Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at San Bruno Skilled Nursing during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was discharged to an emergency department solely after Medicare benefits were exhausted, despite no documented change in condition and no medical necessity for an ED transfer. The discharge care plan lacked specific problems, goals, interventions, and a documented destination preference, and it was not updated with the resident’s or representative’s wishes. Provider documentation conflicted, with orders for discharge home with home health services while social services arranged transport to a VA ED to check benefits and assign a social worker. The resident’s representative reported not being informed about applying for Medi-Cal or paying privately, and VA staff confirmed there was no scheduled benefits appointment, that the resident was brought directly to the ED without medical need, and that no Medicaid application had been filed. Facility records showed poor care coordination, conflicting discharge documentation, and failure to follow internal policies requiring appropriate notice, documentation, and financial assistance counseling at discharge.
A resident did not receive consistent range of motion (ROM) exercises to the left lower extremity, leading to the development of contractures. Initial therapy assessments showed normal ROM, but subsequent documentation revealed a decline in knee extension and mobility that was not properly addressed or reflected in the care plan. Upon hospital transfer, the resident had contractures, multiple wounds, and poor circulation in the affected leg.
The facility failed to provide sufficient space for group activities and communal dining, conducting activities in the hallway and serving meals in residents' rooms. This arrangement disturbed residents near the activity area and limited communal dining options. The Activities Director and Administrator confirmed the lack of designated spaces, with activities held in hallways and meals served in rooms since the pandemic.
A facility failed to maintain the privacy of a resident's care instructions, which were posted on the resident's bedroom wall, exposing their medical condition to others. The resident, with cognitive impairment and multiple diagnoses, had their care instructions posted by a family member. The DON acknowledged the issue but noted the family's involvement. This action violated the facility's policy on treating residents with dignity and respect.
A facility failed to assess and educate a resident on the self-administration of doxycycline, an antibiotic, as required by policy. The resident was observed with doxycycline on their bedside table and stated they were taking it for a bacterial infection. The RN and ADON were unaware of a care plan for the medication, and the resident's care plan only included five other medications for self-administration. The care plan was updated after the issue was identified, but the medication orders did not reflect the resident's use of doxycycline.
A resident's POLST form was found incomplete, lacking clear signatures and the identity of the individual with whom it was discussed. The DON confirmed the absence of necessary information, which could impact honoring the resident's end-of-life choices.
A facility failed to provide a resident with the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) while receiving Medicare Part A services. The resident, who had multiple diagnoses and was responsible for his own decisions, did not receive the SNF ABN due to being out for dialysis on the day it was supposed to be issued. Although a Notification of Medicare Non-Coverage (NOMNC) was provided, the absence of the SNF ABN meant the resident was not informed about potential financial liability and the right to appeal.
A resident with multiple health issues, including moderate cognitive impairment, reported hip pain later diagnosed as a pathological fracture. Despite no falls or activities explaining the pain, the facility failed to report the injury of unknown origin to the California Department of Public Health, as confirmed by the DON and Director of Staff Development. Facility policies require such injuries to be reported and investigated, but this was not done.
The facility failed to complete MDS assessments for four residents within the required timeframe. Admission and annual assessments were not completed within 14 days of admission or the ARD, as required by the RAI User Manual. The MDS Coordinator confirmed the delays, which could result in delayed identification of residents' needs.
A resident admitted to hospice care with serious health conditions did not have a Significant Change in Status Assessment (SCSA) completed within the required 14-day period. The assessment was completed 16 days after hospice admission, potentially delaying appropriate treatment and services.
The facility failed to complete MDS quarterly assessments within the required timeframe for three residents. The assessments were not completed within 92 days following the previous OBRA assessment, as required. The MDS Coordinator acknowledged the delay, which could result in delayed identification of residents' needs.
The facility failed to implement person-centered care plans for three residents, leading to deficiencies in care. A resident with respiratory issues received incorrect oxygen levels, another resident with COPD was given more oxygen than prescribed, and a resident requiring a two-person assist for transfers was handled by one staff member, contrary to their care plan.
A facility failed to update a resident's care plan after an IDT assessment found their weight loss acceptable due to CHF. The care plan aimed to maintain the resident's weight within 5% of 195 lbs, but the resident's weight dropped to 182.8 lbs. The RD acknowledged the need to update the care plan to align with the IDT's findings, suggesting a BMI-based goal.
