San Rafael Healthcare & Wellness Center, LP

In the surveyor’s words

From the most serious findings on record at San Rafael Healthcare & Wellness Center, LP, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 27, 2025

  Based on interview and record review, the facility failed to implement and monitor the effectiveness of interventions of a care plan for one resident (Resident 1) of three sampled residents when Resident 1 had a fall on 3/3/25 and the facility did not ensure: 1. A physician's order for Physical Therapy (PT) so Resident 1 could receive PT; 2. Nursing staff documented frequent room checks had been conducted; and, 3. The Pharmacist's recommendations to monitor Resident 1 for behaviors which could be objectively (data or information collected free from biases or opinions) measured and quantified (measured as a numerical value). […]

• Actual harm, isolatedF744Mar 8, 2021

  Based on interview and record review, the facility failed to ensure appropriate dementia treatment and services for one resident (Resident 1) when facility staff: 1. Failed to follow Resident 1's care plan for Cognitive Loss/Dementia; 2. Failed to follow the facility policy and procedure titled Behavior Management for Resident 1; 3. Terminated care and services by allowing Resident 1 to self-discharge to an unsafe environment against medical advice; 4. Failed to update Resident 1's Baseline Care Plan to reflect the assessment findings from speech therapy's cognitive assessment of Resident 1, Resident 1's scheduled conservatorship hearing (a court hearing to determine whether an individual is incapable of managing personal, financial, or healthcare decisions) affairs in court, and Resident… […]

• Actual harm, isolatedF678Feb 23, 2021

  Based on interviews, record reviews, and a review the actual 911 (Medical Emergency) dispatch call, the facility failed to assess Resident 1's medical emergency in a timely manner when he was found face down on the floor while the upper part of his body was resting over a waste basket, and provide Basic Life Support (BLS, generally refers to the type of care that first-responders, healthcare providers and public safety professionals provide to anyone who is experiencing [CONDITION(S)], respiratory distress or an obstructed airway), including CPR (Cardiopulmonary Resuscitation is an emergency lifesaving procedure performed when the heart stops beating. […]

• No harm, potential for more than minimal, widespreadF812May 25, 2023

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices requirement were met in the kitchen when: 1. The Ansul System (an automatic fire suppression system) pipeline was observed to have brown and black debris. 2. Two kitchen cabinets that stored kitchen equipment had peeling paint and wood and had yellow and brown stains. 3. Four clear rectangular plastic containers were stored right side up. 4. Four one-gallon clear plastic containers were stored stacked up with visible water in them. 5. The foil and saran wrap holders had the cutters with brown rust. 6. The window air conditioner vents had visible gray debris. 7. […]

• No harm, potential for more than minimal, widespreadF880May 25, 2023

  Based on observation, interview, and record review, the facility failed to ensure: 1. A staff performed hand hygiene while delivering meal trays to one of 21 sampled residents (Resident 11) and one of two unsampled residents (Resident 33). This failure had the potential to contaminate the food of Resident 11 and Resident 33. 2. Resident 28's oxygen tubing was labeled with date and time. This failure had the potential to compromise the integrity and the cleanliness of the tubing and affect the sanitary delivery of oxygen to Resident 28. 3. To develop and implement a water management program. as outlined in their policy and procedure. […]