Inspection Report Summary
The most recent inspection on December 1, 2025, identified deficiencies related to care planning, nursing supervision, medication errors, and clinical recordkeeping. Earlier inspections showed a pattern of issues with resident care plans, medication administration, supervision, environmental safety, and food service sanitation. Complaint investigations substantiated concerns including inadequate supervision leading to falls and injuries, medication mismanagement, and failure to report incidents timely, with one immediate jeopardy finding in mid-2023 that was later resolved. Enforcement actions included staff terminations and corrective plans, but fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates ongoing challenges with care coordination and safety, with some corrective actions taken but deficiencies persisting over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
414% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
121 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Census: 121
Deficiencies: 4
Date: Dec 1, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements for San Rafael Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to develop and implement timely and accurate comprehensive care plans for residents, failure to ensure the Director of Nursing did not serve as a charge nurse during high census days, significant medication errors related to blood pressure medication administration, and failure to maintain accurate clinical records for residents.
Deficiencies (4)
Failure to develop and implement a complete care plan that meets all the resident's needs with measurable objectives and timetables.
Director of Nursing served as a charge nurse during shifts when the average daily census was above 60, potentially dividing attention and risking resident harm.
Residents were not free from significant medication errors, including failure to administer blood pressure medication per prescribed orders and parameters.
Failure to maintain accurate clinical records, including vital signs and blood pressure documentation for multiple residents.
Report Facts
Resident census: 118
Resident census: 121
Resident census: 116
Resident census: 116
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Licensed Vocational Nurse | Named in medication error finding related to failure to administer Clonidine |
| ADON B | Assistant Director of Nursing | Interviewed regarding care plan updates and DON working as charge nurse |
| DON | Director of Nursing | Interviewed regarding care plan responsibilities and working as charge nurse |
| MDS nurse | Responsible for updating clinical portions of care plans; interviewed about care plan deficiencies | |
| RMDS | Interviewed regarding care plan audits and hypertensive medication planning | |
| ADM | Administrator | Interviewed regarding DON working as charge nurse and facility policies |
| LVN C | Licensed Vocational Nurse | Interviewed regarding blood pressure medication administration and documentation |
| MA E | Medication Aide | Interviewed regarding blood pressure checks and documentation |
| MA F | Medication Aide | Interviewed regarding blood pressure medication administration and documentation |
| ADON A | Assistant Director of Nursing | Interviewed regarding importance of accurate blood pressure documentation |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 27, 2025
Visit Reason
The inspection was conducted based on complaints regarding inadequate treatment and care, improper medication storage, incorrect diet provision leading to choking, and failure to maintain accurate clinical records for residents.
Complaint Details
The complaint involved Resident #5 having a dressing on his arm for roughly 8 days without clinical staff assessing underneath, and Resident #1 receiving a whole hot dog instead of a pureed diet leading to choking and anoxic brain injury.
Findings
The facility failed to provide appropriate treatment and care according to orders and resident preferences, failed to secure wound treatment carts, provided incorrect diet texture resulting in a choking incident and anoxic brain injury, and failed to maintain complete and accurate clinical documentation for skin assessments.
Deficiencies (4)
Failure to ensure residents received treatment and care in accordance with professional standards and care plans, specifically for one resident with skin irregularities.
Failure to ensure drugs and biologicals were stored in locked compartments and restrict access to authorized personnel, with one wound care treatment cart found unlocked.
Failure to ensure menus met the needs of residents requiring pureed diets, resulting in a choking incident and anoxic brain injury for one resident.
Failure to maintain clinical records in accordance with accepted professional standards, including incomplete documentation of skin assessments and bandages for one resident.
Report Facts
Residents reviewed for skin irregularities: 3
Wound treatment carts reviewed: 2
Wound treatment carts found unlocked: 1
Residents reviewed for pureed diets: 4
Staff in-serviced on tray ticket auditing: 112
Dietary staff in-serviced: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN E | Licensed Vocational Nurse | Failed to complete thorough head-to-toe assessment and document bandage on Resident #5's arm |
| LVN F | Licensed Vocational Nurse | Failed to document detailed assessment of Resident #5's skin impairment |
| CNA B | Certified Nursing Assistant | Provided incorrect food tray to Resident #1 leading to choking incident |
| Director of Nursing | Director of Nursing (DON) | Provided statements on facility expectations and investigation of incidents |
| Administrator | Facility Administrator | Provided statements on facility policies and investigation of incidents |
| ADON | Assistant Director of Nursing | Assisted in choking incident response and investigation |
| Kitchen Manager | Kitchen Manager | Investigated food tray mix-up leading to choking incident |
| LVN A | Licensed Vocational Nurse | Verbalized wound care cart policy and uncertainty about last user |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 4
Date: Aug 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to timely report and properly investigate an unwitnessed fall with major injury involving Resident #1, who sustained a left hip fracture after wandering into another resident's room and falling.