The facility did not follow physician's orders for oxygen administration for two residents. One resident with respiratory failure was observed with an incorrect oxygen delivery setup, while another resident with COPD received a higher oxygen flow than prescribed. These actions were inconsistent with the facility's policy and the residents' care plans.
A resident with hemiplegia and other conditions was transferred by a single RNA using a sit-to-stand lift, despite the care plan requiring two-person assistance. The sling used was frayed and missing a buckle. Staff interviews revealed a lack of recent training and inconsistencies in understanding transfer requirements.
A medication error rate of 11% was observed in an LTC facility due to improper administration practices. A nurse failed to verify a resident's identity and did not ensure full consumption of MiraLAX, while another nurse improperly administered Flonase by not following recommended guidelines.
The facility failed to ensure safe food handling practices when two kitchen staff members were observed wearing yellow bracelets on both arms during food preparation. The Certified Dietary Manager (CDM) and another staff member were seen preparing food while wearing the bracelets, which they later removed. The facility's policy specifies minimal jewelry and requires hand jewelry to be covered with gloves.
The facility's QAPI program failed to prevent medication errors, resulting in an 11% error rate during a medication pass. Errors included improper resident identification and incorrect administration of medications. The Quality Committee had only met once in the past year and lacked a project to address these errors.
The facility failed to maintain its infection control program for two residents on transmission-based precautions. A resident with MRSA had no PPE available outside their room, contrary to facility policy. Another resident on enhanced barrier precautions had their PPE cart misplaced, and an LVN handled their Foley bag without PPE. These actions were against CDC guidelines and facility policies, potentially increasing infection spread risk.
Improper Discharge to Emergency Department After Medicare Exhaustion Without Adequate Planning or Counseling
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective discharge planning process and to ensure an orderly, appropriate discharge for one of three sampled residents. The resident was admitted with multiple chronic conditions, including COPD with acute exacerbation, centrilobular emphysema, gait and mobility abnormalities, unsteadiness, dysphagia, CKD, and urinary retention. A discharge care plan was initiated but left the discharge destination preference blank and did not identify specific discharge problems, goals, or interventions. The care plan was not revised or updated to reflect any discharge preferences of the resident or the resident’s representative. As the resident’s Medicare Part A coverage approached exhaustion, the facility issued a Notice of Medicare Non-Coverage indicating the end date of coverage. Provider documentation around this time was inconsistent: a practitioner note stated the resident was medically stabilized but not strong enough to return home and that discharge planning was pending therapy progress, while a physician discharge summary documented a planned discharge home with home health services and a stable condition. A physician order later specified discharge home with RN, PT, OT, HHA, and SW services. However, the Notice of Proposed Transfer/Discharge and the facility’s Discharge Summary and Post-Care Instructions instead identified a plan to send the resident to a VA location to check benefits eligibility and assign a social worker for placement under a VA program, with transportation by a friend. On the actual day of discharge, the social worker documented that the resident would be brought to the VA emergency room so that a social worker, VA PCP, and benefits eligibility could be arranged, citing exhaustion of Medicare days at the current and previous SNFs. Nursing documentation recorded that the resident left via a transportation company but did not document the discharge destination or home health information as ordered by the physician. Interviews with the DON and ADON confirmed there was no significant change in the resident’s condition and that the resident was stable on the day of discharge, indicating no medical necessity for an emergency transfer. The social worker and VA staff confirmed that the resident was taken directly to the VA emergency department without an appointment and without an apparent medical reason, and VA staff reported telling the social worker that the resident could not be brought in “for no reason.” The resident’s representative reported not being informed about the option to apply for Medi-Cal or to pay privately to remain at the facility and described the discharge as rushed, with nothing prepared in advance, despite the social worker’s knowledge that the resident had no place to stay because his prior apartment had been demolished. VA staff further stated that no Medi-Cal application had been filed for the resident and characterized the discharge as occurring after the resident ran out of 100 Medicare days. Review of the clinical record showed a lack of documented care coordination and discharge planning discussions with the interdisciplinary team, the resident, and the representative, and the discharge documentation from medical provider, social services, and nursing contained conflicting information. These actions and omissions were inconsistent with the facility’s own transfer/discharge policies, which require that residents not be transferred unless necessary for their welfare, that appropriate notice and documentation be provided, that residents receive assistance with third-party payment applications, and that residents who continue to need LTC services be offered the option to remain privately or with Medicaid assistance.
