Inspection Reports for San Rafael Nursing and Rehabilitation

The facility was found deficient in multiple areas including failure to develop and implement timely and accurate comprehensive care plans for residents, failure to ensure the Director of Nursing did not serve as a charge nurse during high census days, significant medication errors related to blood pressure medication administration, and failure to maintain accurate clinical records for residents.

The complaint involved Resident #5 having a dressing on his arm for roughly 8 days without clinical staff assessing underneath, and Resident #1 receiving a whole hot dog instead of a pureed diet leading to choking and anoxic brain injury.

The facility failed to provide appropriate treatment and care according to orders and resident preferences, failed to secure wound treatment carts, provided incorrect diet texture resulting in a choking incident and anoxic brain injury, and failed to maintain complete and accurate clinical documentation for skin assessments.

The complaint investigation revealed that Resident #1's fall with major injury was not reported to the State Agency within 2 hours as required. The facility failed to conduct a thorough investigation, including interviews and review of supervision at the time of the fall. Resident #1 was moved after the fall despite severe pain and deformity, risking further injury. Staffing on the locked unit was inadequate, with staff distracted and not properly supervising residents, allowing Resident #1 to wander into another resident's room and fall. Immediate Jeopardy was identified and later removed after corrective actions were implemented.

The facility failed to report Resident #1's fall with major injury to the State Agency within the required 2-hour timeframe and did not conduct a thorough investigation of the incident. Resident #1 was moved after the fall despite severe pain and leg deformity, contrary to facility policy. Staffing and supervision on the locked unit were inadequate, allowing Resident #1 to wander unsupervised, resulting in the fall. Corrective actions including staff termination, in-services, installation of cameras, and enhanced supervision plans were implemented.

The facility failed to develop and implement a comprehensive care plan for Resident #43 that included oxygen therapy, despite physician orders for oxygen. This deficiency could place the resident at risk for not receiving appropriate care to maintain their highest practicable physical, mental, and psychosocial well-being.

The facility was found deficient in multiple areas including failure to provide timely written transfer/discharge notifications, incomplete care plans for oxygen therapy, inadequate accident hazard prevention, improper respiratory care oxygen settings, inaccurate medication administration documentation and adherence to hold parameters, expired biologicals in medication rooms, insufficient registered dietician involvement, poor food safety and sanitation practices, failure to maintain infection control protocols including cleaning of blood pressure cuffs and posting of Enhanced Barrier Precaution signs, and unsafe kitchen environment with water leaks and pest infestations.

The complaint investigation was substantiated with findings that Resident #1 was physically abused by Resident #2 resulting in injury, Resident #3's controlled medications were misappropriated, and multiple narcotic medication administrations were not properly documented. The facility took corrective actions including staff interviews, in-services, and disciplinary actions including termination of a nurse involved in medication mismanagement.

The facility failed to protect residents from abuse and misappropriation of medications, specifically involving two residents in an altercation and one resident's controlled medications being misplaced. Additionally, the facility failed to accurately document narcotic medication administration for multiple residents, risking improper medication administration.

The complaint investigation was triggered by a fall incident on 06/12/24 involving Resident #1, who required two staff for assistance but was left unattended by one staff member (CNA B) during care. The resident fell from bed, sustained minor injuries, and was treated at a hospital. The facility suspended and terminated CNA B for the incident. The case worker and multiple staff interviews confirmed the failure to follow care orders requiring two-person assistance.

The facility failed to ensure adequate supervision for Resident #1 during incontinent care, resulting in the resident falling from bed due to only one staff member assisting instead of the required two. The resident sustained minor injuries and was treated at a hospital. Additionally, the facility failed to keep the medication room door locked, posing a risk of unauthorized access to medications.

The complaint investigation revealed that Resident #1 was left alone in her room without a call light, which could have resulted in injury. Interviews with nursing staff and administration confirmed the incident and subsequent counseling of involved staff. The kitchen vent condensation issue was also identified as a safety concern during the investigation.

The facility failed to ensure Resident #1's call light was within reach, placing the resident at risk for falls and lack of staff access. Additionally, the kitchen vent was dripping condensation, creating slipping hazards and potential contamination risks. Staff interviews revealed lapses in care and awareness, and corrective actions including staff counseling and in-service training were noted.

