San Pablo Healthcare & Wellness Center

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to prevent the elopement (a resident leaving the facility unsupervised or without permission) of one of two sampled residents (Resident 1), when staff did not relock the front main door at 6:30 a.m. after letting kitchen staff enter the facility. This failure resulted in Resident 1 leaving the facility unsupervised and without permission and placed the resident at risk for exposure to unfavorable weather conditions and possible injuries. [...]

Inspectors wroteBased on interviews and record review, the facility failed to implement its policy and procedure for injuries of unknown origin to thoroughly investigate an unexplained injury of unknown source for one (Resident 1) of three sampled residents when facility did not know how Resident 1's right great toenail fell off exposing the nail bed. This failure had the potential to cause pain and placed Resident 1 at risk for emotional distress, mistreatment or abuse, and further injury. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/21/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident 1) of three sampled residents' behavior of dangling feet outside bed at times hitting the hard parts of the bed and nearby table were addressed on care plan with appropriate interventions. This failure had the potential to place Resident 1 at risk for pain and injuries. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/21/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy and procedure to not employ or continue to employ anyone found guilty of abuse when: Facility employed one Certified Nursing Assistant (CNA 1) who had a finding of patient abuse record on background screening report conducted prior to employment. Facility did not check information from previous and/or current employers and make reasonable efforts to uncover information about any past criminal prosecutions for CNA 1 prior to employment. Finding is defined as a determination made by the state that validates allegation, mistreatment of residents, or misappropriation of their property. This failure had the potential to place residents at risk for emotional distress, mistreatment, or abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure to report an allegation of financial abuse and misappropriation of resident property as required by law and regulations to the appropriate agencies for one (Resident 1) of three sampled residents when Administrator did not notify law enforcement and report to the department when it was suspected that Certified Nursing Assistant/Customer Relations (CNA 1) used Resident 1's bank card with online purchases. Misappropriation of resident property and Financial Abuse- defined as the deliberate displacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. This failure had the potential to place Resident 1 at risk for emotional distress, mistreatment, or abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice supply was stored and prepared under sanitary conditions when there was reddish-brown matter inside the residents' ice machine and around the ice chute dispenser. These failures had potential to put residents at risk for food borne illness (an illness that comes from eating contaminated food and infection) and cross-contamination (transfer of bacteria or other microorganisms from one substance to another) that could have resulted in infection or spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standards of professional practice were maintained during medication administration for four of four sampled residents (Residents 52, 253, 56 and 93) when licensed nurse pre-poured (generally refers to medications that have been prepared in advance and are ready for administration, rather than being prepared immediately before use) Residents 52, 253, 56 and 93's medication. This failure had the potential for a significant medication error that can lead to serious harm or even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food for four of 12 sampled residents (Residents 22, 56, 38 and 254) that was palatable when food was bland (lacked flavor). This failure had the potential to result in a negative dining experience that could lead to poor dietary intake, compromising the health and nutritional status of Residents 22, 56, 38 and 254 who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of two sampled residents (Resident 72) with dignity and respect when a staff member discussed Resident 72's diagnosis and condition while having lunch in front of another resident. This failure had the potential to affect Residents 72's privacy and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure to refer the resident to the appropriate state-designated authority for level II PASARR evaluation for one of two sample selected resident (Resident 37) when Resident 37 was positive for level I PASARR (the preliminary screening process has identified a potential mental illness or intellectual/developmental disability), and did not refer for PASARR II evaluation. This failure could result in placement in an inappropriate facility, lack of needed mental health services and increase of behavioral issues or hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services related to enteral feeding (also referred to as tube feeding, is the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) nutrition for one sampled resident (Resident 252) on a feeding tube when Resident 252 did not receive the calculated amount of tube feeding formula (designed to provide nutrition to individuals who cannot consume adequate food orally) per physician's order. This failure had the potential to cause dehydration, weight loss, and gastrointestinal (GI, relating to stomach and intestines) problems such as abdominal pain and diarrhea.

