Health inspection·April 1, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their policy and procedure to thoroughly investigate an allegation of abuse for one (Resident 1) of three sampled residents. Resident 1 alleged that a Certified Nursing Assistant (CNA1) hit him on the right leg because he refused to wear a sock. Facility designee/Director of Nursing (DON) did not interview alleged CNA, staff member assigned to provide care for Resident 1 and/or implement care plan to suspend alleged abuser while incident was under investigation. Residents Affected - Few This failure had the potential to place Resident 1 at risk for emotional distress, mistreatment, or abuse. Findings: During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 3/11/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 1 ' s score was 9 meaning mild cognition. Resident 1 had clear speech, difficulty communicating some words or finishing thoughts, misses some part or intent of message. Resident 1 was dependent on helper does all task to put on and take off socks. Resident 1 ' s diagnoses included cerebrovascular accident (CVA) or stroke. During a concurrent observation and interview on 4/1/25 at 10:20 a.m. with Resident 1 in his room. Resident 1 stated he did not want to talk about the allegation. During a review of Resident 1 ' s care plan dated 3/16/25, the care plan indicated Resident 1 alleged physical abuse from facility ' s CNA, interventions included to suspend alleged abuser while incident is under investigation. During an interview on 4/1/25 at 11:01 a.m. with Certified Nursing Assistant (CNA1) , CNA1 stated she was not aware that Resident 1 alleged physical abuse by a CNA. CNA1 stated she was not informed of any allegation of abuse and was not suspended. CNA 1 stated she continued to assist Resident 1 with care as needed. During a concurrent interview and record review on 4/1/25 at 1:56 p.m., with Director of Nursing (DON), the investigation summary completed 3/21/25 was reviewed. The investigation summary did not include documentation that alleged CNA 1 and or Resident 1 ' s care givers were interviewed. DON stated facility process was to interview staff when the allegation involved staff member. DON stated alleged CNA1, and Resident 1 assigned care giver were not interviewed or suspended because Resident 1 was (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 04/01/2025 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)