San Mateo Medical Center SNF: Pharmacy Delays - CA
The resident, identified in inspection records only as Resident 1, was prescribed Olmesartan Medoxomil, a medication used to treat high blood pressure. On the morning of February 12, 2026, the 9 AM dose went unadministered. There was no nursing note explaining the gap. Nothing in the chart flagged it.
It was only during a phone interview on May 28, 2026, that LVN 1 explained what had happened. The medication wasn't available from the pharmacy, she said. She forgot to document it when asked.
That might have been a one-time lapse. It wasn't.
On March 22, 2026, Resident 1 missed a 1 PM dose of Hydroxyzine, a medication prescribed to treat anxiety. A different nurse, LVN 5, did not administer it. This time there was a chart entry, coded as "Other / See Progress Notes," with an accompanying note that read simply: "hydrOXYzine . medication not available."
The Director of Nursing confirmed during a concurrent interview and record review that afternoon that LVN 5 had not given the medication because the pharmacy hadn't delivered it.
Then came the detail that reframed both incidents.
The Director of Nursing acknowledged that the facility shares a pharmacy with the hospital on the same campus, and that the pharmacy tends to be late in delivering medications to the facility, even when nurses have requested refills in advance.
That word, "tends," is doing a lot of work. It suggests this wasn't a surprise to anyone. Nurses knew the pharmacy ran behind. Managers knew. The pattern was familiar enough that the Director of Nursing described it not as an anomaly but as a tendency, something the facility had apparently learned to work around, or hadn't.
What the facility had not done, based on what inspectors found, was solve it. Two months apart, the same resident went without prescribed medications because of the same underlying problem. The pharmacy was late. Nobody had a reliable system to catch it before the dose window closed.
San Mateo Medical Center's skilled nursing facility operates under a policy requiring that all medications be administered according to physician orders in a timely and documented manner. The policy says the facility shall ensure residents receive the correct medications. It does not appear to have ensured that for Resident 1 on either occasion.
Inspectors classified the violations as causing minimal harm or potential for actual harm, and noted that few residents were affected. The complaint inspection was conducted on May 28, 2026.
But classifications like "minimal harm" describe what inspectors could document after the fact, not what a missed blood pressure medication means in the hours after it doesn't arrive. Olmesartan Medoxomil is prescribed because a physician determined the patient needed it, on a schedule, at a specific dose. The same is true of Hydroxyzine. Neither medication was optional. Both were ordered. Neither was given.
Resident 1's name does not appear in the inspection report. What the record does show is a person who, on at least two separate mornings, waited for medications that were sitting somewhere in a shared pharmacy across the campus, and received nothing, and, in the first instance, had no documentation created to explain why until a federal inspector called a nurse on the phone and asked.
The nurse said she forgot.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Mateo Medical Center D/p Snf from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
SAN MATEO MEDICAL CENTER D/P SNF in SAN MATEO, CA was cited for violations during a health inspection on May 28, 2026.
The resident, identified in inspection records only as Resident 1, was prescribed Olmesartan Medoxomil, a medication used to treat high blood pressure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.