San Bruno Skilled Nursing

F-F759) the facility was found to have a medication error rate of 11% during a medication pass on 06/11/24 between the times of 9:00 AM and 10:45 AM, which exceeds the acceptable threshold of 5%. This rate was derived from observing three errors out of twenty-six medication administration opportunities involving two of four residents. Such a high error rate poses a risk to the residents' health and safety. The first error involved a failure to properly identify Resident 10 before administering medication. Registered Nurse 1 attempted to verify the resident's identity by asking for her name, but the resident did not speak English, and the nurse did not seek further verification. Consequently, the medication was administered without confirming the resident's identity, contrary to the facility's policy requiring photo identification or verification from other staff. The second error pertained to the administration of MiraLAX to the same resident by the same nurse. Although MiraLAX should be consumed immediately after mixing with 4 to 6 ounces of fluid, the resident only drank half and left

the rest on the bedside table, where the medication settled and was not fully consumed. The nurse admitted

she had not ensured the entire dose was taken or removed the leftover medication. The third error involved

the improper administration of Flonase to Resident 36. Licensed Vocational Nurse 1 did not follow the correct procedure, which includes the patient blowing their nose beforehand and closing one nostril while inhaling

the spray into the other. Instead, the resident inhaled the medication with both nostrils open and without the proper breathing technique. The nurse acknowledged these mistakes and expressed a commitment to adhere to proper procedures in the future.

During an interview on 6/11/24 at 3:30 PM an interview was conducted with four members of the Quality Committee: the Director of Staff Development, the Assistant Director of Nursing, the Director of Nursing and

the Administrator. During the interview, it was discovered that the quality committee members had attended only a single meeting within the past year. Additionally, the interviewed members could not recall any specific discussions or topics pertaining to medication errors that took place during that meeting. During this interview, it was also noted that they had not identified any recent issues related to medication pass

observations. Furthermore, they did not have a sufficient ongoing performance improvement project specifically aimed at addressing medication errors that showed a measurable improvement in reducing medication errors. The Quality Committee members acknowledged the need for improvements in the medication administration process. They expressed concern over the survey results, which indicated a medication error rate of 11%.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 555276 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555276 B. Wing 06/14/2024

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49264 potential for actual harm Based on observation, interview, and record review, the facility failed to implement and maintain its infection Residents Affected - Few control program for two of two sampled residents (Resident 32 and Resident 34) on transmission-based precautions (specific protections used when a someone has an infection that could be spread easily) when:

1. Resident 32 did not have personal protective equipment (PPE, equipment used to minimize exposure to a hazard) directly outside of the room.

2. Licensed Vocational Nurse (LVN) 1 did not wear full PPE when handling the urine collection bag (Foley bag) of Resident 34, who's on enhanced barrier precautions (EBP- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use

during high contact resident care activities). Additionally, the PPE cart for Resident 34, was placed next to his roommate and not in his care area.

Failure to implement infection prevention practices has the potential to result in increased spread of a communicable disease or infectious bacteria to staff and other residents.

Findings:

1. A review of Resident 32's face sheet (summary of resident's demographic and admitting information), dated 06/14/2024, indicated that Resident 32 was admitted in May of 2024 with multiple diagnoses including INFECTION OF AMPUTATION STUMP [the leg after surgical removal of a section of it], RIGHT LOWER EXTREMITY

A review of Resident 32's care plan, dated 05/13/24, indicated a focus of Resident requires contact single room isolation precautions [use of gloves and gown to decrease risk of infection transmission due to touch] due to klebsiella (infectious bacteria) and MRSA (Methicillin-resistant staphylococcus aureus, infectious bacteria that are resistant to a group of antibiotics) infection . The care plan further indicated interventions including use of personal protective equipment as recommended for type of infection.

A review of the facility policy and procedure, titled Isolation - Transmission-Based Precautions & Enhanced Barrier Precautions, last revised April 2024, indicated that for residents under contact precautions, Staff and visitors wear gloves (clean, non-sterile) when entering the room Staff and visitors wear a disposable gown upon entering the room.

During an observation on 06/11/24 at 10:15 AM, there was no available PPE outside of Resident 32's room.

