Deficiency Records for San Rafael Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for San Rafael Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-03-15 | 2023-03-29 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-15 | 2023-03-24 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-15 | 2023-03-24 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-13 | 2023-03-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-13 | 2023-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-12-06 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-03 | 2021-12-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-15 | 2021-08-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-17 | 2021-07-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-17 | 2021-07-23 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-06-17 | 2021-07-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-17 | 2021-07-23 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-06-17 | 2021-07-23 | 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 | 2021-06-17 | 2021-07-23 | N |
| 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. | Health | 2021-06-17 | 2021-07-23 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-06-17 | 2021-07-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-17 | 2021-07-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-06-17 | 2021-07-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-25 | 2019-05-30 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-03-25 | 2019-05-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-20 | 2019-05-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-03-20 | 2019-05-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-03-25 | 2019-05-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-25 | 2019-05-06 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-03-20 | 2019-04-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-20 | 2019-04-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-03-20 | 2019-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-20 | 2019-04-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-03-20 | 2019-04-26 | 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 | 2019-03-25 | 2019-04-26 | 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 | 2019-03-25 | 2019-04-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-25 | 2019-04-26 | N |
| 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. | Health | 2019-03-20 | 2019-04-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-25 | 2019-04-06 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-03-20 | 2019-04-03 | N |