Failure to Provide Consistent ROM Interventions Resulting in Contractures
Penalty
Summary
A facility failed to provide consistent range of motion (ROM) exercises to a resident's left lower extremity (LLE) from admission until hospital transfer, resulting in the development of contractures. Initial assessments and therapy evaluations indicated that the resident had normal ROM in both lower extremities, with no contractures present. However, subsequent therapy notes and evaluations documented a progressive decline in the resident's left knee extension, with increasing difficulty in straightening the knee and performing transfers. Despite these changes, there was no documented change-of-condition evaluation or timely revision of the resident's care plan to address the decline in mobility. Therapy documentation showed that while some improvement in left knee extension was recorded over a short period, there were also periods with no improvement or worsening of the condition. The care plan addressing physical therapy and restorative nursing ROM was not updated to reflect the resident's declining ROM in the LLE, and there was a lack of documentation indicating that lower extremity ROM exercises were consistently provided. Interviews with facility staff confirmed that changes in the resident's mobility were not properly assessed or documented, and that contractures were not initially recognized or addressed in a timely manner. Upon hospital admission, the resident was found to have contractures in the LLE, along with multiple serious wounds, poor blood flow, and signs of infection and tissue death in the affected leg. The hospital team noted that the resident's poor nutrition, tight leg muscles, and compromised circulation would make wound healing difficult. The failure to provide consistent ROM interventions and to update care plans in response to the resident's declining mobility directly contributed to the development of contractures and associated complications.
Inadequate Space for Activities and Dining
Penalty
Summary
The facility failed to provide adequate space for group activities and communal dining for its 43 residents, as observed during a survey. The facility, licensed for 45 beds, conducted activities in the hallway due to the absence of a designated activity or dining room. This arrangement caused inconvenience to residents whose rooms were near the activity area, as they were disturbed by the noise. Resident 32 expressed discomfort with the noise from activities such as music and karaoke held in the hallway outside his room. The Activities Director confirmed that activities were held in the hallway, and residents in nearby rooms often closed their doors to minimize the noise. Additionally, the facility did not have a designated dining room, resulting in residents eating meals in their rooms. The Certified Dietary Manager stated that all meals were served in residents' rooms since the pandemic, and the previous dining room was repurposed as a rehab room. Resident 20 mentioned a preference for eating in a dining room rather than in his room, highlighting the lack of communal dining space. The Administrator acknowledged that activities and dining were conducted in the therapy room, hallway, or patio, depending on the weather, but noted that residents preferred eating in their rooms or the hallway.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the privacy of a resident's unique care instructions, which were posted in two places on the resident's bedroom wall. This action exposed the resident's medical condition to other residents and visitors. The resident, admitted to the skilled nursing facility with diagnoses including Parkinson's Disease, Diabetes Mellitus, and Major Depressive Disorder, was found to have a cognitive impairment with a BIMS score of 8. During interviews, a CNA mentioned that the resident's daughter posted the care instructions, and the DON acknowledged the posting but suggested that the resident's name should not be included. The facility's policy on Resident's Rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in this instance.
Failure to Assess and Educate Resident on Self-Administration of Doxycycline
Penalty
Summary
The facility failed to ensure that a resident could safely self-administer doxycycline, an antibiotic, as there was no assessment or education provided to the resident regarding its self-administration. The facility's policy requires the interdisciplinary team to assess a resident's cognitive and physical abilities to determine if self-administration is safe and appropriate. However, this was not done for the resident in question, who was observed with a bottle of doxycycline on their bedside table and stated they were taking it for a bacterial infection. The registered nurse was unaware of a care plan for the doxycycline, and the case manager confirmed that a self-medication assessment and care plan should be in place for residents self-administering medications. Further investigation revealed that the resident's care plan, dated several months prior, only included five other medications for self-administration, none of which were doxycycline. The assistant director of nursing was also unaware of the resident taking doxycycline and expressed concern about the risk of overdose. The care plan was updated to include doxycycline only after the issue was identified, but the medication orders still did not reflect that the resident was taking doxycycline. This oversight could lead to potential risks such as overdose, drug interactions, or unrecognized side effects.