SMP Health - St Raphael

In the surveyor’s words

From the most serious findings on record at SMP Health - St Raphael, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 9, 2026

  Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 4 sampled residents (Resident #1) who exhibited and/or were subjected to physical abuse by and/or to other residents. Failure to prevent resident to resident physical abuse resulted in pushing, hitting, and kicking and placed all residents at risk for serious injury, pain, mental anguish, and emotional distress. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation and Misappropriation of Resident Property occurred on 07/07/26. This policy, dated January 2026, stated, . Verbal abuse is defined as any use of oral . communication . that willfully includes disparaging and derogatory terms to residents . […]

• Actual harm, isolatedF697Feb 16, 2024

  Based on information provided by the complainant, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to attain the highest practicable level of well-being and to prevent and/or manage pain for 1 of 1 sampled resident (Resident #1) who experienced a fall with major injury. Failure to identify circumstances when pain could be anticipated and recognize when the resident experienced pain resulted in Resident #1 experiencing uncontrollable pain related to his untreated hip fracture. Findings include: Information provided by the complainant indicated facility staff failed to identify and respond to changes in the physical status of a resident who experienced uncontrollable pain from a hip fracture sustained during a fall. […]

• Actual harm, isolatedF600Jan 31, 2023

  Based on record review, review of facility policies/procedures, review of the facility's investigation reports, review of quality assurance and process improvement (QAPI) audits, and staff interviews, the facility failed to ensure freedom from abuse/neglect for 1 of 1 sampled resident (Resident #1) with a facial injury sustained while residing in the facility. Failure to provide necessary services to protect residents from harm resulted in Resident #1 sustaining pain, facial bruising, and fear after being slapped by a staff member. Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation and Misappropriation of Resident Property occurred on 01/31/23. This policy, revised date 01/23/23, stated, . […]

• No harm, potential for more than minimal, patternF812Sep 24, 2025

  Based on observation, review of temperature logs, review of professional reference, and staff interview, the facility failed to store food in accordance with professional standards for food service safety in 1 of 1 main kitchen and 6 of 7 food storage areas (Third Floor Kitchenette, First Floor Kitchenette, First Floor Sub-station, Special Care Unit, Sunshine Kitchenette, and Circle of Life Cottage Kitchenette). Failure to discard expired food, ensure required refrigerator temperatures, ensure functioning of temperature monitoring devices in refrigerator, ensure clean equipment, and ensure protection of dry food storage from leaking pipes has the potential to affect the quality and safety of food served to the residents. […]

• No harm, potential for more than minimal, patternF880Aug 8, 2024

  Based on observation, record review, facility policy review, and staff interview, the facility failed to follow standards of infection control for 8 of 25 sampled residents (Resident #9, #28, #70, #79, #92, #96, #260, and #360) observed during cares. Failure to follow infection control practices during resident cares related to hand hygiene, glove use, and enhanced barrier precautions (EBP), has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 08/08/24. This policy, revised September 2023, stated, . Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of care. The use of gloves does not replace hand hygiene. […]