure resulted in Resident 7 not receiving individualized activities designed to meet her interests and support psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed identify an environmental hazard for one out of four residents (Resident 2), when the hot water temperature in a shared resident bathroom was greater than 120 degrees Fahrenheit. This failure resulted in Resident 2 having increased risk for burns caused by scalding.

Inspectors wroteNumber of residents sampled:2Number of residents cited:1Based on observation, interview and record review, the facility did not ensure one of two residents, (Resident 5) is receiving the correct amount of oxygen according to physician's order, when order indicates 1L/min. Resident observed to have 2 L/min for three consecutive days. This failure has potential for resident to have oxygen toxicity (lung damage that happens from breathing in too much extra supplemental oxygen. Review of Resident 5's admission Record, indicated admitted on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease (COPD)(chronic lung condition causing shortness of breath), Pneumonia, (a lung infection),Shortness of Breath, Anxiety Disorder ( a mental condition like persistent worry, fear and nervousness), Major Depression(condition with persistent sadness, hopelessness and loss of interest). [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure one out of two sampled residents (Resident 11) had adequate monitoring of their dialysis (a life sustaining medical treatment that filters waste products, excess fluid, and salt from the blood when kidneys fail, performing the kidneys job of cleaning the blood and balancing minerals) access site (a surgically created connected to the bloods stream that allows blood to be removed, cleaned by a dialysis machine); when it had been surgically changed from one site of the body to another. This failure in inadequate nursing assessment and documentation of Resident 11's current dialysis access stie had the potential for missed bleeding or other untoward side effects a dialysis resident could experience without adequate monitoring of the access site resulting in harm and even death. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to secure medications for one out of three residents (Resident 8) in a locked storage area and to limit access to non- authorized personnel. This failure resulted in Resident 8's medication being stored in unsecured and unsafe storage location, accessible to non-authorized personnel and other residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and implement infection prevention measures when; Enhanced barrier precautions were not implemented for one of three sampled residents (Resident 7) during high contact care. One out of four sampled residents (Resident 15), had flecks of debris and crust in their oxygen tubing (delivers supplemental oxygen from a source like a machine or oxygen tank, to a resident usually through tube through the nose also called a nasal cannula). This failure had the potential to result in Resident 7 and 15 developing a transmission based communicable disease or infection.

Inspectors wroteBased on observations, interviews, and a review of records, the facility failed to ensure that one of 9 sampled residents (Resident 1) receive consistent range of motion (ROM) exercises to the left lower extremity (LLE) during the period from admission on [DATE] to hospital transfer on 07/16/2025, to prevent contractures. This failure resulted in the development of contractures in the resident's LLE.During a review of Resident 1's Physical Therapy Medicare, PT Evaluation & Plan of Treatment (PTEPT), dated 11/20/2024, the PTEPT indicated, Resident 1 did not have contractures and that Resident 1's right lower extremity (RLE) and the left lower extremity (LLE) had range of motion (ROM) that was within normal limits (WNL). During a review of Resident 1's Joint Mobility Screen (JMS), dated 01/02/2025, the JMS indicated Resident 1 had full ROM of the left and right hips, knees, and ankles. [...]

Inspectors wroteBased on observation, intervention and record review, the facility did not ensure that re-assessment of one of two residents, Resident 1, when Resident 1 developed an ulcer of left leg, no weekly skin assessment and no MD assessment done to evaluate for healing or change of treatment. This failure has the potential for other residents to not receive necessary care Review of admission Record, dated 8/6/25, indicated, admitted on [DATE] with diagnoses including : Severe Dementia with Psychotic Disturbance, Adult Failure to Thrive, Moderate Protein - Calorie Malnutrition, Altered Mental Status. Full Code Status. Resident transferred to acute 7/16/25. During an interview with Marketing/Admission, on 8/1/25 at 12:10 PM, per Marketing, she assessed resident from Alameda Hospital, approved of her admission meeting skilled criteria. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sufficient space to accommodate group activities and communal dining for 43 residents. This failure resulted in limiting residents to participate in group activities and communal dining; caused inconvenience to residents whose rooms were in the hallway where the activities are conducted; and placed residents at risk for feelings of being isolated or depressed.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that resident's unique care instructions for one resident (Resident 12) are made private, when care instructions are posted in two places in her bedroom wall. This failure can result in exposing her medical condition to other residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident could safely administer a medication when one out of one sampled residents (Resident 11) did not receive an assessment or education regarding the self-administration of doxycycline (an antibiotic). This failure could result in the resident inappropriately taking the medication resulting in overdose (taking beyond the safe amount of a medication), drug interactions (typically unwanted reaction between two medications that someone takes), or unrecognized side effects of the medication.

Inspectors wroteBased on interview and record review, the facility failed to have a valid copy of a resident's Physician Orders for Life-Sustaining Treatment (POLST, a written medical order that assists people in making decisions about medical treatment and life saving measures during end-of-life care or medical crisis) when one of twelve sampled residents (Resident 47) had a POLST lacking a clear signature or identity of who the POLST was discussed with. This failure has the potential to result in a resident's end-of-life choices not being honored.