During an observation on 06/11/24 at 12:12 PM, there was no available PPE outside of Resident 32's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 555276 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555276 B. Wing 06/14/2024

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)

F 0880 During a concurrent observation and interview on 06/11/24 at 12:14 PM with Licensed Vocational Nurse (LVN) 1 outside of Resident 32's room, there was not PPE outside of Resident 32's room. LVN 1 stated that Level of Harm - Minimal harm or he is expected to wear a gown, gloves, and mask before entering the resident's room. LVN 1 further stated potential for actual harm that normally there should be PPE available outside of the resident's room in a cart. When asked where the PPE cart is for the resident, LVN 1 stated I have no idea . I guess they took them out. Residents Affected - Few

During a concurrent observation and interview on 06/11/24 at 12:19 PM with LVN 2 outside of Resident 32's room, there was not PPE outside of Resident 32's room. LVN 2 stated that PPE should be used prior to going into the room. When asked where the PPE is for Resident 32, LVN 2 stated, they removed it.

During an interview on 06/14/24 at 11:52 AM with the Infection Preventionist (IP), the IP stated that she expects for PPE to be available directly outside of a resident's room that is on contact precautions. The IP further stated that if there is no PPE outside of the room, there is a concern that people are entering without PPE. The IP stated that this could increase the risk for spread of an infection or bacteria to staff or residents.

41545

2. Review of Resident 34's admission record indicated, was admitted on [DATE REDACTED] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or partial paralysis on one side of

the body) following a stroke affecting left non-dominant side, aspergillosis (an infection caused by a type of mold [fungus]), encephalopathy (a group of conditions that cause brain dysfunction), and respiratory failure.

During an observation on 6/11/24 at 12:07 PM, in resident's room, there was a small green star sticker next to Resident 34's name by the door and an uncovered Foley bag hanging on the side of the bed. A PPE cart was also observed next to Resident 34's roommate's foot of the bed and by the bathroom door.

During an interview on 6/11/24 at 12:14 PM, LVN 1 stated, the green star next to Resident 34's name means

on enhanced barrier precautions because of his Foley catheter. LVN 1 also stated that gown, gloves, and mask were required when providing care to residents on EBP. During concurrent observation, LVN 1 pointed at the PPE cart and stated, the PPE cart belongs to Resident 34 and should be inside the room by the resident's care area.

During an observation on 6/11/24 at 2:29 PM, in resident's room, Resident 34's Foley bag did not have a label and a cover (dignity bag).

During concurrent observation and interview on 6/11/24 at 2:31 PM, in resident's room, LVN 1 touched Resident 34's Foley bag with no PPE (gowns, gloves, mask) worn. LVN 1 stated the Foley bag should be inside a dignity bag for resident's privacy.

During an interview on 6/13/24 at 5:03 PM, the Infection Preventionist (IP) stated that for EBP, gown, gloves and mask are required during direct contact with the resident including touching a Foley bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 555276 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555276 B. Wing 06/14/2024

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)

F 0880 Review of Resident 34's care plan dated 5/28/24, indicated, .Resident requires enhanced barrier precautions

during high-contact resident care activities due to the presence of: Indwelling device: Foley Catheter not Level of Harm - Minimal harm or known to be infected or colonized with any MDRO (multidrug resistant organism) . Interventions . Ensure potential for actual harm items for following EBP are in place (gloves, gown, alcohol-based hand rub, face-shield, signage, trash receptacle .) . Utilize PPE (gown and gloves; face-shield as indicated) during high contact resident care Residents Affected - Few activities ( .device care, wound care).

According to the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group letter with a subject of Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, indicated, .EBP recommendations now include use of EBP for residents' with chronic wounds or indwelling medical devices

during high-contact resident care activities regardless of their multidrug-resistant organism status .

According to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/24, indicated, Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs356. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: . Device care or use: central line, urinary catheter .

