San Rafael Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF584Jul 17, 2023

  Based on observation, interview, and record review, the facility failed to maintain a safe, clean, sanitary, comfortable, and homelike environment for 5 of 86 resident rooms (room [ROOM NUMBER], 132, 133, 233, and 306) 1of 2 resident common areas in hall 100 and 1 of 1 resident common areas in 300 hall and 1 of 3 hallway (hall 100) reviewed for environment, in that: The facility failed to ensure resident rooms and the facility maintained a temperature of 71-81 degrees. These residents were not being screened for signs and symptoms of dehydration or heat related illness. […]

• Immediate jeopardy, patternF689Jul 17, 2023

  Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 20 residents (Resident #10, Resident #11 Resident #3) reviewed for accidents and hazards: 1. The facility failed to ensure Resident #10 did not elope from facility. Resident #10 eloped on 07/01/23 at around 5:30pm and was found on 07/01/23 at around 10:30pm. 2. The facility failed to ensure Resident #11 did not elope from the facility after he was identified as a moderate elopement risk. Resident #11 eloped from the facility on 07/15/23 at around 6:30pm. 3. The facility failed to ensure Resident #3 did not have a vape pen in his possession. […]

• Immediate jeopardy, isolatedF805Oct 27, 2025

  Based on interview and record review the facility failed to ensure menus met the needs of residents in accordance with established national guidelines for 1 (R#1) of 4 residents reviewed for pureed diets.The facility provided R#1 with a whole hot dog when R#1 required a puree diet, leading to a choking incident on 10/16/25 that required the use of the Heimlich maneuver and resulted in anoxic brain injury. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 10/16/25 and ended on 10/17/25. […]

• Immediate jeopardy, isolatedF689Aug 21, 2025

  Based on observation, interviews, and record reviews the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 1 of 5 residents (Resident #1) reviewed for supervision, accidents, and hazards. The facility failed to keep Resident #1 free from accident and/or hazards when she fell on [DATE] which caused her to sustain a left hip fracture by not providing the necessary monitoring and supervision for Resident #1 with known history of behaviors of wandering into other resident rooms. The three staff assigned to supervise the secure unit were at the nurse's station distracted and engaged in personal conversation when Resident #1 wandered out of her room and into another resident's room. An IJ was identified on 08/20/25. […]

• Immediate jeopardy, isolatedF689Dec 23, 2023

  Based on interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 eloped from the facility at night. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. The noncompliance was identified as Past Non-Compliance. The IJ began on 12/18/23 and ended on 12/18/2023. Verifcation of corrections ended on 12/22/2023. […]