San Pablo Healthcare & Wellness Center
SAN PABLO HEALTHCARE & WELLNESS CENTER in SAN PABLO, CA — inspection on March 30, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
12/02/25, the care plan did not include the wander guard as an intervention.During a review of the
the departure.
The resident elopement was confirmed by reviewing the close circuit television
evaluation indicated the resident had a history of elopement or attempted leaving the facility without informing staff, the resident wandered, the resident had expressed the desire to go home, wandering behavior was goal directed and the wandering was likely to affect safety of self and others.During a review of Resident 1's progress note, dated 11/28/25, the progress note indicated the resident continued to demonstrate noncompliance with wearing the assigned wander guard.
Resident was assessed as a high elopement risk, with a pattern of attempts to leave the unit and exit seeking behaviors.
During an interview on 2/6/26, at 12:24 p.m., with the DON, the DON stated staff unlocked the front main door on 11/25/25 to allow the kitchen staff to enter and forgot to relock the door as it was almost 7:00 a.m. DON stated he did interview the staff who unlocked the door, but the investigation summary lacked the written interviews.
Other attempts to interview the staff who unlocked the main front door was unsuccessful.During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, dated 1/31/23, the P&P indicated elopement is a behavior that leads to a resident leaving the facility unsupervised or without permission. If the resident exits the facility despite efforts to stop them, a staff member may accompany or follow the resident.During a review of the facility's P&P titled, Unusual Occurrence reporting, dated 5/30/24, the P&P indicated, the investigation and documentation should include but is not limited to interviews with residents, staff and any other witnesses.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN PABLO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SAN PABLO HEALTHCARE & WELLNESS CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.