San Mateo Medical Center D/P SNF

In the surveyor’s words

From the most serious findings on record at San Mateo Medical Center D/P SNF, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jul 3, 2025

  Based on observation, interview, and record review, the facility failed to provide a safe environment free from potentially serious accident hazards for all residents when its policies and procedures were not implemented for the following practices:1. The facility failed to ensure hot water in 6 of 8 residents' bathroom sinks were at a comfortable and safe temperature level.This deficient practice placed the residents (Residents 165, 187, and 259) at increased risk for scalding.An Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was declared at the [NAME] campus on 6/23/25 at 5:27 PM in the presence of the Administrator,… […]

• Immediate jeopardy, isolatedF600Oct 20, 2023

  Based on observation, interview, and record review, the facility failed to protect three of 3 sampled residents (Resident 2 and Resident 3, and Resident 8) from sexual abuse (non-consensual sexual contact of any type with a resident) by Resident 1 when: 1. Facility did not identify, report, and initiate an investigation of Resident 1 touching Resident 3's breast in the dining room in July 2023. Additionally, the facility did not develop and implement interventions to address Resident 1's behavior of touching female resident's sensitive area. This resulted in delayed identification and implementation of interventions to address Resident 1's sexually inappropriate behavior towards a female resident. 2. […]

• Immediate jeopardy, isolatedF607Oct 20, 2023

  Based on observation, interview, and record review, the facility failed to provide process oversight and ensure effective implementation of its abuse policies and procedures to protect three of three sampled residents (Resident 2, Resident 3, and Resident 8) when: 1. Facility did not ensure three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were reported to the State Survey Agency (SSA) within the required timeframe of two (2) hours for Resident 2 and Resident 3. Additionally, Certified Nursing Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 1 who witnessed and reported the sexual abuse allegations to the nurse-in-charge were placed on suspension. 2. […]

• Actual harm, patternF610Oct 20, 2023

  Based on observation, interview, and record review, the facility failed to conduct a thorough investigation for six of 7 sampled residents (Resident 1, Resident 2, Resident 3, Resident 5, Resident 6, and Resident 7) when: 1. Three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were not thoroughly investigated for Resident 1, Resident 2, and Resident 3. In addition, there was no documented evidence Resident 1's sexually inappropriate behavior towards Resident 2 and Resident 3 was addressed and measures were not implemented to prevent further sexual abuse towards Resident 2. […]

• Actual harm, isolatedF600Mar 21, 2024

  Based on observation, interview, and record review, the facility failed to prevent abuse to one of one sample resident (Resident 35) when another resident threw a bottle of deodorant at her resulting to an injury. The facility's failure resulted to Resident 35 to sustain a bump (swelling) over the right eye, and bruising (when a part of the body is injured and the blood gets trapped under the skin) to the right orbital areas (skin area around the eye). Findings: A review of the medical record face sheet (a document that provides resident information) indicated Resident 35 was admitted with diagnoses including dementia (decline in memory or other thinking skills) and stroke. […]