Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at San Rafael Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with cognitive impairment and physical limitations was subjected to verbal and physical abuse by an RN, who aggressively handled and transferred the resident without consent. The incidents were witnessed by CNAs who delayed reporting, allowing the RN continued access to the resident, violating the facility's abuse policy.
The facility failed to ensure immediate reporting of abuse allegations involving multiple residents. CNAs witnessed a RN aggressively transferring a resident and delayed reporting, allowing further incidents. Another case involved delayed reporting of potential resident-to-resident sexual abuse, and a separate verbal abuse allegation was not reported promptly. These delays indicate systemic issues in handling abuse allegations, compromising resident safety.
The facility failed to properly investigate abuse allegations involving a resident and an RN, and another incident of resident-to-resident aggression. The RN was reported to have forcibly transferred a resident against their will, and the facility's investigation was inadequate, lacking interviews with other residents and skin assessments. In a separate incident, a resident displayed aggressive behavior towards another resident, and the facility's investigation was incomplete, missing a sheriff's report and a nurse's statement.
The facility failed to implement interventions to prevent falls for two residents, resulting in multiple injuries. Additionally, a resident with COPD and asthma had medications left at their bedside without a documented self-administration assessment. Furthermore, a resident with severe cognitive impairment eloped from the facility, and there was no evidence of a wandering risk assessment. The facility's investigation into the elopement was incomplete.
The facility failed to maintain a clean and sanitary kitchen, affecting all residents receiving meals. Observations revealed dirty appliances and inadequate cleaning documentation. The Dietary Manager cited staffing shortages as a reason for the lack of monitoring and deep cleaning. The DON and Administrator expected daily cleaning, but the kitchen was not thoroughly inspected.
A facility failed to provide required training on abuse prevention and reporting, leading to a deficiency. An RN allegedly abused a resident, and the incident was reported late. Interviews revealed that a CNA and the RN did not receive necessary training, and documentation was lacking. The administration acknowledged deficiencies in tracking and documenting training.
The facility failed to develop individualized care plans for four residents, omitting critical elements such as oxygen use, catheter care, and respiratory issues. These deficiencies were identified during a survey through observation, interviews, and record reviews, with staff acknowledging the oversights.
A facility failed to implement infection control policies, specifically Enhanced Barrier Precautions (EBP) during catheter care, and did not conduct annual TB risk screenings for residents. Staff were observed providing catheter care without gowns, and interviews revealed a lack of awareness and training on EBP. Additionally, TB testing was not conducted annually, and no risk assessments were documented. The DON and Administrator were unaware of these lapses, attributing them to changes in infection prevention staff.
The facility failed to address and follow up on concerns raised by the Resident Council, such as hot water issues, room changes, and food quality. Despite the facility's policy requiring grievances to be logged and investigated, no RC grievances were recorded, and unresolved issues persisted. Interviews revealed ongoing problems like unmade beds and disturbances from loud televisions, with the Resident Advocate admitting to not managing these concerns as formal grievances. The DON and Administrator were unaware of some issues and did not ensure proper follow-up, leading to a deficiency in honoring residents' rights.
The facility failed to ensure physician's orders included specified dosages for medications prescribed to two residents. One resident with a history of diabetes and osteoporosis had orders for vitamin C and D3 without dosages, while another with heart disease had an incomplete order for vitamin D3. Interviews confirmed that orders should include dosages, highlighting a lapse in policy adherence.
A resident with severe cognitive impairment and a history of chronic heart failure had an unsecured indwelling urinary catheter, contrary to facility policy and state guidelines. The catheter was not anchored due to an allergic reaction to the adhesive on the stabilization device, and no alternative securing methods were attempted. The resident's care plan did not address catheter use, and there was no physician's order for the catheter, although catheter care was ordered.
A facility failed to address pharmacy recommendations for a resident with schizophrenia and paranoid personality disorder, who was receiving multiple medications including lorazepam without an end date. Despite a pharmacy report recommending a 14-90 day auto-stop date, the medication was administered multiple times without reassessment. The DON acknowledged missing the recommendation, and the Consultant Pharmacist confirmed the facility's non-compliance.
A facility failed to specify the duration of use for a PRN psychotropic medication for a resident with schizophrenia and paranoid personality disorder. The resident's order for lorazepam lacked an end date, contrary to the facility's policy requiring a 14-day stop date. Interviews with staff and the Consultant Pharmacist revealed the facility's ongoing issue with placing stop dates on orders, leading to this deficiency.