Complaint Details
The complaint investigation revealed that Resident #1's fall with major injury was not reported to the State Agency within 2 hours as required. The facility failed to conduct a thorough investigation, including interviews and review of supervision at the time of the fall. Resident #1 was moved after the fall despite severe pain and deformity, risking further injury. Staffing on the locked unit was inadequate, with staff distracted and not properly supervising residents, allowing Resident #1 to wander into another resident's room and fall. Immediate Jeopardy was identified and later removed after corrective actions were implemented.
Findings
The facility failed to report Resident #1's fall with major injury to the State Agency within the required 2-hour timeframe and did not conduct a thorough investigation of the incident. Resident #1 was moved after the fall despite severe pain and leg deformity, contrary to facility policy. Staffing and supervision on the locked unit were inadequate, allowing Resident #1 to wander unsupervised, resulting in the fall. Corrective actions including staff termination, in-services, installation of cameras, and enhanced supervision plans were implemented.
Deficiencies (4)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to respond appropriately to all alleged violations including lack of thorough investigation of Resident #1's fall.
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, including moving Resident #1 after fall despite severe pain and deformity.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in Resident #1's fall and fracture.
Report Facts
Census: 26
Staffing: 2
Staffing: 1
Fall date: Jun 1, 2025
Surgical date: Jun 2, 2025
Plan of Removal implementation date: Jul 30, 2025
Camera installation date: Aug 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN-I | Licensed Vocational Nurse | Assessed Resident #1 after fall, failed to prevent moving resident with suspected fracture, terminated on 07/30/2025 |
| ADON-A | Assistant Director of Nursing | Provided statements on fall investigation and supervision, involved in staff in-services |
| DON | Director of Nursing | Received fall report, did not investigate supervision or incident thoroughly, involved in corrective actions |
| Administrator | Received fall report, did not investigate incident initially, involved in corrective actions | |
| CNA-J | Certified Nursing Assistant | Witnessed notification of fall, stated staff were distracted and did not question resident who found fall |
| CNA-K | Certified Nursing Assistant | Observed hallways during fall, stated staff were distracted and monitoring was insufficient |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically focusing on the development and implementation of comprehensive person-centered care plans for residents.
Findings
The facility failed to develop and implement a comprehensive care plan for Resident #43 that included oxygen therapy, despite physician orders for oxygen. This deficiency could place the resident at risk for not receiving appropriate care to maintain their highest practicable physical, mental, and psychosocial well-being.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, including oxygen therapy for Resident #43.
Report Facts
Residents reviewed for comprehensive person-centered care plans: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN-G | Licensed Vocational Nurse | Interviewed regarding nurses' use of care plans and oxygen parameters |
| MDS Nurse | Minimum Data Set Nurse | Interviewed about care plan updates and oxygen care plan absence |
| DON | Director of Nursing | Interviewed about care plan updates and importance of oxygen care planning |
| ADON-F | Assistant Director of Nursing | Interviewed about care plan updates and use by nursing staff |
Inspection Report
Routine
Deficiencies: 13
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including timely notification of transfers or discharges, development of comprehensive care plans, accident hazard prevention, respiratory care, pharmaceutical services, medication administration accuracy, drug and biological storage, dietary staffing, food safety and sanitation, infection prevention and control, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to provide timely written transfer/discharge notifications, incomplete care plans for oxygen therapy, inadequate accident hazard prevention, improper respiratory care oxygen settings, inaccurate medication administration documentation and adherence to hold parameters, expired biologicals in medication rooms, insufficient registered dietician involvement, poor food safety and sanitation practices, failure to maintain infection control protocols including cleaning of blood pressure cuffs and posting of Enhanced Barrier Precaution signs, and unsafe kitchen environment with water leaks and pest infestations.
Deficiencies (13)
Failure to send timely written notice of transfer or discharge to residents, representatives, or ombudsman for urgent medical transfers for 2 residents.
Failure to develop and implement a comprehensive care plan including oxygen therapy for a resident with COPD.
Failure to ensure floor mats were in place beside a resident's bed to prevent accidents.
Failure to ensure oxygen concentrator was set at the correct ordered setting for a resident.
Failure to provide pharmaceutical services ensuring accurate medication administration and documentation for blood pressure medications for 2 residents.
Failure to dispose of expired biologicals in medication rooms.
Failure to ensure registered dietician attended weekly weight meetings and provided adequate oversight.
Failure to store, prepare, distribute, and serve food in accordance with professional standards including lack of internal thermometers in freezers, poor kitchen cleanliness, improper food labeling, personal items in food storage areas, pest infestation, and inadequate water temperatures for sanitation.
Failure to maintain medical records with accurate and complete documentation of vital signs prior to medication administration for a resident.
Failure to sanitize blood pressure cuff between residents during medication pass.
Failure to post Enhanced Barrier Precaution signs outside resident rooms requiring such precautions.
Failure to maintain a safe, clean, and sanitary kitchen environment including water leaks from electrical outlet, lighting fixture, and AC ducts.