Review of facility's policy and procedure titled, Isolation - Transmission-Based Precautions & Enhanced Barrier Precautions, revised April 2024, indicated, .Enhanced Barrier Precautions are indicated for residents with any of the following: . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 1. Wear gowns and gloves while performing the following high-contact tasks associated with the greatest risk for MDRO contamination of staff hands, clothes, and the environment such as: .b. Device care, for example, urinary catheter . 3.PPE supplies such as gowns and gloves may be placed near or outside the resident's room .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 555276 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555276 B. Wing 06/14/2024

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)

F 0920 Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41545

Residents Affected - Many Based on observation, interview, and record review, the facility failed to provide a sufficient space to accommodate group activities and communal dining for 43 residents.

This failure resulted in limiting residents to participate in group activities and communal dining; caused inconvenience to residents whose rooms were in the hallway where the activities are conducted; and placed residents at risk for feelings of being isolated or depressed.

Findings:

The facility is licensed for 45 beds and the resident census on 6/11/24 was 43.

During an observation on 6/11/24 at 9:29 AM, in the hallway between room [ROOM NUMBER] and 5, four residents were sitting on their wheelchair with one staff in front of them playing music on an iPad (a brand of

a tablet computer).

During an interview on 6/11/24 at 9:48 AM, Resident 32 mentioned about the noise outside his room especially when they play music or karaoke in the hallway. Resident 32 stated, a man comes every Wednesday to sing karaoke together with the residents in the hallway outside his room. Resident 32 further stated, he would close his door whenever the noise from the activities outside his room became loud.

During an interview on 6/11/24 at 12:17 PM, the Activities Assistant (AA) stated, there is no designated activity room that is why group activities are conducted in the hallway.

During an observation on 6/11/24 at 12:18 PM, in the hallway, Today's Activities June 11th 2024 Tuesday was posted on the wall between room [ROOM NUMBER] and 7 indicating, 9:30 daily news, 10:00 music/coffee social, 10:30 movement exercise/balloon toss, 11:30 table games, 2:00 ball toss, 2:30 word finds/puzzles.

During an interview on 6/11/24 at 12:19 PM, the Activities Director (AD) stated, group activities are conducted in the hallway since there is no designated activity or dining room. The AD also stated the number of residents joining depends how many are up. The AD further stated residents in the room close to the hallway where the activities are conducted do not like the noise and would close the door to minimize the noise. During concurrent observation, two tables were in the hallway right outside a resident's room who was

on transmission based precautions (are used in addition to standard precautions when the route of transmission is not completely interrupted). The AD stated the two tables were set up in the hallway for the board games.

During an observation on 6/12/24 at 11:06 AM, on the patio outside the rehab room, six residents were on their wheelchairs listening and watching [person's name] sing and dance for them.

During dining observation on 6/12/24 at 12:15 PM, residents were eating their meals (lunch) inside their rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 555276 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555276 B. Wing 06/14/2024

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)

F 0920 During concurrent observation and interview on 6/12/24 at 12:16 PM, in resident's room, Resident 20 was sitting on a wheelchair at his bedside eating his meal. During concurrent interview, Resident 20 stated that Level of Harm - Minimal harm or he prefers to eat sitting up on a chair rather than in bed, would be nice to have a dining room. Resident 20 potential for actual harm also stated he participates in the activities conducted in the hallway, plays bingo three times a week. Resident 20 further stated, It would be nice to have a room than the hallway. Residents Affected - Many

During an interview on 6/14/24 at 1:39 PM, the Administrator (ADM) stated, the designated spot for activity/dining were the therapy (rehab) room, the hallway, or outside on the patio when weather permits.

Review of facility's policy and procedure titled, Activity Programs, revised August 2006, indicated, .9. Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met.

43913

During an interview on 6/11/24 at 9:30 AM, with Certified Dietary Manager (CDM), per CDM all meals are served in the patient's rooms. There is no one who eats in the dining room, there is no dining room. Since pandemic, everyone eats in their own room. They did not open that room for dining , its now a rehab room.

During an interview on 6/14/24 at 10:43 AM, with Administrator, per Administrator it's patient's preference,

they prefer to eat in the room or in the hallway. We have a dining room set up in the patio offered to patients, but nobody wants to go. There are tables and chairs in the rehab room that we can set up for small group if

they want to.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 555276