Inspectors wroteBased on observation and interview, the facility had 12 residents (Rt)'s rooms (room [ROOM NUMBER],10, 11, 15, 16, 17, 22, 25, 26, 29, 30, and 40) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had potential to result in inadequate space for delivery of care to each of the residents in each room, or for storage of the resident's belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of six residents (Resident 1 and Resident 3) were free from physical abuse when: 1) Resident 1 was hit in the head by Resident 2, 2) Resident 3 had lemonade thrown at her by Resident 4. This failure resulted in Resident 1 and Resident 3 being the recipient of physical abuse which affected their physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure to thoroughly investigate an allegation of abuse for one (Resident 1) of three sampled residents. Resident 1 alleged that a Certified Nursing Assistant (CNA1) hit him on the right leg because he refused to wear a sock. Facility designee/Director of Nursing (DON) did not interview alleged CNA, staff member assigned to provide care for Resident 1 and/or implement care plan to suspend alleged abuser while incident was under investigation. This failure had the potential to place Resident 1 at risk for emotional distress, mistreatment, or abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure necessary treatment and care services was provided for one (Resident 2) of three sampled residents in accordance with professional standards of practice when, rehabilitation referral for restorative nursing (RNA) for Resident 1 was not followed up. This failure had the potential for Resident 1 to not receive the necessary care and services to ensure mobility and muscle strength.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide choice based on resident preferences for one of two sampled residents (Resident 1) when Resident 1 was not changed to his hospital gown upon request and was left in street clothes overnight. This failure had the potential to cause physical discomfort and emotional distress to Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of two sampled residents (Resident 1) when Resident 1 ' s call light was not answered in a timely manner. This failure had the potential to cause physical discomfort and emotional distress to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for one of two sampled residents (Resident 1) when Resident 1 ' s room had: 1. Uncovered trash bin which contained an overflow of soiled diapers and dirty gloves. 2. Resident 1 ' s clothing stored in a mesh bag which was on the floor right next to the overflowing trash. This deficient practice had the potential to cause an unsanitary environment and spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 3), received the necessary services to maintain good grooming, and personal hygiene when they were not receiving showers consistently and as scheduled. This failure resulted in these residents being unhappy and facility not meeting their physical, mental, and psychological needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the physical environment in accordance with standards of practice, when one resident room and the bathroom used by five residents was not clean. This failure did not ensure residents were provided with a clean, sanitary, and comfortable environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2), were free from physical abuse when Resident 1 hit Resident 2 on his left lower leg while Resident 2 was sleeping and Resident 2 punched Resident 1 on the chest during a second altercation few hours later. This failure placed Resident 1 and Resident 2 at significant risk for physical and emotional harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policies and procedures to mitigate the spread of COVID-19 (a respiratory virus that can cause mild to severe respiratory illness) when: 1. Resident room doors in the COVID-19 positive wing were left open. 2. The portable air conditioning unit filters were not cleaned per manufacturer's recommendation. 3. The portable air conditioning unit in the COVID-19 positive wing was turned off.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all registry employees were screened for background check and trained on abuse prevention when one registry Certified Nurse Assistant (CNA) 1 did not have a background check or abuse prevention training prior to taking care of residents in the facility. This failure had the potential to put residents at risk for injury or harm.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide pain management to Resident 1 consistent with comprehensive person-centered plan of care and resident's goals when Resident 1 was not administered pain medication (hydromorphone, an opioid analgesic to treat moderate to severe pain) as ordered. This failure resulted in Resident 1's pain not being control resulting in increased agitation and verbal aggression.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide pharmaceutical services and procedures that assure accurate dispensing and administration of controlled drugs when administration of hydromorphone (a controlled opioid medication to treat pain) was not accurately recorded in the Medication Administration Record (MAR). This failure had the potential to result in confusion in dosing administration and drug diversion.

Inspectors wroteBased on observation, interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure allegation of a missing wallet was investigated thoroughly. This failure had the potential to result in further potential misappropriation of Resident 1's personal property.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy and document review, the facility failed to implement systems and processes to ensure that 1 (Resident #29) of 8 residents who smoked were supervised while smoking and did not have access to cigarettes and lighters. Specifically, on 01/29/2024 at 1:33 PM, Resident #29 was observed with smoking materials in their possession unsupervised It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25d Accidents, at a scope and severity of K. The IJ began on 01/29/2024 at 1:33 PM, when Resident #29 was observed with smoking materials in their possession unsupervised. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure residents who had medication in their room and self-administered medications had a physician's order to do so and were assessed as safe to self-administer medication(s). The deficiency affected 4 (Residents #18, #28, #49, and #82) of the 21 sampled residents.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure that 1 (Resident #6) of 2 sampled residents reviewed for advance directives had an order in their electronic health record (EHR) that was consistent with the resident's wishes for no cardiopulmonary resuscitation (CPR).