Failure to maintain effective pest control with ongoing roach infestation in the kitchen.
Report Facts
Expired swab kits: 19
Blood pressure checks missed: 15
Blood pressure checks missed: 10
Pest sightings: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Named in findings for failure to sanitize blood pressure cuff between residents and inaccurate medication administration documentation |
| LVN I | Licensed Vocational Nurse | Named in findings for inaccurate medication administration documentation and failure to document blood pressure readings |
| LVN E | Licensed Vocational Nurse | Named in findings for inaccurate medication administration documentation and failure to follow hold parameters |
| LVN D | Licensed Vocational Nurse | Named in findings for expectations on medication administration and infection control |
| ADON F | Assistant Director of Nursing | Named in findings for interviews regarding medication administration, infection control, and dietary services |
| DON | Director of Nursing | Named in findings for interviews regarding medication administration and infection control |
| DM | Dietary Manager | Named in findings for dietary services and kitchen sanitation |
| RD | Registered Dietician | Named in findings for failure to attend weekly weight meetings and limited involvement |
| MS | Maintenance Supervisor | Named in findings for kitchen maintenance and pest control |
| ADM | Administrator | Named in findings for interviews regarding pest control and kitchen maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 6, 2025
Visit Reason
The inspection was conducted due to complaints regarding abuse, neglect, misappropriation of property, and inaccurate medication documentation at San Rafael Nursing and Rehabilitation.
Complaint Details
The complaint investigation was substantiated with findings that Resident #1 was physically abused by Resident #2 resulting in injury, Resident #3's controlled medications were misappropriated, and multiple narcotic medication administrations were not properly documented. The facility took corrective actions including staff interviews, in-services, and disciplinary actions including termination of a nurse involved in medication mismanagement.
Findings
The facility failed to protect residents from abuse and misappropriation of medications, specifically involving two residents in an altercation and one resident's controlled medications being misplaced. Additionally, the facility failed to accurately document narcotic medication administration for multiple residents, risking improper medication administration.
Deficiencies (3)
Failure to protect Resident #1 from abuse resulting in a fall and head injury due to another resident pushing her.
Failure to prevent misappropriation of Resident #3's lorazepam and tramadol medications.
Failure to accurately document administration of narcotic medications for Residents #3, #4, and #5.
Report Facts
Lorazepam tablets misappropriated: 7
Tramadol tablets misappropriated: 19
Lorazepam administrations undocumented: 9
Tramadol administrations undocumented: 2
ABH gel administrations undocumented: 9
Acetaminophen-Codeine administrations undocumented: 30
Tramadol administrations undocumented: 2
Ativan administrations undocumented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN H | Licensed Vocational Nurse | Involved in medication misappropriation incident; suspended and terminated after investigation |
| LVN G | Licensed Vocational Nurse | Morning nurse who found missing medication bag; involved in medication handling |
| ADON D | Assistant Director of Nursing | Involved in investigation and handling of medication misappropriation incident |
| ADON E | Assistant Director of Nursing | Involved in investigation and handling of medication misappropriation incident |
| DON | Director of Nursing | Led investigation into medication misappropriation and staff disciplinary actions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall incident where the facility allegedly failed to provide adequate supervision and assistance during care, resulting in a resident falling from bed and sustaining minor injuries.
Complaint Details
The complaint investigation was triggered by a fall incident on 06/12/24 involving Resident #1, who required two staff for assistance but was left unattended by one staff member (CNA B) during care. The resident fell from bed, sustained minor injuries, and was treated at a hospital. The facility suspended and terminated CNA B for the incident. The case worker and multiple staff interviews confirmed the failure to follow care orders requiring two-person assistance.
Findings
The facility failed to ensure adequate supervision for Resident #1 during incontinent care, resulting in the resident falling from bed due to only one staff member assisting instead of the required two. The resident sustained minor injuries and was treated at a hospital. Additionally, the facility failed to keep the medication room door locked, posing a risk of unauthorized access to medications.
Deficiencies (2)
Failure to ensure adequate supervision to prevent accidents, resulting in a resident fall during incontinent care with only one staff member present instead of two as required.
Failure to ensure medication room door was kept closed and locked, leaving medications accessible.
Report Facts
Fall risk evaluation score: 15
Fall risk evaluation score: 7
Incident date: Jun 12, 2024
Medication room unlocked duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in the finding for failing to have a second staff assist during care, resulting in resident fall; suspended and terminated |
| ADON C | Assistant Director of Nursing | Interviewed regarding the incident and facility monitoring; confirmed CNA B's suspension and termination |
| ADON D | Assistant Director of Nursing | Interviewed about incident details, facility policies, and staff education |
| LVN A | Licensed Vocational Nurse | Observed leaving medication room door unlocked; received corrective action |
| CNA E | Certified Nursing Assistant | Interviewed about Resident #1's care needs and incident |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 6, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to reasonably accommodate resident needs and preferences, specifically related to call light accessibility for a resident, and to assess the safety and sanitary conditions of the kitchen area.
