San Rafael Health and Rehabilitation

Inspectors wroteBased 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. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation, F600, at a scope and severity of J. [...]

Inspectors wroteBased 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. Subsequently, the CNAs witnessed a second incident on 11/26/2023 in which RN #6 grabbed Resident #38 and shook the resident to convince the resident to allow staff to transfer them back to their bed for care. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to maintain a clean and sanitary kitchen. These failures had the potential to affect 39 of 39 residents who received meals from the dietary department.

Inspectors wroteBased on interview, document review, and facility policy review, the facility failed to provide annual and periodic training in accordance with facility policy, to educate staff on activities that constitute abuse and procedures for reporting incidents of abuse for 2 (Certified Nurse Aide [CNA] #8 and Registered Nurse [RN] #6) of 4 staff reviewed.

Inspectors wroteBased on interview, facility document review, and facility policy review, the facility failed to consistently follow up on concerns presented by the Resident Council (RC) and provide a verbal or written response to the RC regarding any actions taken to address their concerns. There was incomplete or no follow-up documented for 5 (January, May, July, August, and September 2024) of 10 months of RC minutes reviewed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop individualized resident-centered care plans with measurable objectives for 4 (Residents #1, #3, #24, and #4) of 14 residents whose care plans were reviewed. Specifically, the facility failed to ensure care plans addressed oxygen use for Resident #1 and Resident #3, failed to ensure a care plan addressed an indwelling urinary catheter for Resident #24, and failed to ensure a care plan addressed respiratory care for a diagnosis of chronic obstructive pulmonary disease (COPD) and respiratory medications for Resident #4.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure physician's orders included all necessary components, including the specified dosages for 2 (Residents #13 and Resident #20) of 3 residents who were observed during the medication administration task.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement infection control and prevention policies. Specifically, the facility failed to ensure staff followed enhanced barrier precautions (EBP) when completing indwelling urinary catheter care for 1 (Resident #24) of 1 resident reviewed for indwelling urinary catheter care. Additionally, the facility failed to conduct annual tuberculosis (TB) risk screenings for 4 (Residents #1, #3, #4, and #27) of 5 residents whose immunization histories were reviewed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure an indwelling urinary catheter was secured to prevent potential pulling/trauma to the urethral meatus for 1 (Resident #24) of 1 sampled resident observed for indwelling urinary catheter care.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure pharmacy recommendations were addressed for 1 (Resident #26) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure an as-needed (PRN, pro re nata) psychotropic medication order specified the duration of use for 1 (Resident #26) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to maintain accurate medical records for 1 (Resident #190) of 19 sampled residents.

Inspectors wroteBased on interview and record review, the facility did not make information on how to file a grievance or complaint available, specifically an anonymous grievance. In addition, the facility did not have a grievance log.

Inspectors wroteBased on interview and record review, the facility did not ensure that 4 of 21 sample residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Resident identifiers: 19, 27, 35, and 87.

Inspectors wroteBased on interview and record review, the facility did not ensure that the pharmacist's recommendations and physician's approval were acted upon. Specifically, for 1 of 21 sampled residents, the facility did not implement the Medical Director's (MD) orders as they pertained to the pharmacist's recommendations. Resident identifier: 4.

Inspectors wroteBased 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 room 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.

Inspectors wroteBased on observation, interview, and record the review it was determined, for 1 of 19 sample residents, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident that complained of pain was unable to get a change in pain relief from the facility Medical Director (MD) for a week. Resident identifier: 17.

Inspectors wroteBased on interview and record review it was determined, for 4 of 19 sampled residents, the facility did not ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Specifically, residents were not seen timely by the Medical Director (MD). Resident identifiers: 1, 17, 21, and 23.

Inspectors wroteBased on interview and record review it was determined, for 3 of 19 sampled residents, the facility did not ensure the attending physician documented that the identified pharmacy irregularity had been reviewed and what, if any, actions had been taken to address it. Specifically, pharmacy recommendations were not reviewed and acted upon by the attending physician, facility Medical Director (MD), and Director of Nursing (DON). Resident identifiers: 12, 17, and 21.

Inspectors wroteBased on interview and record review it was determined, for 4 of 19 sampled residents, the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Additionally, as needed (PRN) orders for psychotropic drugs are limited to 14 days, unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, and should document their rationale in the resident's medical record and indicate the duration for the PRN order. [...]

Inspectors wroteBased on interview and record review it was determined, for 4 of 19 sampled residents, the facility did not maintain medical records on each resident that were complete, accurately documented, and readily accessible. Specifically, influenza records and physician visits were not readily accessible and accurately documented within the residents' medical records. Resident identifiers: 12, 17, 21 and 22.

Inspectors wroteBased on interview and record review it was determined, for 2 of 19 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, two residents that had multiple falls were not provided interventions and the care plan was not implemented. In addition, a resident that had a smoking incident was not provided interventions and the care plan was not implemented. Resident identifiers: 6 and 10.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 19 sampled residents, the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI) and restore continence to the extent possible. Specifically, the facility did not ensure completion of a physician ordered urology referral for a resident who was incontinent and a candidate for bladder retraining. In addition, the resident was treated for a UTI on four occurrences. Resident identifier:

Inspectors wroteBased on interview and record review it was determined, for 2 of 19 sampled residents, the facility did not obtain laboratory (lab) services to meet the needs of the residents. Specifically, 2 resident's had physician's orders to obtain a basic metabolic panal (BMP) for medication monitoring purposes and the labs were not completed as ordered. Resident identifiers: 12 and 17.

Inspectors wroteBased on interview and record review it was determined the facility did not maintain a quality assessment and assurance (QAA) committee consisting at a minimum of the director of nursing services, the Medical Director or his/her designee and at least three other members of the facility's staff. Specifically, the Medical Director (MD) did not attend quarterly QAA meetings.