The investigation was complaint-driven, focusing on the undocumented fall of Resident #1 on 06/21/24. The complaint was substantiated as staff failed to report, assess, and document the fall properly. Interviews with CNA A, CNA C, LVN G, the DON, ADON D, the Administrator, and Resident #1 confirmed the incident and lapses in following policy. The facility did not conduct a timely investigation or notification as required.

The facility failed to document and report a fall of Resident #1 that occurred on 06/21/24 in the shower room. Staff did not follow the facility's accident/incident policy, resulting in lack of timely nurse assessment, incomplete documentation, and no proper investigation. Interviews with staff and the resident confirmed the fall and inadequate response. The facility's policies and training on falls were reviewed, revealing lapses in adherence.

The facility failed to maintain resident rooms and common areas in safe and good repair, including water damage in closets, broken and missing furniture parts, exposed electrical cords, and inadequate maintenance follow-up. The smoking area lacked self-closing lids on cigarette butt containers. Maintenance work orders were often signed off without completion. These deficiencies posed risks to residents' quality of life.

The complaint investigation found that Resident #1 eloped from the facility on 12/18/2023 and the facility failed to report the incident to the State Survey Agency within the required 24-hour timeframe. The resident was found uninjured by law enforcement and returned to the facility. Interviews revealed staff confusion about reporting responsibilities and delays in submitting the incident report. The facility was also found to have malfunctioning door alarms and inadequate supervision at the time of the elopement.

The facility failed to report the elopement of Resident #1 to the State Survey Agency within the required timeframe and failed to provide adequate supervision to prevent the elopement. Resident #1 was found uninjured after being picked up by law enforcement. The facility implemented corrective actions including door alarm repairs, staff re-education on elopement protocols, and enhanced supervision measures.

The facility was found deficient in multiple areas including failure to provide call lights within reach for residents, unsafe and unsanitary environmental conditions, unsecured hazardous materials, medication errors including administration of wrong medication and failure to follow physician orders, inadequate wound care documentation and performance, and food service sanitation and equipment maintenance issues.

The facility was found deficient in securing hazardous chemicals and shower room doors, medication administration errors including failure to hold medication per physician orders, food service sanitation and equipment maintenance issues, and inadequate wound care documentation and performance. These deficiencies posed risks of accidental poisoning, medication errors, foodborne illness, and compromised wound care.

The facility failed to update the care plan of one resident (R#1) to include a history of fabricating stories and to document an actual event that occurred on 11/12/2023. This failure could place residents at risk for unmet needs and psychosocial complications. Interviews with staff revealed inconsistencies in care plan updates and concerns about staff awareness of the resident's needs.

The facility failed to ensure that one resident's indwelling urinary catheter tubing was positioned correctly to allow gravity drainage, as the catheter bag was held above the bladder and placed on the bed during care, risking urine backflow and potential infection. Interviews with staff confirmed the improper positioning and acknowledged the risk of infection, despite prior training and competency checks.

The investigation was triggered by a complaint regarding the unauthorized installation of a trapeze bar by a resident's family member, which led to the resident sustaining serious injuries. The complaint was substantiated by interviews, record reviews, and observations.

The facility failed to prevent the installation and use of an unapproved trapeze bar by a resident's family member, resulting in the equipment falling on the resident and causing a left tibia and fibula fracture and concussion. The facility lacked proper policies and oversight to prevent unauthorized equipment installation and failed to ensure adequate supervision and maintenance of medical equipment.

The facility failed to maintain resident rooms and common areas at safe temperatures, resulting in an immediate jeopardy that was later removed but with ongoing noncompliance. The facility also failed to prevent elopements of two residents identified as at risk, and failed to follow smoking policies related to resident possession of vape pens. Plans of removal were submitted and accepted addressing these issues.

The facility failed to ensure residents were treated with respect and dignity, specifically regarding the use of privacy bags for foley catheter drainage bags. Additionally, the facility failed to maintain an effective infection prevention and control program, as staff and vendors were observed not wearing required PPE during a COVID-19 outbreak.

The facility failed to ensure that residents with Foley catheters had privacy bags covering their drainage bags, leaving urine visible and potentially compromising residents' dignity. Interviews revealed staff lacked consistent knowledge or training about the use of privacy bags, despite facility policies and recent in-services.

The facility was found deficient in maintaining resident privacy and dignity, ensuring safe and clean environment, developing comprehensive care plans, providing adequate supervision and assistance devices to prevent accidents, ensuring appropriate catheter care, maintaining food safety standards, controlling pests effectively, and having sufficient emergency water supply.