San Rafael Healthcare & Wellness Center, LP

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with dignity and respect when staff failed to follow through on requests for assistance for five of six sampled residents, Residents 1, 2, 3, 5, and 6. This failure caused the residents to feel lousy and piss[ed] off and affected the residents' psychosocial well-being. During an interview on 7/1/26 at 12:01 p.m. with Resident 3 and Resident 4, who resided in the same room, Resident 3 stated he waited 20 to 30 minutes for assistance when he pressed his call light, and one time he waited an hour and a half. Resident 3 stated when he was waiting for assistance, he had been incontinent of stool and was sitting in a soiled brief. Resident 3 stated he waited long periods of time for his soiled brief to be changed so often that, he stated, Sadly, I've gotten used to it. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision, accurate assessment and interventions for one of three sampled residents reviewed for elopements (Resident 1) to prevent the resident from eloping (the act of leaving the facility unsupervised and without prior authorization). These failures resulted in Resident 1 walking three blocks on a busy two lane street and being found wandering on the sidewalk and had the potential to result in serious physical harm or death. Based on interview and record review, the facility failed to provide adequate supervision, accurate assessment and interventions for one of three sampled residents reviewed for elopements (Resident 1) to prevent the resident from eloping (the act of leaving the facility unsupervised and without prior authorization). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for one resident (Resident 1) of five sampled residents when Resident 1 left the facility unaccompanied and wandered several busy streets until he was found by a friend and driven to his Responsible Party's (RP, a person who makes health care decisions on behalf of the resident when the resident does not have the mental capacity to do so) home. This failure decreased the facility's potential to provide supervision and to prevent severe injury to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one resident (Resident 1) of four sampled residents from abuse when Resident 1 wandered into Resident 2's room and became verbally and physically aggressive. This failure resulted in Resident 2 punching Resident 1 in the face when Resident 1 would not leave Resident 2's room after repeated requests. On 7/3/25 at 4:33 p.m., the Department received a report from the facility that indicated, On 7/3/25 at 1:40 p.m. [Resident 1] was observed in [Resident 2's] room by the housekeeper and had to be separated immediately. Upon interviewing [Resident 2], he stated that [Resident 1] came into his room and would not leave. [Resident 1] was standing at the bedside with his hands up in a fist while [Resident 2] was laying down telling him to leave. According to [Resident 2] he struck [Resident 1] in the face and chest. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure two out of five sampled residents (Resident 1 and Resident 2) were treated with respect and dignity when: 1. A call light (a signal that residents in healthcare facilities use to alert staff when they need assistance) was not answered timely by facility staff, and 2. A foley catheter (FC, a hollow tube inserted into the bladder to drain or collect urine) drainage bag (bag that collects the drained urine) did not have a privacy cover. These failures had the potential to negatively affect residents' sense of dignity and privacy.[AV3]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide service aligned with professional standards for one out of five sampled residents (Resident 1) when medication was left unattended on Resident ' s overbed table. This failure had the potential for the medication to be taken by unintended persons with potentially serious consequences.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to a safe and sanitary environment for three out of five sampled residents when: 1. Toothbrushes found in a shared bathroom were not labeled with the resident names, and 2. Resident's foley catheter (FC, a hollow tube inserted into the bladder to drain or collect urine) tubing (a thin, flexible tube connected to a catheter that drains urine from the bladder into a collection bag) was on a contaminated surface. These failures put the residents at risk for the transmission of infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure: 1. An alleged sexual abuse incident on 4/28/25 was reported to the local ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), the California Department of Public Health (the state) and local law enforcement within 2 hours after the allegation was made, 2. Staff were knowledgeable of the abuse reporting guidelines: whom to report abuse allegations and the time frame for reporting abuse allegations, and 3. The facility ' s Abuse Policy and Procedure (P&P) titled Reporting Abuse, revised 1/8/2014, reflects the current reporting guidelines. These failures could put all 52 residents of the facility at risk for abuse without timely interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of five sampled residents (Resident 1, Resident 3, Resident 4 and Resident 5) could call for staff assistance through a communication system when the call lights (a device that allows residents to signal staff for assistance) were not found within the residents' reach. These failures had the potential to result in residents ' inability to notify staff when needing help and could lead to safety issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided to 1 of 3 sampled residents (Resident 1), when Resident 1 ' s pain intensity level was not re-assessed for effectiveness one hour after administration of pain medication administration. This failure resulted in Resident 1 ' s report of experiencing pain, feeling like she had a ball inside her, while grimacing and holding her hands around her abdomen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the residents' right to be informed of the plan of care when five of nine sampled residents were not told before admission that their physical therapy (treatment that helps improve how the body performs physical movements) would be done via telehealth (health-related services through live video call) or that they would only receive one session per week. This failure caused residents to feel let down, feel that their progress was slower than they expected, and caused Resident 7 and Resident 8 to not participate in physical therapy.