Complaint Details
The complaint investigation revealed that Resident #1 was left alone in her room without a call light, which could have resulted in injury. Interviews with nursing staff and administration confirmed the incident and subsequent counseling of involved staff. The kitchen vent condensation issue was also identified as a safety concern during the investigation.
Findings
The facility failed to ensure Resident #1's call light was within reach, placing the resident at risk for falls and lack of staff access. Additionally, the kitchen vent was dripping condensation, creating slipping hazards and potential contamination risks. Staff interviews revealed lapses in care and awareness, and corrective actions including staff counseling and in-service training were noted.
Deficiencies (2)
Failed to provide reasonable accommodation of resident needs and preferences for call lights, specifically Resident #1's call light was not within reach.
Failed to provide a safe, functional, sanitary, and comfortable environment in the kitchen; kitchen vent was dripping condensation creating slipping hazards and possible contamination.
Report Facts
Staff attendance at nursing in-service: 25
Duration resident left without call light: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Named in the finding related to leaving Resident #1 without a call light and receiving counseling/re-education. |
| LVN A | Licensed Vocational Nurse | Interviewed regarding the incident of Resident #1 being left without a call light. |
| DON | Director of Nursing | Interviewed about the incident and staff counseling. |
| Administrator | Facility Administrator | Interviewed about the incident and staff counseling. |
| Kitchen Manager | Kitchen Manager | Interviewed regarding the kitchen vent condensation issue. |
| Maintenance Director | Maintenance Director | Interviewed regarding the kitchen vent condensation and maintenance work orders. |
| Assistant Director of Nurses | Assistant Director of Nurses | Interviewed regarding kitchen service to residents. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 30, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain complete and accurate clinical records for Resident #1, specifically related to a fall incident on 06/21/24 that was not documented or properly reported.
Complaint Details
The investigation was complaint-driven, focusing on the undocumented fall of Resident #1 on 06/21/24. The complaint was substantiated as staff failed to report, assess, and document the fall properly. Interviews with CNA A, CNA C, LVN G, the DON, ADON D, the Administrator, and Resident #1 confirmed the incident and lapses in following policy. The facility did not conduct a timely investigation or notification as required.
Findings
The facility failed to document and report a fall of Resident #1 that occurred on 06/21/24 in the shower room. Staff did not follow the facility's accident/incident policy, resulting in lack of timely nurse assessment, incomplete documentation, and no proper investigation. Interviews with staff and the resident confirmed the fall and inadequate response. The facility's policies and training on falls were reviewed, revealing lapses in adherence.
Deficiencies (1)
Failure to maintain clinical records in accordance with accepted professional standards, specifically not documenting Resident #1's fall on 06/21/24.
Report Facts
Resident's BIMS score: 14
Fall risk score: 9
Incident date: Jun 21, 2024
Training dates: Feb 9, 2024
Training dates: Apr 17, 2024
Training dates: May 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Reported and assisted Resident #1 during the fall incident; provided a written statement and interview regarding the fall and reporting procedures. |
| CNA C | Certified Nursing Assistant | Assisted CNA A with Resident #1 after the fall; interviewed about the incident and reporting practices. |
| LVN G | Licensed Vocational Nurse | Responsible for assessing Resident #1 after the fall and completing documentation; interviewed about the incident and reporting lapses. |
| DON | Director of Nursing | Interviewed regarding fall policies, incident awareness, and investigation procedures; stated unawareness of the fall until surveyor intervention. |
| ADON D | Assistant Director of Nursing | Interviewed about fall incident reporting and staff training; acknowledged lack of proper documentation and notification. |
| Administrator | Facility Administrator | Interviewed about fall incident awareness and facility policies; stated unawareness of the incident until surveyor intervention. |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 7, 2024
Visit Reason
The inspection was conducted to assess the safety, functionality, sanitation, and comfort of the nursing home environment, including resident rooms, smoking areas, and maintenance practices.
Findings
The facility failed to maintain resident rooms and common areas in safe and good repair, including water damage in closets, broken and missing furniture parts, exposed electrical cords, and inadequate maintenance follow-up. The smoking area lacked self-closing lids on cigarette butt containers. Maintenance work orders were often signed off without completion. These deficiencies posed risks to residents' quality of life.
Deficiencies (4)
Resident rooms were not safe and in good repair, including water damage, broken furniture, and exposed electrical cords.
Smoking area lacked self-closing lids for discarded cigarette butts, with trash and cigarette butts found outside containers.
Maintenance log work orders were signed off despite repairs not being completed.
Closet ceilings and hallways were unsafe and in disrepair, including missing closet doors and exposed air conditioning ductwork.