A resident's medical records at an LTC facility contained inaccurate admission dates, with records indicating an admission on one day, while staff interviews confirmed the resident arrived the following day. The discrepancy arose from initial plans and communications with the hospital, which were not updated in the electronic health record system.
Failure to Protect Resident from Abuse by RN
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a registered nurse (RN). On two separate occasions, the RN was reported to have aggressively handled the resident, including yelling in the resident's face, shaking them, and transferring them to bed without consent. The incidents were witnessed by certified nurse aides (CNAs) who did not immediately report the abuse, allowing the RN to continue working with access to the resident. The resident involved had a medical history of hemiplegia, hemiparesis, muscle wasting, difficulty walking, and anxiety disorder. The resident was admitted to the facility with moderate cognitive impairment and required assistance with daily activities. The resident was known to have behavioral symptoms that interfered with care and had a history of rejecting care. The facility's policy prohibits any form of abuse, yet the RN's actions were in direct violation of this policy. The CNAs who witnessed the incidents were unsure of how to respond and delayed reporting the abuse. The facility's failure to immediately address the situation and protect the resident from further abuse resulted in a deficiency related to the resident's right to be free from abuse, neglect, and exploitation.
Failure to Report Abuse Allegations Promptly
Penalty
Summary
The facility failed to ensure that staff immediately reported allegations of abuse involving several residents. On one occasion, certified nurse aides (CNAs) witnessed a registered nurse (RN) aggressively transferring a resident against their will, but did not report the incident immediately. This allowed the RN to continue working with access to the resident, leading to a second incident where the RN shook the resident to convince them to allow a transfer. The CNAs delayed reporting these incidents to facility management, which resulted in a failure to protect the resident from potential harm. In another case, a CNA reported an incident involving potential resident-to-resident sexual abuse, but the RN on duty failed to notify management immediately. This delay resulted in the facility not submitting an initial report to the State Survey Agency (SSA) within the required timeframe. The resident involved had a history of dementia and anxiety disorder, and the incident involved another resident with similar cognitive impairments. Additionally, there was a failure to report an allegation of verbal abuse involving another resident. Staff members who were aware of the allegation did not report it to management immediately, and once management was informed, the facility failed to report the allegation to the SSA within the required two-hour window. This pattern of delayed reporting indicates a systemic issue in the facility's handling of abuse allegations, potentially compromising resident safety.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents. On one occasion, a registered nurse (RN) was reported to have yelled at a resident, shook them, and forcibly transferred them to bed against their will. This incident was witnessed by several certified nurse aides (CNAs) who did not immediately report the abuse to the administration, resulting in a delay in initiating an investigation and implementing protective measures. Consequently, the RN continued to work and was involved in another incident of abuse with the same resident. The facility's investigation was inadequate as it did not include interviews with other residents or skin assessments to check for potential injuries. In another incident, the facility reported an allegation of resident-to-resident abuse. A resident was reported to have blocked a CNA from taking another resident for a shower, displaying aggressive behavior. The resident later reported that the aggressor had attempted to force them into sexual activity. The facility's investigation into this incident was incomplete, lacking a copy of the sheriff's office report and a witness statement from the nurse involved at the time of the incident. The facility's non-compliance with the requirements of participation was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation began when the RN forcibly transferred a resident against their will, and the facility's subsequent investigation was insufficient, failing to document interviews or conduct a thorough inquiry into the incidents.
