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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.