Inspectors wroteBased 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). [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a copy of the notice of transfer was sent to the representative of the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for one out of two sampled residents (Resident 1), when the facility was not able to provide evidence that the notice of transfer was sent to the Ombudsman. This failure had the potential to put Resident 1 at risk of being inappropriately transferred or discharged from the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was free from unnecessary psychotropic medications (drugs that affect the brain and central nervous system to treat mental health conditions) when prescribed a psychotropic medication without: 1. non-pharmacologic interventions (NPIs, treatments or therapies that do not involve the use of medications) in place to address residents' behavior, and 2. monitoring of behaviors, response to the anti-anxiety (AA, psychotropic medication used to reduce symptoms of anxiety- fear, worry) medication, including side effect (SE, reaction to a medicine) or adverse drug reaction (ADR, dangerous harmful reaction to drugs) in place These failures put the Resident 1 at risk of side effects and adverse drug reactions related to psychotropic medication use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when: 1. Resident 54 did not receive scheduled medications in a timely manner. 2. Certified Nurse Assistant (CNA) 1 was observed laying in Resident 37's bed using her personal cellphone. These failures increased the resident's potential to have unmet health needs and decreased the facility's potential to provide responsible and accurate care for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure insulin (medication used to reduce blood sugar) was not administered when blood sugar was below 120 (target range for blood sugar when insulin is not required) for one of 26 sampled Residents (Resident 7) for 10 out of 19 days in March 2025. This failure had the potential to result in low blood sugar symptoms for Resident 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications, supplements, and supplies were appropriately labeled and stored in accordance with accepted standards of practice when: 1. A prescription nystatin powder (a medication to treat yeast or fungal infection of the skin) was found at Resident 9's bedside table. 2. Two medication bubble packs were left unattended on top of a medication cart. 3. Two used topical medications had no caps to cover the tubes in the treatment cart. 4. A collagen matrix dressing (a type of wound dressing that promotes wound healing) package and a Xeroform (a type of wound dressing that promotes wound healing) package dressing were found open in the treatment cart. 5. Five expired syringes with needles were found in the emergency cart. 6. The refrigerator storage for medications was not maintained at a safe temperature. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored in safe and sanitary conditions in the food service department when: 1. The kitchen refrigerator and the Dry Food Storage Area contained food that was not labeled and not covered. 2. The emergency food storage area contained food that was not labeled and expired. These failures had the potential to expose residents to food contamination and food-borne illnesses (sickness by consuming contaminated food or drinks).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light for one of 26 sampled residents (Resident 13) was within her reach. This failure had the potential for Resident 13's needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 26 sampled residents (Resident 1) was notified of a room/roommate change with a written notice that included the reason before the facility had changed the resident's room. This failure had the potential to result in negatively impacting Resident 1's emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the shower's water temperature was comfortable for one of 26 sampled residents (Resident 1). This failure resulted in Resident 1 not receiving a comfortable shower.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of notice of transfer/discharge was sent to the Ombudsman (an advocate for residents of nursing homes) for two of 26 sampled residents (Residents 58 and 59) when: 1. Resident 58 was transferred to the hospital on 2/26/25. 2. Resident 59 was discharged home on [DATE]. These failures had the potential for residents to be inappropriately transferred or discharged which could result in violating their rights.

Inspectors wroteBased on interview and record review, the facility failed to assess and submit accurate data for one of 26 sampled residents (Resident 37) when: 1. the Level I PASRR (Preadmission Screening and Resident Review- used to receive needed mental health services) screening was not reassessed upon admission to the facility. This failure had the potential for Resident 37 to not receive specialized mental health services to meet their needs. 2. the Minimum Data Set (MDS- an assessment tool used to guide resident care) did not reflect Resident 37's current status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS).

