Deficiency Records for San Rafael Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for San Rafael Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-12-14 | 2024-01-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-14 | 2024-01-22 | Y |
| Keep all essential equipment working safely. | Health | 2023-12-14 | 2024-01-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-23 | 2023-12-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-23 | 2023-12-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-26 | 2023-12-20 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-12-19 | 2023-12-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-19 | 2023-12-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-19 | 2023-12-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-12-19 | 2023-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-19 | 2023-12-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-14 | 2023-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-14 | 2023-12-15 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-14 | 2023-12-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-14 | 2023-12-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-14 | 2023-12-15 | Y |
| 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 | 2023-10-06 | 2023-10-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-29 | 2023-09-30 | Y |
| Keep all essential equipment working safely. | Health | 2023-09-29 | 2023-09-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-17 | 2023-07-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-17 | 2023-07-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-17 | 2023-07-18 | Y |
| Have policies on smoking. | Health | 2023-07-17 | 2023-07-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-14 | 2023-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-14 | 2023-04-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-04 | 2023-03-04 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-01-06 | 2023-01-07 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-01-06 | 2023-01-07 | Y |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-09-15 | 2022-10-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-15 | 2022-10-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-15 | 2022-10-13 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-09-15 | 2022-10-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-09-14 | 2022-10-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-14 | 2022-10-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-14 | 2022-10-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-14 | 2022-10-12 | 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 | 2022-09-14 | 2022-10-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-14 | 2022-10-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-14 | 2022-10-12 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2022-09-14 | 2022-10-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-31 | 2022-04-19 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-11-30 | 2021-12-23 | Y |
| 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 | 2021-11-30 | 2021-12-23 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-07-29 | 2021-09-28 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-07-28 | 2021-08-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-28 | 2021-08-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-28 | 2021-08-20 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-07-28 | 2021-08-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-29 | 2021-08-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-29 | 2021-08-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-29 | 2021-08-20 | N |
