ElderGrade

Inspection citations at San Rafael Health And Rehabilitation

27 citations on record, 6 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2024 14 4
2023 3 0
2021 10 2
D November 15, 2024 Tag F0842 Complaint investigation Corrected Dec 2024

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D November 15, 2024 Tag F0758 Corrected Dec 2024

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D November 15, 2024 Tag F0756 Corrected Dec 2024

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

D November 15, 2024 Tag F0690 Corrected Dec 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E November 15, 2024 Tag F0880 Corrected Dec 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E November 15, 2024 Tag F0658 Complaint investigation Corrected Dec 2024

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

E November 15, 2024 Tag F0656 Corrected Dec 2024

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

E November 15, 2024 Tag F0565 Complaint investigation Corrected Dec 2024

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

No actual harm, potential for more than minimal harm

F November 15, 2024 Tag F0943 Complaint investigation Corrected Dec 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

No actual harm, potential for more than minimal harm

F November 15, 2024 Tag F0812 Corrected Dec 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

G November 15, 2024 Tag F0689 Complaint investigation Corrected Dec 2024

Quality of Life and Care Deficiencies

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

Actual harm to a resident

J November 15, 2024 Tag F0610 Complaint investigation Corrected Dec 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Immediate jeopardy to resident health or safety

J November 15, 2024 Tag F0609 Complaint investigation Corrected Dec 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Immediate jeopardy to resident health or safety

J November 15, 2024 Tag F0600 Complaint investigation Corrected Dec 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety

D March 15, 2023 Tag F0756 Corrected Mar 2023

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

E March 15, 2023 Tag F0712 Corrected Mar 2023

Nursing and Physician Services Deficiencies

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

No actual harm, potential for more than minimal harm

E March 15, 2023 Tag F0585 Corrected Mar 2023

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

No actual harm, potential for more than minimal harm

C June 17, 2021 Tag F0868 Corrected Jul 2021

Administration Deficiencies

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

No actual harm, minimal potential

D June 17, 2021 Tag F0770 Corrected Jul 2021

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

D June 17, 2021 Tag F0690 Corrected Jul 2021

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D June 17, 2021 Tag F0656 Corrected Jul 2021

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

E June 17, 2021 Tag F0842 Corrected Jul 2021

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

E June 17, 2021 Tag F0758 Corrected Jul 2021

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

E June 17, 2021 Tag F0756 Corrected Jul 2021

Pharmacy Service Deficiencies

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

No actual harm, potential for more than minimal harm

E June 17, 2021 Tag F0712 Corrected Jul 2021

Nursing and Physician Services Deficiencies

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

No actual harm, potential for more than minimal harm

G June 17, 2021 Tag F0697 Corrected Jul 2021

Quality of Life and Care Deficiencies

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

Actual harm to a resident

G June 17, 2021 Tag F0689 Corrected Jul 2021

Quality of Life and Care Deficiencies

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

Actual harm to a resident

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.