Health inspection·October 9, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 3), received the necessary services to maintain good grooming, and personal hygiene when they were not receiving showers consistently and as scheduled. Residents Affected - Few This failure resulted in these residents being unhappy and facility not meeting their physical, mental, and psychological needs. Findings: During a review of Resident 1's face sheet, the face sheet indicated, Resident 1 was admitted to the facility with diagnoses that included Diabetes (a long-term (chronic) disease in which the body cannot regulate the amount of sugar in the blood), severe obesity, generalized weakness, and depression. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 7/21/24, the MDS indicated, a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 15 indicating no cognitive impairment. The MDS also indicated, Resident 1 required substantial/maximal assistance from staff for showers/bathing. During a review of Resident 2's face sheet, the face sheet indicated, Resident 2 was admitted to the facility with diagnoses that included paraplegia (leg paralysis), muscle weakness, and sepsis (the body's extreme response to an infection). During a review of Resident 2's MDS dated [DATE], the MDS indicated, a BIMS score of 15 indicating no cognitive impairment. The MDS also indicated, Resident 1 required staff supervision or touching assistance for showers/bathing. During an interview on 10/9/24 at 11:30 a.m., with Resident 1, Resident 1 stated he was supposed to be getting a shower twice a week (Mondays and Thursdays) but getting it once every three weeks and that is so upsetting to him and he had to fight staff before he could get one, and before he could get a basin for bath. During an interview on 10/9/24 at 11:36 a.m., with Resident 3, Resident 3 stated he needed to remind staff multiple times before he could get his showers. During an interview on 10/9/24 at 12 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated all residents have a sponge bath every day and showers twice a week. CNA 1 stated they have a shower (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 056359 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Pablo Healthcare & Wellness Center 13328 San Pablo Avenue San Pablo, CA 94806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)