San Mateo Medical Center D/P SNF
222 West 39th Avenue · San Mateo, CA · 94403 · 6505733678
345 certified beds Government - County Hospital-based
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Staffing levels are well below research benchmarks for safe care.
- Federal penalties on record: $40,118 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
5 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 2 · $104,000 |
Inspection citations (54 in the current record)
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Potential for harm · D February 19, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected March 6, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 19, 2026 · found via complaint
Respond appropriately to all alleged violations.
Corrected March 6, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · K July 3, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 1, 2025 · Quality of Life and Care
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Potential for harm · D July 3, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected August 1, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 3, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected August 1, 2025 · Resident Rights
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Potential for harm · D July 3, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected August 1, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 3, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected August 1, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 3, 2025
Assess the resident when there is a significant change in condition
Corrected August 1, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 3, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected August 1, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 3, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected August 1, 2025 · Quality of Life and Care
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Potential for harm · D July 3, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected August 1, 2025 · Pharmacy Service
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Potential for harm · E July 3, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected August 1, 2025 · Nutrition and Dietary
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Potential for harm · F July 3, 2025
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected August 1, 2025 · Administration
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Potential for harm · D July 3, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected August 1, 2025 · Infection Control
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Potential for harm · D July 3, 2025
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected August 1, 2025 · Infection Control
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Potential for harm · E July 3, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected August 1, 2025 · Environmental
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Actual harm · G March 21, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 21, 2024 · Quality of Life and Care
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Actual harm · G March 21, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 19, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E March 21, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected April 19, 2024 · Resident Rights
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Potential for harm · D March 21, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 19, 2024 · Resident Assessment and Care Planning
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Potential for harm · D March 21, 2024
Post nurse staffing information every day.
Corrected April 19, 2024 · Nursing and Physician Services
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Potential for harm · D March 21, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 19, 2024 · Pharmacy Service
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Potential for harm · D March 21, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected April 19, 2024 · Pharmacy Service
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Potential for harm · D March 21, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected April 19, 2024 · Pharmacy Service
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Potential for harm · E March 21, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected April 19, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 3, 2025 | Fine | $40,118 |
| July 3, 2025 | Payment Denial | 9 days |
| January 30, 2024 | Fine | $63,882 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 555034 · certified since July 1, 1976. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.