San Bruno Skilled Nursing

In the surveyor’s words

From the most serious findings on record at San Bruno Skilled Nursing, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF920Jun 14, 2024

  Based 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. Findings: The facility is licensed for 45 beds and the resident census on 6/11/24 was 43. During an observation on 6/11/24 at 9:29 AM, in the hallway between room [ROOM NUMBER] and 5, four residents were sitting on their wheelchair with one staff in front of them playing music on an iPad (a brand of a tablet computer). […]

• No harm, potential for more than minimal, patternF627Jul 10, 2026

  Based 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.During an interview on 07/03/2026 at 10:55 AM with FM 2 of Resident 6, FM 2 stated the social worker… […]

• No harm, potential for more than minimal, patternF565Dec 5, 2025

  Based 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.Findings:During a group interview on 12/03/2025 at 3:00 PM with Residents (58, 24, 26, 27, 43), Resident 24 stated, Resident Council meetings are often held in a hallway due to limited private spaces within the facility. Resident 24 stated, The only space is the old dining room, but that is being used for the gym now. When asked if a private space to participate in resident council meetings was requested by the participating residents. […]

• No harm, potential for more than minimal, patternF605Dec 5, 2025

  Based 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. Findings: During a concurrent interview and record review on 12/04/2025 at 5:37 PM with Licensed Vocational Nurse 1 (LVN1), Resident 2's blood pressure values on 11/07/2025 was reviewed. […]

• No harm, potential for more than minimal, patternF756Dec 5, 2025

  Based 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. […]