Report Facts
Work Order #3278: 1
Work Order #2962: 1
Work Order #3141: 1
Work Order #3178: 1
Work Order #3355: 1
Work Order #3356: 1
Work Order #3416: 1
Work Order #3193: 1
Work Order #3223: 1
QAPI 90-day plan: 80
Floor tech work rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADM | Administrator | Interviewed regarding 90-day repair plan, maintenance work orders, and smoking policy enforcement. |
| MS A | Maintenance staff who signed off on incomplete work orders. | |
| MS B | Maintenance staff who signed off on incomplete work orders. | |
| HSK A | Housekeeper | Interviewed about building condition and housekeeping duties. |
| HSK B | Housekeeper | Interviewed about cleaning practices and mattress replacement. |
| HS | Housekeeping Supervisor | Interviewed about repairs, mattress replacement, and housekeeping procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 18, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of resident neglect involving Resident #1 who eloped from the facility on 12/18/2023.
Complaint Details
The complaint investigation found that Resident #1 eloped from the facility on 12/18/2023 and the facility failed to report the incident to the State Survey Agency within the required 24-hour timeframe. The resident was found uninjured by law enforcement and returned to the facility. Interviews revealed staff confusion about reporting responsibilities and delays in submitting the incident report. The facility was also found to have malfunctioning door alarms and inadequate supervision at the time of the elopement.
Findings
The facility failed to report the elopement of Resident #1 to the State Survey Agency within the required timeframe and failed to provide adequate supervision to prevent the elopement. Resident #1 was found uninjured after being picked up by law enforcement. The facility implemented corrective actions including door alarm repairs, staff re-education on elopement protocols, and enhanced supervision measures.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft to proper authorities for Resident #1 who eloped.
Failure to ensure adequate supervision to prevent accidents resulting in Resident #1 eloping from the facility at night.
Report Facts
Incident report delay: 3
BIMS score: 4
Date of survey completion: Dec 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding elopement incident and reporting delays | |
| CFO | Interviewed about incident report submission delay and reporting responsibilities | |
| ADON B | Interviewed about resident return and reporting procedures | |
| LVN A | Charge Nurse | Provided care for Resident #1 during the night of the elopement; multiple attempts to contact for interview |
| CNA A | Interviewed about resident care and staffing challenges during elopement | |
| RN A | Interviewed about elopement process and protocols | |
| LVN B | Interviewed about elopement process and protocols | |
| LVN C | Interviewed about elopement process and protocols | |
| CNA B | Interviewed about elopement process and protocols | |
| Social Worker | Interviewed about door alarm issues and elopement protocols |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Dec 14, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements related to resident care, safety, medication administration, wound care, food service, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to provide call lights within reach for residents, unsafe and unsanitary environmental conditions, unsecured hazardous materials, medication errors including administration of wrong medication and failure to follow physician orders, inadequate wound care documentation and performance, and food service sanitation and equipment maintenance issues.
Deficiencies (7)
Facility staff did not provide call lights within reach for 4 residents, placing them at risk for unmet needs.
Facility failed to provide a safe, functional, sanitary, and comfortable environment for 33 residents, including leaking water, peeling paint, inoperable toilets and lights, and foul odors.
Facility failed to secure shower room door and store chemicals safely, exposing residents to poisonous hazards.
Medication error rate exceeded 5 percent with 2 errors involving Resident #1, including administration of another resident's IV medication and failure to hold blood pressure medication as ordered.
Facility failed to ensure Resident #101 received wound care as ordered; wound care nurse did not provide care for 2 days but documented it was done.
Facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including unclean dishes, equipment, improperly contained food, unlabeled items, and unclean floors.
Facility failed to maintain kitchen equipment in safe operating condition, including whitish residue on dishes, rusted vent hood manifolds, and inoperable freezers.
Report Facts
Residents affected: 33
Medication error rate: 8
Medication administration: 2
Plastic bowls with residue: 17
Plastic coffee cups with residue: 14
Plastic drinking glasses with residue: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Administered wrong IV medication to Resident #1 and failed to check medication label properly |
| MA A | Medication Aide | Administered Metoprolol Tartrate to Resident #1 despite blood pressure below physician's hold parameter |
| LVN B | Wound Care Nurse | Failed to provide wound care for Resident #101 for 2 days but documented it was done |
| DON | Director of Nursing | Provided statements regarding call light policy, medication administration expectations, and wound care oversight |
| CFM | Certified Food Manager | Provided statements regarding kitchen sanitation and equipment issues |
| ADM | Administrator | Provided statements regarding kitchen equipment maintenance and vent hood cleaning |
| Shower Aide A | Shower Aide | Observed and interviewed regarding call light placement for Resident #49 |
| LVN A | Licensed Vocational Nurse | Interviewed about call light placement and medication administration |
| CNA A | Certified Nursing Assistant | Interviewed about call light placement and shower room safety |
Inspection Report
Routine
Deficiencies: 6
Date: Dec 12, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident safety, medication administration, food service safety, wound care, and equipment maintenance at San Rafael Nursing and Rehabilitation.