Failure to Implement Fall Prevention and Medication Safety Measures
Penalty
Summary
The facility failed to implement interventions to prevent future falls for two residents who were reviewed for falls. One resident, who had a history of dementia, seizures, bipolar disorder, and anxiety disorder, experienced multiple falls resulting in injuries such as a head laceration, a right clavicle fracture, and abrasions. Despite these incidents, there was no evidence that the facility initiated any interventions to prevent future falls. The Director of Nursing (DON) acknowledged the lack of documented interventions and stated that the nurses were responsible for investigating the root cause of falls and implementing new interventions. The facility also failed to ensure resident safety regarding medication administration. A resident with a history of chronic obstructive pulmonary disease (COPD) and asthma was observed with medications left at their bedside, including a rescue inhaler and nasal spray. The facility's policy required an assessment to determine if self-administration of medications was safe, but there was no documentation of such an assessment for this resident. Interviews with nursing staff revealed inconsistencies in understanding and implementing the policy, with some staff unaware of the requirement for a self-administration assessment. Additionally, the facility did not adequately assess or address the risk of elopement for a resident with severe cognitive impairment and a history of wandering. The resident eloped from the facility shortly after admission, and there was no evidence of a wandering or elopement risk assessment being completed. The facility's investigation into the elopement was incomplete, lacking documentation of interviews, corrective actions, and a root cause analysis. The Administrator admitted to not maintaining documentation of the incident, and the DON acknowledged that a wandering assessment should have been conducted but was missed.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect all 39 residents receiving meals from the dietary department. Observations during the initial tour of the kitchen revealed that various appliances, including the commercial oven, convection oven, grill, and steamer, were dirty with grease and splatters. Further observations showed that the top of the microwave had a layer of fuzz and dirt, and crumbs covered the counter behind the toaster and microwave. Additional inspections revealed thick layers of dirt and food splatters on the grill, steamer, and conventional stove top/oven combination, as well as dust and grease on the convection oven. The facility's cleaning schedules and chore lists indicated that required cleaning tasks were not consistently completed or documented. The AM Cook's Daily Cleaning Schedule showed that tasks were not signed off on certain days, and the PM Cook's Daily Cleaning Schedule also lacked documentation for required cleaning. The facility's September and October Chore Lists revealed that tasks were either not signed off or had lines through them, indicating they were not completed. Interviews with staff, including the Dietary Manager (DM), revealed that the kitchen was short-staffed, and the DM had been working shifts in the kitchen, which affected her ability to monitor and ensure cleaning tasks were completed. The DM acknowledged that the appliances were dirty and stated that she usually performed deep cleaning three to four times a year but had not been able to do so recently. The Director of Nursing (DON) and the Administrator both expressed expectations that the kitchen should be cleaned daily and before every meal. The Administrator noted that the kitchen had always been in top shape during previous inspections but admitted to not thoroughly inspecting the kitchen during his visits.
Deficiency in Staff Training on Abuse Prevention and Reporting
Penalty
Summary
The facility failed to provide annual and periodic training in accordance with its policy to educate staff on activities that constitute abuse and procedures for reporting incidents of abuse. This deficiency was identified through interviews, document reviews, and facility policy reviews. The facility's policy, dated February 2017, required that all employees receive training during orientation and ongoing in-services on issues related to the prohibition of abuse, including appropriate behavioral interventions, reporting procedures, and signs of burnout that may lead to abuse. However, it was found that two staff members, a CNA and an RN, did not receive the required training. An incident was reported where an RN allegedly physically and verbally abused a resident. The incident was reported to the state agency four days after it occurred, indicating a delay in reporting. The RN was accused of yelling at the resident, grabbing their arms and wrist, and moving them to the bed against their will. Despite the serious nature of the allegations, the facility unsubstantiated the abuse claims and did not provide immediate retraining for the involved staff members. Interviews with staff revealed that the CNA did not recall receiving any training on abuse prohibition or reporting, and the RN did not receive retraining after the incident. The facility's documentation was lacking, with no sign-in sheets for a March 2024 training session and no evidence of individual training for staff who missed sessions. The facility's administration acknowledged the deficiencies in tracking and documenting training, which contributed to the failure to ensure staff were adequately trained on abuse prevention and reporting.
