San Pablo Healthcare & Wellness Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jun 26, 2025

  Based 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. Findings: During an observation and interview on 6/24/25 at 2:10 p.m. with the Maintenance Director (MD) and Registered Dietician (RD). […]

• No harm, potential for more than minimal, patternF606Feb 2, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF658Jun 26, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF804Jun 26, 2025

  Based 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. Findings: During an observation and interview on 6/23/25, at 10:41 a.m. with Resident 22, Resident 22 stated the facility's food always tasted bland and lacked flavor. Resident 22 stated, Look at those salt and pepper I have on my table. That's how terrible their food is. […]

• No harm, potential for more than minimal, patternF880Jul 3, 2024

  Based 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. Findings: During an interview on 7/2/24 at 1:57 p.m. with Infection Preventionist (IP), IP stated there were 36 active cases of COVID-19 as of 7/2/24. During an interview and concurrent record review on 7/2/24 at 2:04 p.m. with IP, facility map and list of COVID-19 residents were reviewed. […]