Deficiency Records for San Rafael Healthcare and Wellness Center, LP
Updated as of March 01, 2024
A list of the most recent deficiencies for San Rafael Healthcare and Wellness Center, LP. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-08-02 | 2023-08-02 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-05-25 | 2023-07-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-25 | 2023-07-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-05-25 | 2023-07-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-25 | 2023-07-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-25 | 2023-07-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-25 | 2023-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-25 | 2023-07-14 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-05-25 | 2023-07-14 | N |
| Dispose of garbage and refuse properly. | Health | 2023-05-25 | 2023-07-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-25 | 2023-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-25 | 2023-07-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-25 | 2023-07-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-06-07 | 2023-06-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-07 | 2023-06-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-06-07 | 2023-06-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-07 | 2023-06-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-07 | 2023-06-28 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-06-07 | 2023-06-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-06-07 | 2023-06-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-07 | 2023-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-07 | 2023-06-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-06-07 | 2023-06-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-07 | 2023-06-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-14 | 2023-05-02 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-14 | 2023-05-02 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-04-14 | 2023-05-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-23 | 2022-08-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-22 | 2022-06-27 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-03-04 | 2022-05-23 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-03-08 | 2021-08-12 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-07-08 | 2021-07-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-20 | 2021-06-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-09 | 2021-05-21 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-04 | 2020-03-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-17 | 2020-03-16 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-01-17 | 2020-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-17 | 2020-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-17 | 2020-03-16 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-03-12 | 2019-03-28 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-03-12 | 2019-03-28 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-03-12 | 2019-03-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-03-12 | 2019-03-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-12 | 2019-03-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-12 | 2019-03-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-12 | 2019-03-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-12 | 2019-03-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-12 | 2019-03-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-12 | 2019-03-28 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2019-01-18 | 2019-03-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-01-18 | 2019-03-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-18 | 2019-03-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-18 | 2019-03-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-18 | 2019-03-27 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-01-18 | 2019-03-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-01-18 | 2019-03-27 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-01-18 | 2019-03-27 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-01-18 | 2019-03-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-18 | 2019-03-27 | N |
| Keep all essential equipment working safely. | Health | 2019-01-18 | 2019-03-27 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-01-18 | 2019-03-27 | N |