Inspectors wroteBased on interview and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage, Form CMS-10055 (SNF ABN, Form Centers for Medicare & Medicaid Services-10055 - a written notice used to inform the resident/beneficiary of potential financial liability for the non-covered stay and the right to appeal to receive care and services which may not be covered by Medicare) for one of three sampled residents (Resident 32) receiving Medicare Part A services. This failure had the potential for residents and/or resident representative not being aware of the financial liability and the right to appeal for the denial or termination of resident's Medicare Part A services.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin within the required timeframes in one out of one sampled resident (Resident 8) when Resident 8 reported hip pain that was later diagnosed as a pathological fracture (a break in the bone because of disease rather than physical trauma). This failure has the potential to result in delayed identification and investigation of possible harm occurring from abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the admission and annual Minimum Data Set (MDS, a resident assessment tool) assessment was completed within the required period of 14 calendar days of admission and Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) for four of 12 sampled residents (Resident 29, Resident 16, Resident 17, and Resident 8). Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 29, Resident 16, Resident 17, and Resident 8.

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA, is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 12 sampled residents (Resident 3) who was admitted to hospice care on 11/11/23. This failure could potentially delay the provision of appropriate treatment and services for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act of 1987) assessment for three of 12 sampled residents (Resident 20, Resident 3, and Resident 17). Failure to complete quarterly resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered care plan was implemented for three of 12 sampled residents (Resident 3, Resident 29, and Resident 16) when: 1. The facility did not ensure oxygen (O2) at 5 liters per minute (LPM) via nasal cannula (NC, a device that delivers extra oxygen through a tube and into the nose) was administered to Resident 3. 2. The facility did not ensure O2 at 2 LPM via NC was administered to Resident 29. 3. The facility did not ensure two-persons assist was provided for Resident 16 during transfer from bed to wheelchair using a sit-to-stand/standing lift. The deficient practice resulted in Resident 3 and Resident 29 to not receive the appropriate amount of oxygen as prescribed by the physician; and can increase the risk for an accident such as a fall and/or injury to Resident 16.

Inspectors wroteBased on interview and record review, the facility failed to update a care plan after an interdisciplinary team (IDT) assessment when one of twelve sampled residents (Resident 41) with care plans had a body weight that was beyond the recommendation from their care plan. This failure has the potential to result in the clinical staff not recognizing significant changes in weight due to a difference in care planned goals versus those decided by an interdisciplinary team.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment provided meet professional standards when the physician's order for oxygen (O2) administration was not followed for two of 12 sampled residents (Resident 29 and Resident 3). The deficient practice had the potential to compromise the health and safety of Resident 29 and Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and safe transfer technique for one of 12 sampled residents (Resident 16) when: a. The Restorative Nursing Assistant (RNA) transferred Resident 16 from bed to wheelchair using a sit-to-stand lift (or standing lift) by herself when the care plan indicated two persons. b. The mesh and/or material of the standing sling used for Resident 16 were frayed and torn and one of the belts had a missing buckle. Failure to provide adequate supervision and safe transfer technique may result in an accident and can increase the risk for fall and/or injury.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 6/11/24, three medication errors were observed out of twenty-six opportunities for two out of four residents, resulting in an error rate of 11%. This failure had the potential to result in more than minimal harm in the health and safety of residents.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure safe food handling practices when jewelries were worn during food handling, when two kitchen staff observed wearing yellow bracelets on both arms during food preparation and handling. This failure can result in food contamination, when it touches food products.

Inspectors wroteBased on observation, interview, and document reviews it was found that the facilities' Quality Assessment Performance Improvement (QAPI) program was ineffective. Despite its purpose to proactively identify and prevent medication administration errors, it fell short. This was evident during a medication pass observation conducted during the survey, which revealed a concerning 11% medication error rate (See F759). Findings Based on observation, interview and document reviews (See deficiency under F759) the facility was found to have a medication error rate of 11% during a medication pass on 06/11/24 between the times of 9:00 AM and 10:45 AM, which exceeds the acceptable threshold of 5%. This rate was derived from observing three errors out of twenty-six medication administration opportunities involving two of four residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain its infection control program for two of two sampled residents (Resident 32 and Resident 34) on transmission-based precautions (specific protections used when a someone has an infection that could be spread easily) when: 1. Resident 32 did not have personal protective equipment (PPE, equipment used to minimize exposure to a hazard) directly outside of the room. 2. Licensed Vocational Nurse (LVN) 1 did not wear full PPE when handling the urine collection bag (Foley bag) of Resident 34, who's on enhanced barrier precautions (EBP- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure Residents 20, 28, and 32, three out of 14 sampled residents, were protected from neglect. All three residents reported delayed response from staff to their requests for assistance. This pattern of delayed staff response resulted in Residents 20, 28, and 32 being left in pain for prolonged periods of time. These residents reported: increased pain while waiting, feelings of frustrations, feelings of anger and feelings of being neglected.

Inspectors wroteBased on observation and interview the facility failed to provide pharmaceutical services to meet the needs of each resident when multiple expired medications were available for resident use in the medication room.

Inspectors wroteBased on observation, interview, and document review the facility failed to maintain a medication error rate less than five percent when three medications errors were observed for thirty three observed opportunities which would equal a medication error rate of nine percent.