Inspectors wroteBased on interview and record review, the facility failed to develop care plans for two of 26 sampled residents (Resident 1 and 9) when: 1. There was no fall care plan for Resident 1. This failure had the potential to cause multiple falls due to lack of interventions and proper monitoring. 2. There was no physical therapy (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) care plan for Resident 9. This failure had the potential for Resident 9 to not receive the specific services necessary to meet her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist one of 26 sampled residents (Resident 50) with feeding in a timely manner. This failure had the potential for Resident 50 to lose weight.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary services to attain the highest practicable physical, mental, and psychosocial well-being for one of 26 sampled residents (Resident 9) when physician's orders for physical therapy treatment (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) were not provided. This failure resulted in Resident 9 feeling frustrated on her functional and physical progress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label an enteral feeding (a method to provide food through a tube placed in the nose, the stomach, or the small intestine) bottle, an enteral feeding pump bag (a feeding bag consists of a feeding bag and tubing), and a syringe used for enteral feeding for one of 26 sampled residents (Resident 22). This failure had the potential for enteral feeding supplement and equipment to be misused by staff causing cross contamination for Resident 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN) appropriately primed (removing air bubbles from the needle to ensures that the needle is open and working) a Lantus insulin (a long acting medication used to control high blood sugar) pen (a device resembling a pen that delivers insulin injection) before administering to one of 26 sampled residents (Resident 7). This failure had the potential to compromise the medication dose given to Resident 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not greater than five percent when three identified medication errors out of 36 opportunities were observed: 1. Losartan Potassium (medication to manage high blood pressure) was administered without obtaining a blood pressure prior to administration for one of 26 sampled residents (Resident 7). 2. Insulin Glargine [Lantus] (medication to manage high blood sugar) was administered outside of dosing parameter instructions for one of 26 sampled residents (Resident 7). 3. Metoprolol Succinate ER(medication to manage high blood pressure) was not administered per the physician's order for one of 26 sampled residents (Resident 7). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide physical therapy treatment (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) as ordered by a physician for one of 26 sampled residents (Resident 9). This failure had the potential for Resident 9 to not attain her highest possible level of physical and functional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and implement infection control practices for three of 26 sampled residents (Residents 7, 55, and 1) when: 1. Physical Therapist Assistant (PTA) 1 was not wearing a gown while proving care to Resident 7 who was on Enhanced Barrier Precautions (EBP, are infection control intervention designed to reduce the spread of multidrug-resistant organism, MDROs - a germ that is resistant to many antibiotics) 2. Restorative Nursing Assistant/ Certified Nursing Assistant (RNA) 1 was not wearing a gown while repositioning and changing blanket of Resident 55 who was on EBP. 3. Resident 1 was not placed on EBP. This failure had the potential to result in the spread of infectious diseases among residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a sanitary environment when one of 26 sampled residents (Resident 3) was observed with black insects crawling in her bed. This failure had the potential to result in Resident 3 being exposed to insect bites and potentially triggering an allergic reaction.

Inspectors wroteBased on interviews and record review, the facility failed to provide a written notice to a resident's Responsible Party (RP) for one resident (Resident 2) of three sampled residents when Resident 2 was moved to a different room without prior notification of the reason why, when the change would occur, and the opportunity to participate in the decision. This failure decreased the facility's potential to respect the resident or the RP's right to participate in the decision to move to a different room which had the potential to affect the resident's psychosocial well-being.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a person-centered care plan for one resident (Resident 1) when the facility did not initiate a care plan for Resident 1's wandering and high risk of elopement behavior. This failure contributed to a breakdown in the facility's system to provide the person-centered supervision required for Resident 1 when she eloped from the facility unsupervised in her wheelchair.

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate supervision to one resident (Resident 1) of three sampled residents when Resident 1 eloped from the facility. This failure resulted in Resident 1 leaving the facility without staff knowledge and decreased the facility's potential to prevent accident and injury to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to manage the dialysis (use of a machine to clean the blood when the kidneys are no longer able to do this) care of one of two sampled residents (Resident 1) when facility staff did not obtain a physician's order for Resident 1's dialysis, did not include his dialysis schedule in his care plan, did not transport Resident 1 to his scheduled dialysis appointments or transported Resident 1 late to his appointments, did not document Resident 1's missed appointments, did not notify Resident 1's physician about his missed appointments, and did not document the reason the appointments were missed. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a system for validating the competencies of registry nurses. This failure had the potential to result in residents being cared for by nurses who may not have all the skills needed to provide safe care.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1's) right to be free from financial abuse when the Social Services Director (SSW) used Resident 1's ATM (Automated Teller Machine) card for her personal use without authorization. This finding caused Resident 1 anxiety and sadness, and had the potential to result in severe psychological and emotional distress in addition to financial exploitation.

