Health inspection·August 1, 2025

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, intervention and record review, the facility did not ensure that re-assessment of one of two residents, Resident 1, when Resident 1 developed an ulcer of left leg, no weekly skin assessment and no MD assessment done to evaluate for healing or change of treatment. This failure has the potential for other residents to not receive necessary care Review of admission Record, dated 8/6/25, indicated, admitted on [DATE] with diagnoses including : Severe Dementia with Psychotic Disturbance, Adult Failure to Thrive, Moderate Protein - Calorie Malnutrition, Altered Mental Status. Full Code Status.Resident transferred to acute 7/16/25.During an interview with Marketing/Admission, on 8/1/25 at 12:10 PM, per Marketing, she assessed resident from Alameda Hospital, approved of her admission meeting skilled criteria. Plan is short term rehab and discharge to Assisted Living facility per daughter, as RP. Patient was skilled for 2 months and discontinued and work on discharge plan.Interview on 8/1/25 at 1:25 PM, with CNA, per CNA she worked for 2 years at facility and knows this resident. Patient's vision is not good, but she is used to my voice. Takes time to give her care, her knees are really stiff, and she needs to move slowly. Left leg and knees are very stiff. The therapist instructed me to do some stretching every day and up on wheelchair, she won't eat when in bed. She was able to spoon food to her mouth. Escorted to activities, she knows her name but does not understand what is going on. Non skin breaks, knees are elevated with pillows, heels have boots and pillows. She is a feeder; at breakfast she eats 100%. She is on Ensure drink 2 times a day, not on pureed diet. I give her a shower, she helps when given a face towel. Interview on 8/1/25 at 1:50 PM, with Social Services, per SS she knows the daughter, they are in constant update and communication with her. Daughter will request for appointment transportation and escort and requests to talk to RD and other staff. Daughter spoke to Ombudsman about conservatorship. Daughter spoke to Hospice but decision was not made to enroll to Hospice till transferred to acute.Concurrent interview and record review on 8/1/25 at 3 PM with Director of Nursing, per DON, the resident came at high risk for skin breakdown, Preventive measures were put in place. Resident is on psychotropic medication, has a neurologist managing her medication. Has telehealth consult with daughter and facility staff regarding medication changes. Resident discovered on 5/27/25 with left heel opened blister, treatment order given. We did all possible interventions to prevent ulcer. Daughter was talking to Hospice agency for possible Hospice referral, but did not make decision to enroll to Hospice.On Wound MD evaluation? Per DON, they did not refer patient to Wound MD because of the Kind of wound the patient has, that for Hospice patients that just developed, like the [NAME] Ulcer? The reason she was transferred to acute was, the ulcer was getting worst so MD decided to send her for evaluation.Review of MD progress notes dated 11/22/24, Physical Exam: Skin: No open sores, cellulitis or wounds, feet with extremely long and curled under nails, very poor hygiene.Review of facility MD progress notes dated 5/7/25, Physical Exam: Extremities: calves non tender, no edema. Skin: warm and dry. Progress notes dated 6/9/25, indicated, no recent CBC noted, order to repeat [DATE], Residents Affected - Few (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: 555276 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 555276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Bruno Skilled Nursing 890 El Camino Real San Bruno, CA 94066 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)