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure that allegations of abuse were reported to facility administration immediately for 1 (Resident #6) of 2 sampled residents reviewed for abuse. Specifically, Resident #6 made an allegation of abuse to a charge nurse that was not immediately reported to the Administrator.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to schedule and complete a quarterly care plan review for 3 (Residents #8, #28, and #82) of 4 sampled residents reviewed for care planning.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy and document review, the facility failed to follow appropriate infection control procedures during wound care for 2 (Resident #11 and Resident #76) of 3 sampled residents reviewed for pressure ulcer/injury.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 12 (Rooms 3, 10, 11, 15, 16, 17, 22, 25, 26, 29, 30, and 40) of 41 resident rooms in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy regarding discharge planning for three residents (Resident 50, 51 and 75) of 25 sampled residents when the facility did not complete a discharge plan within seven days of admission. This resulted in Residents 50, 51 and 75 not having plans for discharge and causing unnecessary anxiety and frustrations.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide professional nursing care for three residents (Resident 35, 51 and 52) of 25 sample residents on hemodialysis (an artificial kidney procedure used to clean the patient's blood), when; 1. Staff did not remove the dressing and assess the hemodialysis venous access site per policy post hemodialysis for resident 35. 2. Staff did not assess and monitor the hemodialysis venous access site for Resident 51,. 3. Intake and Output (I&O) was not monitored since admission and dietary recommendations from the Registered Dietician (RD) were not carried out for Resident 52. These failures had the potential for life-threatening complications including severe bleeding for Resident 35 and 51 and severe kidney compromise and fluid overload for Resident 52.

Inspectors wroteBased on observation and interview, the facility failed to answer residents call lights in a timely fashion due to a lack of sufficient staff. These failures resulted in Resident 75 having an episode of urinating and defecating in her bed which made her feel hopeless and embarrassed and Resident 243 urinated in the bed waiting for assistance from the staff.

Inspectors wroteBased on Observation, interview and record reviews the facility failed to ensure that two (Resident 52 and 51) of 25 sampled residents medications were not given medications with meals as ordered by their physicians. 1. Resident 52's medication Renvela (lowers phosphorus level in the blood), prescribed for end stage kidney disease, was not given with food as ordered . 2. Resident 51 did not receive Selvelamer (lowers the phosphorus level in the blood), as prescribed for end stage kidney disease. These failures had the potential to increase the residents 52 and 51's phosophorus levels which could cause further kidney damage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted respect and dignity of two residents (Resident 54, 20) in a sample of 25 residents when, the Certified Nursing Assistant (CNA) 4 stood over Resident 54 and resident 20 while assisting them with their meals. This deficient practice had the potential for residents 20 and 54 not feeling respected and a diminishment of their individual dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to address lost of personal property for two (Resident 51 and 90) of 25 sampled residents when: 1. A personal Hoyer lift sling (a soft material used to support and wrap around part of the patient's body, and attach to patient lifts) for Resident 51 was lost. 2. A wallet containing Identification Cards (ID) and money belonging to Resident 90 was missing. These failures resulted in loss of personal possessions belonging to Residents 51 and 90.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care to maintain good nutrition and personal hygiene for three Residents (54, 58, and 74) of 42 sampled residents when: 1. Resident 54 was not fed lunch until half hour after the meal was served. This failure had the potential to result in the meal being cold and unpalatable 2. Resident 58, and Resident 74 were not provided the needed assistance with nail care appearing poorly groomed. This failure had the potential to cause emotional distress and physical discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for one resident (Resident 54) in a sample of 42 residents, when the bed was not returned to a low position after Resident 54 was assisted with a meal. This failure had the potential to place Resident 54 at risk for injury from fall.

Inspectors wroteBased on observation and interview, the facility had 12 resident rooms (room numbers 3, 10, 11, 15, 16, 17, 22, 25, 26, 29, 30, and 40) with a designated total of 30 beds that provided less than 80 square feet (sq. ft.) per resident who occupied these rooms. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for storage of residents' belongings.