Inspectors wroteBased 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. A dietary staff did not change gloves and perform hand hygiene in between cleaning kitchen equipment and preparing food. 8. A dietary staff did not wear gloves while preparing food. [...]

Inspectors wrote2. During a concurrent observation and interview on 5/22/23, at 8:50 a.m., with the Infection Preventionist (IP), Resident 28's oxygen cannula and tubing (a system to deliver oxygen from a tank to the Resident's nose) was observed with no date or time labeled on the tubing. The IP stated, the tubing should be labeled with date and time at least every seven days. Review of facility's policy and procedure titled, Oxygen Therapy, Nursing Manual - General, dated November 2017, indicated, Policy: Oxygen is administered under safe and sanitary conditions to meet resident needs . II. Oxygen - Storage, Maintenance, and Handling . C. Oxygen tubing, mask, and cannulas will be changed no more than every seven (7) days and as needed. The supplies will be dated each time they are changed. Based on observation, interview, and record review, the facility failed to ensure: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not record accurate diagnoses on the Minimum Data Set Reports (MDS- an assessment tool) and the admission Record (a document containing resident profile information) for Residents 29, 39, 43, 47, 152 and 153. This failure had the potential to result in inaccurate care plans and inappropriate medical care for these residents.

Inspectors wroteBased on interview and record review, the facility failed to complete and obtain informed consents (a consent that provides the risks and benefits of taking a medication, possible side effects, alternate treatments, and risk of no use) for three psychoactive medications (chemical substances that affect mental processes such as perception, mood, cognition, and behavior) for one of 21 sampled residents (Resident 14). This failure had the potential for Resident 14's representative to not be fully informed and consented for Resident 14 to receive psychoactive medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light and the phone were within reach for one of 21 sampled residents (Resident 37). This failure had the potential for Resident 37 to be unable to contact staff when in need of assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 21 sampled residents (Resident 37) had a Physician Orders for Life-Sustaining Treatment (POLST - a form that communicates a person's wishes of medical orders during an emergency) that was signed by the resident's durable power of attorney (DPOA - a person who makes medical decisions anytime a resident is incapable to do it on her/his own). This failure had the potential for Resident 37 to receive inaccurate treatment during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order for a floor pad next to the bed was implemented for one Resident, with a history of falls (Resident 20), of 21 sampled residents. This failure had the potential for Resident 20 to sustain injuries in a fall from the bed to the unpadded floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 21 sampled residents (Resident 5 and Resident 37) were provided juice supplement per physician's orders. This failure had the potential for Resident 5 and Resident 37 nutritional needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. The Residents' Refrigerator was free of ice buildup. 2. The Residents' food that was brought into the facility was labeled and had received dates. This failure had the potential for the quality of the Residents' food to be diminished and the food to be consumed beyond the expired date.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage was disposed of properly when one of the garbage dumpster lids was not closed, and the surrounding area had trash on the ground. This failure had the potential to attract pests and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Medication Administration Records (MAR) for two sampled residents (Resident 5 and Resident 37) accurately reflect that a 6 oz (ounce) of juice supplement was documented as not given during a meal. This failure resulted in an inaccuracy of nutritional supplement intakes for Resident 5 and 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for one resident, with an intellectual disability (Resident 101), out of 21 sampled residents, when potentially hazardous items were kept at Resident 101's bedside. This failure had the potential for Resident 101 to injure himself with unsupervised use of the items.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide oversight and supervision, by a Registered Dietician, to kitchen staff (Cook C). This failure resulted in the Registered Dietician not carrying out competency and skills assessments for [NAME] C, thereby compromising the functions of the food and nutrition services.

Inspectors wroteBased on observation, interview and review of documents, the facility failed to ensure food was prepared, stored, served or distributed in accordance with professional standards of food service safety when: 1) Mixer was not cleaned and sanitized, and, 2) Potentially Hazardous Food (food that supports the rapid and accelerating growth of infectious or toxic microorganisms) Cool Down Log procedures were not followed. These failures to ensure effective food and nutrition service operations may result in placing residents at risk for food borne illness and the growth of microorganism as well as chemical contamination of ingested items.

Inspectors wroteBased on observation, interview, and policy review the facility did not maintain infection control practices when one resident ( Resident 23) was not offered hand hygiene prior to his meal and when one licensed nurse did not sanitize the glucometer between residents. Not offering hand hygiene prior to a meal and not sanitizing the glucometer between residents had the potential to contribute to transmission based infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident 38) received oxygen therapy per physician's order and facility policy. This failure had the potential to contribute to Resident 38's discomfort and decreased ability to breathe.