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Inspection visit

Health inspection

San Rafael Health and RehabilitationCMS #46508510 citations on this visit
10 citations recorded

Citations

10 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0689SeriousS&S Gactual harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0690GeneralS&S Dpotential for harm

    F690 - Incontinence

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • 0697SeriousS&S Gactual harm

    F697 - Pain Management

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0712GeneralS&S Epotential for harm

    F712 - Frequency of physician visits

    Ensure that the resident and his/her doctor meet face-to-face at all required visits.

  • 0756GeneralS&S Epotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0758GeneralS&S Epotential for harm

    F758 - Medication Errors

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  • 0770GeneralS&S Dpotential for harm

    F770 - Laboratory Services

    Provide timely, quality laboratory services/tests to meet the needs of residents.

  • 0842GeneralS&S Epotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0868GeneralS&S Cno actual harm

    F868 - Quality assessment and assurance

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

FAQ · About this visit

Common questions about this visit

What happened during the June 17, 2021 survey of San Rafael Health and Rehabilitation?

This was a inspection survey of San Rafael Health and Rehabilitation on June 17, 2021. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at San Rafael Health and Rehabilitation on June 17, 2021?

Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.