Health inspection·December 30, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to implement its policy and procedure to report an allegation of financial abuse and misappropriation of resident property as required by law and regulations to the appropriate agencies for one (Resident 1) of three sampled residents when Administrator did not notify law enforcement and report to the department when it was suspected that Certified Nursing Assistant/Customer Relations (CNA 1) used Resident 1's bank card with online purchases. Misappropriation of resident property and Financial Abuse- defined as the deliberate displacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.This failure had the potential to place Resident 1 at risk for emotional distress, mistreatment, or abuse.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 9/10/25, 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.) score was 11 and indicated mild cognitive impairment. The MDS indicated Resident 1 was not able to recall the day of the week. MDS indicated Resident 1 had clear speech, difficulty communicating some words or finish thoughts but able if prompted or given time. MDS indicated Resident 1 had adequate vision see fine detail, such as regular print in newspapers/books and does not use corrective lenses. MDS indicated Resident 1 had diagnoses that included anxiety disorder (a mental condition characterized by excessive and persistent feelings of anxiety and fear that interfere with daily life).During a review of Resident 1's progress notes titled, Social Services, dated 10/29/25, the social services notes indicated Resident 1 stated he believed that someone was using his bank card and online store account. The social services notes indicated facility assisted Resident 1 to replace debit card and change password for online store account and online bank account. The social services notes indicated facility informed Resident 1 that if he needed assistance with purchasing items from an online store to inform social services for assistance.During an interview on 12/4/25, at 10:28 a.m., with Resident 1, Resident 1 stated he believed that a staff that had assisted him with purchases online used his debit card on his online store account. Resident 1 stated facility was aware of his concern and the staff that had assisted Resident 1 with purchases. Resident 1 stated he did not want to talk about the staff anymore. Resident 1 stated facility had assisted him to change his password to his bank and online store account. During an interview on 12/4/25, at 11:15 a.m., with Social Services Director (SSD), SSD stated Resident 1 suspected that CNA 1 used his bank card to make purchases online. SSD stated Resident 1 asked CNA 1 to assist with purchases online. SSD stated facility asked the bank to replace Resident 1's bank card. SSD stated initially facility did not take it seriously when implementing intervention to replace Resident 1's bank card. During an interview on 12/4/25, at 11:30 a.m., with Administrator (Admin) and SSD, Admin (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 2 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 12/30/2025 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)