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to maintain a valid Physician Orders for Life-Sustaining Treatment (POLST) for one of the residents, identified as Resident 47. The POLST, which is a critical document for guiding medical treatment decisions during end-of-life care, was found to be incomplete. Specifically, the POLST lacked a clear signature or identity of the individual with whom the POLST was discussed, which is a requirement for its validity. This deficiency was identified during a review of Resident 47's records, which showed that the POLST form did not have the necessary signatures or printed names of either the patient or a legally recognized decision maker. During an interview and record review with the Director of Nursing (DON), it was confirmed that the section of the POLST indicating whether the information was discussed with the patient or a legally recognized decision maker was left blank. The DON acknowledged the absence of a clear signature and printed name, stating that the form was incomplete. Resident 47, who was admitted in April 2024, had a cognitive status indicating intact cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. The lack of a valid POLST form has the potential to result in the resident's end-of-life choices not being honored.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN, Form CMS-10055) to a resident receiving Medicare Part A services. This notice is essential to inform residents of potential financial liability for non-covered stays and their right to appeal. The deficiency was identified for a resident who was admitted with multiple diagnoses, including orthopedic aftercare following surgical amputation, a non-pressure wound, type 2 diabetes mellitus, and end-stage kidney disease. The resident was responsible for his own decisions and was receiving Medicare Part A skilled services, which started on May 12, 2024, and the last covered day was May 31, 2024. The case manager stated that the resident had reached his maximum potential and was saving the remaining Part A days for an upcoming surgery. Although a Notification of Medicare Non-Coverage (NOMNC) was provided to the resident before the last covered day, the SNF ABN was not issued because the resident was out for dialysis on the day it was supposed to be given. The previous Social Services Director confirmed that the SNF ABN was not issued due to the resident's absence for dialysis. The facility's failure to provide the SNF ABN meant the resident was not informed about the potential financial liability and the right to appeal the termination of Medicare Part A services.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required timeframes for a resident who reported hip pain, which was later diagnosed as a pathological fracture. The resident, who had multiple diagnoses including end-stage renal disease, anemia, and muscle wasting and atrophy, was admitted in January 2024. The resident had a Brief Interview for Mental Status score indicating moderate cognitive impairment. On a specific date, the Director of Nursing (DON) noted the resident's complaint of right hip pain and an X-ray revealed a right distal femoral fracture. Despite the absence of any reported falls or activities that could explain the pain, the incident was not reported to the California Department of Public Health as required. Interviews with the DON and the Director of Staff Development confirmed that the injury should have been reported as an injury of unknown origin. The facility's policies on investigating resident injuries and recognizing signs of abuse/neglect indicate that such injuries should be reported and investigated according to established guidelines. However, the interdisciplinary team deemed the injury as likely a spontaneous pathological fracture, and no report was made to the authorities. This oversight in reporting the injury of unknown origin could lead to delayed identification and investigation of possible harm from abuse.
Failure to Timely Complete MDS Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessments for four residents within the required timeframe, as mandated by the Resident Assessment Instrument (RAI) User Manual. Specifically, the admission and annual MDS assessments for Residents 29, 16, 17, and 8 were not completed within 14 days of admission or the Assessment Reference Date (ARD). For Resident 29, the admission MDS assessment was completed 16 days after admission. Resident 16's annual MDS assessment was completed 16 days after the ARD, while Resident 17's annual MDS assessment was completed 17 days after the ARD. Resident 8's admission MDS assessment was completed 29 days after admission. The MDS Coordinator confirmed during interviews that the assessments were completed late and acknowledged the requirement for the admission MDS assessment to be completed by the 14th day of admission and the annual MDS assessment to be completed 14 days after the ARD. The facility's policy and procedure on comprehensive assessments, as well as the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, were reviewed and indicated the necessity for timely completion of these assessments to assist in developing person-centered care plans. The failure to adhere to these timelines could result in delayed identification of residents' needs and significant issues affecting their well-being.
Failure to Timely Complete SCSA for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice care. The resident, who had diagnoses including stroke, respiratory failure, pulmonary fibrosis, and lung involvement in systemic lupus erythematosus, was admitted to hospice on November 11, 2023. According to the facility's records, the SCSA was completed on November 26, 2023, which was 16 days after the resident's admission to hospice care, exceeding the required 14-day timeframe. Interviews and record reviews revealed that the Licensed Vocational Nurse (LVN) and the MDS Coordinator were aware of the resident's hospice admission. The MDS Coordinator confirmed that the SCSA should have been completed within 14 days of the hospice admission. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that an SCSA is required when a terminally ill resident enrolls in a hospice program, and the assessment must be completed within the specified timeframe. The delay in completing the SCSA could potentially delay the provision of appropriate treatment and services for the resident.