Findings
The facility was found deficient in securing hazardous chemicals and shower room doors, medication administration errors including failure to hold medication per physician orders, food service sanitation and equipment maintenance issues, and inadequate wound care documentation and performance. These deficiencies posed risks of accidental poisoning, medication errors, foodborne illness, and compromised wound care.
Deficiencies (6)
Failed to secure shower room door and store chemicals out of residents' reach, posing risk of accidental poisoning.
Medication error rate exceeded 5% with errors including administering wrong IV medication and failure to hold blood pressure medication as ordered.
Failed to ensure residents were free from significant medication errors related to blood pressure medication administration.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including unclean dishes, unsealed food items, unlabeled and undated refrigerated items, and unclean kitchen areas.
Failed to safeguard resident-identifiable information and maintain accurate wound care documentation; wound care nurse did not provide wound care as ordered for 2 days but documented it as done.
Failed to maintain essential kitchen equipment in safe operating condition, including whitish residue on dishes, rusted vent hood manifolds, and two inoperable freezers.
Report Facts
Medication error rate: 8
Medication errors: 2
Plastic bowls with residue: 17
Plastic coffee cups with residue: 14
Plastic drinking glasses with residue: 10
Undated bags of dried pasta: 2
Undated bags of instant potatoes: 1
Open spice containers: 5
Unlabeled 2 qt. containers in refrigerator: 2
Wound care missed days: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON A | Assistant Director of Nursing | Interviewed regarding unsecured shower room door and chemical storage |
| Maintenance Assistant | Interviewed about shower door lock and chemical storage | |
| DON | Director of Nursing | Interviewed regarding medication errors and shower room safety |
| CNA A | Certified Nursing Assistant | Interviewed about shower room usage and chemical tube observation |
| LVN A | Licensed Vocational Nurse | Involved in medication errors including administering wrong IV medication |
| MA A | Medication Aide | Administered medication outside physician's order parameters |
| LVN B | Licensed Vocational Nurse | Wound care nurse who failed to provide wound care as ordered for Resident #101 |
| CFM | Certified Food Manager | Interviewed about kitchen sanitation and equipment issues |
| ADM | Administrator | Interviewed about dishwasher and kitchen equipment maintenance |
| COOK | Interviewed about kitchen sanitation issues, unavailable for follow-up |
Inspection Report
Routine
Deficiencies: 1
Date: Nov 26, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the development and implementation of a comprehensive person-centered care plan for residents, triggered by concerns about one resident's care plan not reflecting recent events and history of fabricating stories.
Findings
The facility failed to update the care plan of one resident (R#1) to include a history of fabricating stories and to document an actual event that occurred on 11/12/2023. This failure could place residents at risk for unmet needs and psychosocial complications. Interviews with staff revealed inconsistencies in care plan updates and concerns about staff awareness of the resident's needs.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, with measurable objectives and time frames, specifically failing to update the care plan to include history of fabricating stories and an actual event on 11/12/2023.
Report Facts
Residents reviewed for care plans: 6
BIMS score: 7
Care plan initiation date: Jun 7, 2023
Care plan revision dates: Nov 16, 2023
Incident date: Nov 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Notified by family member of allegation, filed grievance form, and provided details about R#1's behavior and event on 11/12/2023 |
| DON | Director of Nursing | Conducted investigation into allegation, provided interviews about care plan updates and facility procedures |
| MDS Coordinator | Minimum Data Set Coordinator | Provided interviews regarding care plan updates, documentation, and facility policy |
| Administrator | Facility Administrator | Participated in interviews regarding care plan updates and facility procedures |
Inspection Report
Routine
Deficiencies: 1
Date: Oct 6, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with appropriate care standards for residents with indwelling urinary catheters, specifically to ensure proper catheter care and prevention of urinary tract infections.
Findings
The facility failed to ensure that one resident's indwelling urinary catheter tubing was positioned correctly to allow gravity drainage, as the catheter bag was held above the bladder and placed on the bed during care, risking urine backflow and potential infection. Interviews with staff confirmed the improper positioning and acknowledged the risk of infection, despite prior training and competency checks.
Deficiencies (1)
Failure to ensure Resident #1's indwelling catheter tubing was allowed to flow freely via gravity drainage; catheter bag was incorrectly positioned above the bladder and on the bed during care.
Report Facts
Date of competency check-off attendance: Mar 29, 2023
Date of record review: Oct 6, 2023
Catheter size: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in deficiency for improper catheter bag positioning and care | |
| DON | Director of Nursing | Provided interview confirming proper catheter care procedures and staff training |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 29, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision and maintenance of medical equipment, specifically a trapeze bar installed by a family member without facility consent, which led to a resident injury.
Complaint Details
The investigation was triggered by a complaint regarding the unauthorized installation of a trapeze bar by a resident's family member, which led to the resident sustaining serious injuries. The complaint was substantiated by interviews, record reviews, and observations.
