San Rafael Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at San Rafael Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 15, 2024

  Based on observation, interview, record review, and facility document and policy review, the facility failed to protect Resident #38's right to be free from verbal and physical abuse perpetrated by Registered Nurse (RN) #6. This deficient practice affected 1 (Resident #38) of 4 sampled residents reviewed for abuse. Specifically, on 11/24/2023, RN #6 ; however, the CNA. On 11/26/2023, RN #6 yelled in Resident #38's face, shook the resident, and insisted the resident allow staff to transfer the resident back to bed. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• Immediate jeopardy, isolatedF609Nov 15, 2024

  Based on interview, record review, and facility document and policy review, the facility failed to ensure staff immediately reported allegations of abuse for 3 (Residents #38, #35 and #3) of 4 residents reviewed for abuse. Specifically, on 11/24/2024, certified nurse aides (CNAs) witnessed an incident involving Registered Nurse (RN) #6 and Resident #38 in which RN #6 aggressively transferred Resident #38 against their will; however, the CNAs who witnessed the transfer did not immediately report that they considered what they witnessed to be abusive, which allowed RN #6 to continue working with access to the resident. […]

• Immediate jeopardy, isolatedF610Nov 15, 2024

  Based on observation, interview, record review, document review, and facility policy review, the facility failed to thoroughly investigate allegations of abuse for 2 (Resident #35 and Resident #38) of 3 residents reviewed for abuse. Specifically, on 11/26/2023, RN #6 yelled in Resident #38's face, shook the resident, and insisted the resident allow staff to transfer the resident back to bed. Staff who witnessed the abuse did not immediately report the incident to administration, which resulted in a delay in initiating an investigation and implementing protective measures to prevent further abuse. As a result, RN #6 continued working in the facility and was involved in another incident of abuse toward Resident #38 on 11/26/2023. […]

• Actual harm, isolatedF689Nov 15, 2024

  Based on observation, interview, facility document review, and facility policy review, the facility failed to put interventions in place to prevent future falls for 2 (Resident #35 and Resident #27) of 2 residents reviewed for falls. The failure resulted in Resident #35 sustaining falls on 11/04/2023 which resulted in a laceration to the resident's head, 12/19/2023, 02/23/2024 which resulted in a right clavicle fracture, 05/21/2024 which resulted in an abrasion to their left knee, 07/12/2024, 07/22/2024 which resulted in swelling to the face and an abrasion on the nose, 07/27/2024, and 08/06/2024 with no evidence the facility initiated interventions after the falls to prevent future falls. […]

• Actual harm, isolatedF689Jun 17, 2021

  Based on observation, interview, and record review it was determined, for 2 of 19 sampled residents, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, two residents that had multiple falls were not provided interventions or adequate supervision to prevent falls from occurring. One resident had to be transported to the emergency roiagnom on two occasions after sustaining lacerations that required sutures. In addition, a resident was not provided adequate supervision during smoking. Resident identifiers: 6 and 10. Findings include: 1. […]