Failure to Complete MDS Quarterly Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) quarterly assessments were completed within the required timeframe for three residents. Specifically, the assessments were not completed within 92 days following the previous OBRA assessment, as mandated by regulations. For Resident 20, the quarterly MDS with an Assessment Reference Date (ARD) of May 9, 2024, was completed 26 days after the ARD, instead of the required 14 days. Similarly, Resident 3's quarterly MDS with an ARD of May 14, 2024, was completed 21 days after the ARD, and Resident 17's quarterly MDS with an ARD of May 16, 2024, was completed 17 days after the ARD. The MDS Coordinator acknowledged during interviews that the assessments were not completed within the required timeframe. The facility's policy and procedure, as well as the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, require that the MDS completion date must be no later than 14 days after the ARD. The failure to adhere to these timelines could result in delayed identification of needs and significant issues affecting the residents' well-being.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement a person-centered care plan for three residents, leading to deficiencies in their care. Resident 3, who was readmitted with diagnoses including stroke and respiratory failure, was observed with an ill-fitting non-rebreather mask on top of a nasal cannula. The Licensed Vocational Nurse (LVN) noted that Resident 3 was receiving oxygen at 2 liters per minute (LPM) via nasal cannula, contrary to the active order which required 5 LPM. This discrepancy in oxygen administration was not aligned with the resident's care plan, which specified the need for continuous oxygen at 3-5 LPM. Resident 29, admitted with conditions such as heart failure and chronic obstructive pulmonary disease (COPD), was found to be receiving oxygen at 3 LPM instead of the prescribed 2 LPM. The LVN confirmed the error upon reviewing the active orders and adjusted the oxygen flow accordingly. The care plan for Resident 29 indicated the necessity for continuous oxygen at 2 LPM, highlighting a failure to adhere to the prescribed oxygen settings. Resident 16, who has hemiplegia and vascular dementia, required a two-person assist for transfers using a standing lift. However, during an observation, a Restorative Nursing Assistant (RNA) attempted to transfer the resident alone, stating familiarity with the resident's needs. This was contrary to the care plan, which mandated a two-person assist to ensure safety during transfers. The discrepancy between the care plan and the actual practice posed a risk of falls or injury to the resident.
Failure to Update Care Plan After IDT Assessment
Penalty
Summary
The facility failed to update a care plan following an interdisciplinary team (IDT) assessment for a resident whose body weight was beyond the recommended range specified in their care plan. The care plan, initiated on May 14, 2024, aimed to maintain the resident's body weight within 5% of 195 pounds. However, a review on June 4, 2024, showed the resident's weight had dropped to 182.8 pounds, which was below the 5% threshold. Despite this significant weight loss, the care plan was not updated to reflect the IDT's assessment, which considered the weight loss acceptable due to the resident's diagnosis of congestive heart failure (CHF). During interviews and record reviews, both the Director of Nursing (DON) and the Consultant Registered Dietician (RD) acknowledged the discrepancy between the care plan's weight goals and the IDT's assessment. The RD noted that the care plan should have been updated to align with the IDT's findings, suggesting that a goal based on body mass index (BMI) might be more appropriate for the resident. This oversight in updating the care plan could lead to clinical staff not recognizing significant changes in the resident's weight, potentially impacting their care.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to professional standards of care by not following the physician's orders for oxygen administration for two residents. Resident 3, who was readmitted with conditions including stroke, respiratory failure, and pulmonary fibrosis, was observed wearing an ill-fitting non-rebreather mask over a nasal cannula, contrary to the physician's order of 5 LPM via nasal cannula. The care plan indicated the need for continuous oxygen due to acute respiratory failure, but the observed practice did not align with the prescribed treatment. Similarly, Resident 29, admitted with diagnoses such as heart failure and COPD, was found receiving oxygen at 3 LPM instead of the ordered 2 LPM via nasal cannula. The active orders specified continuous oxygen at 2 LPM, with adjustments only if oxygen saturation fell below 92% or if there was shortness of breath. The facility's policy on oxygen administration emphasized verifying physician orders and ensuring the correct flow of oxygen, which was not followed in these instances.
