Inspection·September 6, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one of one residents reviewed for call lights. Residents Affected - Few The facility did not ensure Resident #1's call light was with in reach. This failure could place residents at risk for illness due to cross contamination in the kitchen and left a resident without access to staff and at risk for falling. Findings included: Record review of a face sheet dated 9/4/2024 indicated Resident #1 was a [AGE] year old who was admitted on [DATE] with diagnoses of Hemiplegia and hemiparesis of the left side following a cerebral infarction affecting the left non-dominant side (a stroke causing weakness or total paralysis of the left side of the body), Vascular Dementia (a progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), lack of coordination, and abnormalities of gait and ambulation (walking). Review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 10 which indicated moderate cognitive impairment. Record review of Resident #1's care plan, undated revealed, Resident #1 has functional limitation in range of motion of extremities, to encourage the resident to use the call light, and the resident needs the assistance of 1-2 staff members for transfers (from bed to wheelchair and return from wheelchair to bed). The care plan also revealed the resident is at risk for falls and interventions include ensuring the call light is within reach. On 9/4/2024 at 2:42 pm, observation of Resident #1 in her room in her wheelchair with the door closed and no call light within reach (call light was attached to side of bed.) The resident stated she was uncomfortable and wanted to go to bed. On 9/4/2024 at 3:22 pm, during an interview with LVN A she stated, anything could have happened with Resident #1 being in the room by herself with no call light, she could have thrown herself down in the floor and hurt herself. LVN B stated I was on break, but next time I will check on her before I go on break. The aides should know what to do. I am unsure who left her in the room without her call light. On 9/5/2024 at 11:50 am, during a second interview with LVN A, she stated, the other nurse (LVN B) (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 675717 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)