San Marino Healthcare Center

In the surveyor’s words

From the most serious findings on record at San Marino Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Aug 12, 2026

  Based on observation, interview, and record review, the facility failed to maintain resident room temperatures within the required range of 71 to 81 degrees Fahrenheit ( F, a scale used to measure temperature) for three (3) of four (4) sampled residents (Residents 2, 3, and 4) in accordance with the facility's policy. This deficient practice had the potential to adversely affect Residents 2, 3, and 4's health, comfort, and overall quality of life. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included polyneuropathy (conditions affecting nerve function in various parts of the body, leading to symptoms such as weakness, numbness, and… […]

• No harm, potential for more than minimal, patternF550Jan 9, 2026

  Based on observation, interview, and record review, the facility failed to promote dignity and respect for three (3) of three residents (Resident 8, 7, and 39) reviewed under dignity care area when:Certified Nursing Assistant 1 (CNA 1) used labels to address Resident 8 on 1/6/2026.CNA 1 used labels to address Resident 7 and was standing over while assisting the resident during meals on 1/6/2026. Facility staff used labels when addressing Resident 39 on 1/6/2026, 1/7/2026 and 1/8/2026. These deficient practices had the potential to affect Resident 8,7, and 39's sense of self-worth and self-esteem which could negatively affect the residents' emotional and mental well-being.Findings:1. […]

• No harm, potential for more than minimal, patternF584Jan 9, 2026

  Based on observation, interview, and record review, the facility failed to follow its policy to maintain a safe, clean, comfortable, and homelike environment for three (3) of five (5) sampled residents (Residents 2, 4, and 44) under environment task, when the facility failed to ensure:Resident 2's room was free of trash on the floor, and the wall did not have splattered brownish colored stains.Resident 4's wheelchair was in good condition, with no peeling armrests.Resident 44's wheelchair was in good condition, with no peeling armrests.These deficient practices had the potential to negatively affect Residents 2, 4, and 44 well-being and quality of life. Findings: 1. […]

• No harm, potential for more than minimal, patternF677Jan 9, 2026

  Based on observation, interview, and record review, the facility failed to provide grooming services for two (2) of three (3) sampled residents (Resident 9 and 22) under activities of daily living (ADLs- are activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) care area, in accordance with the facility's policy. This deficient practice resulted in Resident 9 and 22 having long and jagged (having rough, sharp points protruding) fingernails, potentially leading to skin injury, infection, and scarring (mark left on the skin after a wound or injury has healed).Findings: 1. […]

• No harm, potential for more than minimal, patternF689Jan 9, 2026

  Based on observation, interview, and record review, the facility failed to provide a safe environment for three (3) of six (6) sampled residents (Residents 6, 44, and 45) reviewed under accidents care area, as indicated on the facility policy by failing to: Ensure electrical cords were properly organized and were not wrapped around the metal bed frame of Resident 44.Implement interventions to address Resident 6's wandering behavior, who entered another resident's room.Implement interventions to address Resident 28's wandering behavior, who entered another resident's room. This deficient practice placed Resident 44, 6, and 28, as well as other residents in the facility, at risk for serious injury and/or death.Findings: 1. […]