Findings
The facility failed to prevent the installation and use of an unapproved trapeze bar by a resident's family member, resulting in the equipment falling on the resident and causing a left tibia and fibula fracture and concussion. The facility lacked proper policies and oversight to prevent unauthorized equipment installation and failed to ensure adequate supervision and maintenance of medical equipment.
Deficiencies (2)
Failure to ensure adequate supervision and services to prevent accident hazards related to unapproved trapeze bar installation.
Failure to maintain essential equipment in safe operating condition, specifically the trapeze bar installed without consent.
Report Facts
Residents reviewed for accidents: 5
Residents affected: 1
Date trapeze bar attached: Jun 23, 2023
Date trapeze bar removed: Jun 24, 2023
Resident admission date: Jan 17, 2023
Physician order date: Apr 25, 2023
Hospital radiology report date: Jun 26, 2023
Care plan date: Jul 19, 2023
BIMS score: 11
In-service dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON A | Interviewed regarding incident and resident supervision | |
| ADON B | Interviewed regarding trapeze bar installation and supervision | |
| DON | Interviewed regarding maintenance and rounding expectations | |
| Administrator | Interviewed regarding facility policies and family equipment installation | |
| Maintenance Director | Interviewed regarding work orders and equipment installation | |
| CNA A | Interviewed regarding discovery of trapeze bar and resident condition | |
| LVN A | Interviewed regarding resident assessment and incident report | |
| CNA B | Interviewed regarding resident call light and bruise observation | |
| Social Worker (SW) | Interviewed regarding knowledge of incident and family installation | |
| Chief Compliance Officer | Interviewed regarding incident notification and family installation | |
| LVN B | Interviewed regarding shift observations and rounding | |
| Previous Administrator | Interviewed regarding family installation and facility protocols | |
| Previous Maintenance Director | Interviewed regarding work orders and equipment installation | |
| Director of Housekeeping | Interviewed regarding family member interactions and room checks | |
| MA A | Interviewed regarding overheard conversations and trapeze bar observations | |
| Resident #1's family member | Interviewed regarding trapeze bar installation and communication with facility |
Inspection Report
Enforcement
Census: 86
Deficiencies: 4
Date: Jul 17, 2023
Visit Reason
The inspection was conducted due to an immediate jeopardy related to failure to maintain safe temperatures in the facility and failure to prevent resident elopements, as well as other compliance issues including smoking policy violations.
Findings
The facility failed to maintain resident rooms and common areas at safe temperatures, resulting in an immediate jeopardy that was later removed but with ongoing noncompliance. The facility also failed to prevent elopements of two residents identified as at risk, and failed to follow smoking policies related to resident possession of vape pens. Plans of removal were submitted and accepted addressing these issues.
Deficiencies (4)
Failure to maintain resident rooms and facility at temperatures between 71-81 degrees, with temperatures reaching up to 88.5 degrees, placing residents at risk of heat-related illness.
Failure to develop and implement a comprehensive care plan for Resident #11 that included measurable objectives and timeframes related to elopement risk and history.
Failure to ensure adequate supervision to prevent elopements for Residents #10 and #11, resulting in elopements on 07/01/23 and 07/15/23 respectively.
Failure to follow smoking policy by allowing Resident #3 to possess and use a vape pen without proper supervision or smoking safety evaluation.
Report Facts
Residents affected by temperature issue: 5
Resident rooms reviewed for environment: 86
Temperature recorded: 88.5
Outside temperature: 100
Residents eloped: 2
Resident #10 elopement distance: 2.5
Resident #11 elopement time: 18
Resident #3 BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN L | Licensed Vocational Nurse | Involved in preventing Resident #11 elopement and reporting |
| CNA K | Certified Nursing Assistant | Unlocked door allowing Resident #11 to elope |
| Administrator | Provided statements on temperature issues and smoking policy | |
| Maintenance Director | Provided statements on HVAC issues and temperature monitoring | |
| DON | Director of Nursing | Provided statements on supervision and elopement policies |
| ADON D | Assistant Director of Nursing | Involved in Resident #10 elopement assessment and follow-up |
| CNA B | Certified Nursing Assistant | Involved in Resident #11 elopement prevention and reporting |
| CNA F | Certified Nursing Assistant | Reported on door magnet status on day of Resident #10 elopement |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity and privacy, infection prevention and control, and overall facility adherence to health and safety standards.
Findings
The facility failed to ensure residents were treated with respect and dignity, specifically regarding the use of privacy bags for foley catheter drainage bags. Additionally, the facility failed to maintain an effective infection prevention and control program, as staff and vendors were observed not wearing required PPE during a COVID-19 outbreak.
Deficiencies (2)
Failure to ensure residents were treated with respect and dignity; foley catheter drainage bag did not have a privacy bag, leaving urine visually exposed.
Failure to maintain an infection prevention and control program; staff member exited COVID-19 Red Zone without mask and vendors entered facility without appropriate PPE.