Inadequate Supervision and Unsafe Transfer Technique
Penalty
Summary
The facility failed to provide adequate supervision and safe transfer techniques for a resident, identified as Resident 16, who required assistance due to medical conditions including hemiplegia, hemiparesis, aphasia, and vascular dementia. The resident's care plan specified the need for two-person assistance during transfers using a sit-to-stand lift. However, a Restorative Nursing Assistant (RNA) conducted the transfer alone, contrary to the care plan instructions. The RNA justified her actions by stating familiarity with the resident, despite acknowledging the requirement for two-person assistance. Additionally, the equipment used for the transfer was found to be in poor condition. The sling used was frayed, torn, and had a missing buckle, which the RNA admitted needed replacement. Interviews with other staff, including a Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON), revealed inconsistencies in understanding the transfer requirements and a lack of recent training on the use of mechanical lifts. The facility's policy and user manuals clearly stated the need for two-person assistance and the importance of using equipment in good condition, which was not adhered to in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of 11% during a medication pass. This was due to three medication errors out of twenty-six opportunities involving two residents. One incident involved a registered nurse who administered medication to a resident without verifying their identity, as the resident did not speak English and no photo identification was available. Additionally, the nurse did not ensure the resident consumed the entire dose of MiraLAX, leaving half of the mixture at the bedside, contrary to the manufacturer's instructions. Another error involved a licensed vocational nurse who improperly administered Flonase to a resident. The resident did not blow their nose before administration, and both nostrils were sprayed simultaneously without closing one nostril as recommended. The nurse did not instruct the resident to exhale through their mouth after administration, failing to adhere to the proper technique for optimal delivery and absorption of the medication.
Unsafe Food Handling Practices Due to Jewelry
Penalty
Summary
The facility failed to ensure safe food handling practices when two kitchen staff members were observed wearing yellow bracelets on both arms during food preparation and handling. This was noted during an initial tour of the kitchen, where the Certified Dietary Manager (CDM) and another kitchen staff member were seen preparing food for lunch while wearing the bracelets. During an interview, the CDM acknowledged the oversight and mentioned that the bracelets had been removed. The staff explained that wearing bracelets is a cultural practice for Indians, signifying marriage. The facility's policy on food preparation and service, dated November 2022, specifies that jewelry should be worn minimally, and hand jewelry should be covered with gloves.
Ineffective QAPI Program Leads to High Medication Error Rate
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) program was found to be ineffective in preventing medication administration errors, as evidenced by a medication pass observation revealing an 11% error rate, which exceeds the acceptable threshold of 5%. During the observation, three errors were identified out of twenty-six medication administration opportunities involving two residents. The first error involved a failure to properly identify a resident before administering medication, as the nurse did not verify the resident's identity due to a language barrier and did not follow the facility's policy for identification. The second error occurred when the same nurse administered MiraLAX to the same resident, who did not consume the entire dose, leaving the medication to settle on the bedside table. The third error involved the improper administration of Flonase to another resident, where the nurse did not follow the correct procedure, resulting in the resident inhaling the medication incorrectly. An interview with the Quality Committee members revealed that they had only attended one meeting in the past year and could not recall any discussions on medication errors. They also lacked an ongoing performance improvement project specifically aimed at reducing medication errors, acknowledging the need for improvements in the medication administration process.
Inadequate Implementation of Infection Control Protocols
Penalty
Summary
The facility failed to implement and maintain its infection control program for two residents on transmission-based precautions. Resident 32, who was admitted with multiple diagnoses including an infection of an amputation stump and MRSA, was supposed to be under contact single room isolation precautions. However, during multiple observations, there was no personal protective equipment (PPE) available outside of Resident 32's room, which was necessary for staff and visitors to wear before entering. Licensed Vocational Nurses (LVNs) confirmed the absence of PPE and expressed uncertainty about its removal, which was against the facility's policy requiring PPE to be available directly outside the room. For Resident 34, who was on enhanced barrier precautions due to a Foley catheter, the facility also failed to adhere to infection control protocols. The PPE cart intended for Resident 34 was incorrectly placed next to his roommate's area instead of his care area. Additionally, during an observation, LVN 1 handled Resident 34's Foley bag without wearing the required PPE, which included a gown, gloves, and mask. The Infection Preventionist confirmed that these precautions were necessary during direct contact with the resident, including touching the Foley bag. The facility's policy and procedure, as well as guidelines from the Centers for Disease Control and Prevention (CDC), emphasize the importance of using PPE during high-contact resident care activities to prevent the spread of multidrug-resistant organisms. Despite these guidelines, the facility did not ensure the proper placement and use of PPE for residents on transmission-based and enhanced barrier precautions, potentially increasing the risk of infection spread among staff and residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 459 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Bruno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Millbrae Care Center | 2.4 mi | — | 2 | 0 |
| Peninsula Post-acute | 3.4 mi | — | 12 | 0 |
| Pacifica Nursing And Rehabilitation Center | 4.1 mi | — | 0 | 0 |
| Golden Pavilion Healthcare | 4.5 mi | — | 2 | 0 |
| Golden Heights Healthcare | 4.5 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for San Bruno Skilled Nursing.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.