Report Facts
Residents affected: 1
Residents affected: 1
Residents on droplet precautions: 7
Foley drainage bag urine volume: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Stated foley bags need dignity bags to promote privacy; aware of privacy bag necessity but could not recall last in-service | |
| ADON | Stated all foley catheters must have dignity bags; nursing staff educated annually and in-services done | |
| LVN B | Licensed Vocational Nurse | Observed exiting Red Zone without mask and speaking to unmasked resident; in-serviced on COVID-19 precautions two weeks prior |
| ADON B | Stated staff required to wear masks and full PPE in resident areas and during COVID-19 outbreak; visitors educated on PPE requirements | |
| Administrator | Mandated mask and PPE use for staff, visitors, and vendors; stated facility follows CDC guidelines | |
| Regional Administrator and Regional RN | Stated staff must wear N95 and PPE in hot zones; visitors encouraged but not mandated to wear masks |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 4, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with residents' rights to dignity and privacy, specifically regarding the use of privacy bags for urinary catheter drainage systems.
Findings
The facility failed to ensure that residents with Foley catheters had privacy bags covering their drainage bags, leaving urine visible and potentially compromising residents' dignity. Interviews revealed staff lacked consistent knowledge or training about the use of privacy bags, despite facility policies and recent in-services.
Deficiencies (1)
Residents #1 and #2's Foley catheter drainage bags did not have privacy bags, leaving urine visually exposed.
Report Facts
Urine volume in catheter bag: 100
Urine volume in catheter bag: 200
Date of in-service: Sep 14, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Interviewed; stated she did not know dignity bags were to be placed over urinary catheter drainage systems |
| LVN A | Licensed Vocational Nurse | Interviewed; acknowledged need for privacy cover but did not know where to get covers |
| CNA D | Certified Nursing Assistant | Interviewed; stated privacy coverings were needed for all Foley bags |
| CNA E | Certified Nursing Assistant | Interviewed; stated privacy coverings were needed for all Foley bags |
| DON | Director of Nursing | Interviewed; confirmed facility has privacy bags and recent in-services on catheter care |
Inspection Report
Routine
Deficiencies: 8
Date: Sep 14, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, dignity, safety, care planning, catheter care, environmental conditions, food safety, pest control, and emergency preparedness at San Rafael Nursing and Rehabilitation.
Findings
The facility was found deficient in maintaining resident privacy and dignity, ensuring safe and clean environment, developing comprehensive care plans, providing adequate supervision and assistance devices to prevent accidents, ensuring appropriate catheter care, maintaining food safety standards, controlling pests effectively, and having sufficient emergency water supply.
Deficiencies (8)
Failed to ensure resident privacy and confidentiality during medical treatment and personal care for two residents.
Failed to provide a safe, functional, sanitary, and comfortable environment; floors, walls, and ceilings were not clean or in good repair.
Failed to develop and implement comprehensive person-centered care plans addressing mental illness, fall prevention, catheter care, and oxygen assistance for four residents.
Failed to ensure adequate supervision and proper placement of fall mats for a resident at high risk for falls.
Failed to provide appropriate catheter care including securing catheters, timely catheter changes, and obtaining necessary orders for catheter care for three residents.
Failed to store, prepare, distribute, and serve food according to professional standards; dishwasher malfunction, forged sanitation logs, presence of flies, dirty cups, expired and unlabeled food items, and deficient emergency water supply.
Failed to maintain an effective pest control program; flies observed throughout the facility and pest control measures insufficient.
Failed to ensure adequate emergency water supply for the facility; only 105 gallons available for 126 residents and 50 employees, insufficient for minimum three-day supply.
Report Facts
Residents reviewed for dignity issues: 10
Residents reviewed for person-centered care plans: 26
Residents reviewed for catheter care: 6
Residents affected by environmental deficiencies: 4
Residents affected by fall supervision deficiencies: 1
Residents affected by pest control deficiencies: Some
Residents affected by food safety deficiencies: Many
Emergency water supply volume: 105
Facility census: 126
Facility employees: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA B | Named in privacy violation for Resident #53 and #124 | |
| LVN C | Interviewed regarding privacy and fall mat placement | |
| DON | Director of Nursing | Interviewed regarding privacy, fall prevention, catheter care, and care planning |
| MDS J | Interviewed regarding care plan deficiencies | |
| LVN L | Interviewed regarding catheter care and documentation | |
| ADON E | Assistant Director of Nursing | Interviewed regarding catheter care and compliance |
| DWA | Dietary worker interviewed regarding dishwasher issues | |
| DS | Dietary Supervisor | Interviewed regarding dishwasher, sanitation logs, pest control, and emergency water |
| ADM | Administrator | Interviewed regarding pest control and emergency water supply |
| MDK | Maintenance Director | Interviewed regarding dishwasher repair and pest control |
| LVN G | Interviewed regarding catheter care and pest control | |
| CNA H | Interviewed regarding pest control | |
| Housekeeper F | Interviewed regarding pest control | |
| CNA I | Interviewed regarding flies on food tray |
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