Failure to Develop Individualized Care Plans
Penalty
Summary
The facility failed to develop individualized, resident-centered care plans with measurable objectives for four residents. Specifically, the care plans did not address oxygen use for two residents, an indwelling urinary catheter for another resident, and respiratory care for a resident with COPD and asthma. These omissions were identified during a survey through observation, interviews, and record reviews. Resident #1, who had a medical history of unspecified heart failure, was receiving oxygen therapy as per an order dated February 2023. However, the resident's care plan, last revised in August 2024, did not include any interventions addressing oxygen use. Similarly, Resident #3, with a history of morbid obesity, was also receiving oxygen therapy, but their care plan, last revised in September 2024, lacked any mention of oxygen use. Both the MDS Coordinator and the Director of Nursing acknowledged these oversights during interviews. Resident #24, who had severe cognitive impairment and an indwelling urinary catheter, did not have their catheter care included in their care plan. Additionally, Resident #4, with a history of COPD and asthma, had orders for multiple respiratory medications, but their care plan did not address respiratory issues or the need for these medications. The Director of Nursing and the MDS Coordinator confirmed that these elements should have been included in the care plans to ensure proper care and communication among staff.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to implement infection control and prevention policies, specifically regarding the use of Enhanced Barrier Precautions (EBP) during indwelling urinary catheter care for a resident. The facility's policy required the use of gowns and gloves during high-contact resident care activities, including catheter care. However, during an observation, a registered nurse and a nurse aide provided catheter care to a resident without donning gowns, only wearing gloves. Interviews with staff revealed a lack of awareness and training on EBP, with some staff members not having heard of the term or being instructed to use gowns during such care. The facility also failed to conduct annual tuberculosis (TB) risk screenings for several residents. The facility's policy required annual risk assessments to determine TB risk classification and subsequent testing based on the classification. However, reviews of immunization records for multiple residents showed that TB testing had not been conducted annually, and there was no documentation of annual risk assessments. Interviews with the Infection Preventionist and the Director of Nursing confirmed that annual TB risk assessments had not been completed for residents, attributing the oversight to changes in infection prevention staff. The Director of Nursing and the Administrator were both unaware of the lapses in EBP implementation and TB risk assessments. The Director of Nursing admitted to not having a good reason for not initiating EBP for residents with catheters and wounds, while the Administrator expected EBP to be followed and was unaware that annual TB risk assessments for residents had not been completed. The lack of proper training and oversight contributed to the deficiencies in infection control practices at the facility.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to consistently follow up on concerns presented by the Resident Council (RC) and did not provide a verbal or written response regarding actions taken to address these concerns. The facility's policy required all grievances and complaints to be investigated and recorded in a grievance log, but no RC grievances were logged from January to October 2024. The RC minutes from several months indicated various concerns, such as hot water issues, room changes, and food quality, but lacked documentation of planned actions or follow-up discussions to resolve these issues. Interviews with residents revealed ongoing unresolved issues, such as sheets not being changed regularly, beds not being made, and disturbances from loud televisions at night. The Resident Advocate (RA) admitted to documenting concerns during RC meetings and verbally communicating them to department managers but did not manage these concerns as formal grievances with written plans or summaries of actions taken. The RA acknowledged that unresolved issues appearing multiple times in RC meetings indicated they had not been addressed. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of some concerns, such as beds not being made, and had not followed up on others, like the loud television issue. The Administrator expected the RA to communicate all RC concerns to department managers and anticipated immediate changes with follow-up within a week, but this did not occur. The lack of documentation and follow-up on RC concerns led to ongoing unresolved issues, indicating a deficiency in honoring residents' rights to organize and participate in facility groups effectively.
Incomplete Physician's Orders for Medication Dosages
Penalty
Summary
The facility failed to ensure that physician's orders included all necessary components, specifically the specified dosages for medications prescribed to residents. This deficiency was identified during a review of the medication administration task for two residents. Resident #13, who was admitted on January 3, 2024, had a medical history including type two diabetes mellitus, chronic kidney disease, hypertension, intervertebral disc degeneration, and osteoporosis. The resident's Order Summary Report showed active orders for vitamin C and vitamin D3, but the physician's orders did not specify the dosages for these medications. Similarly, Resident #20, admitted on January 11, 2023, with a medical history of hypertensive heart disease with heart failure, tremor, atherosclerotic heart disease, and atrial fibrillation, had an order for a vitamin D3 tablet without a specified dosage. Interviews with the Director of Nursing and the Administrator confirmed that physician's orders should include the intended dosages, indicating a lapse in adherence to the facility's policy on medication orders. This oversight in documenting complete medication orders was noted as a deficiency by the surveyors.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter was properly secured for a resident, leading to potential risks of pulling or trauma to the urethral meatus. The facility's policy on catheter care, revised in August 2022, required that catheters be secured with a device to reduce friction and movement at the insertion site. However, during an observation, it was noted that the resident's catheter was not secured. The resident, who had severe cognitive impairment and a history of chronic diastolic heart failure, was admitted with frequent bladder incontinence and had a catheter placed due to fragile, sensitive skin. Despite the facility's policy and the State Operations Manual guidance, the catheter was not anchored, which could lead to urethral tears or dislodging. The resident's care plan did not address the use of an indwelling urinary catheter, and there was no physician's order for its use, although there was an order for catheter care. The RN and NA involved in the resident's care noted that the resident had a reaction to the adhesive on the stabilization device, which led to its removal. The Director of Nursing confirmed the resident's allergy to the adhesive and acknowledged that no alternative securing methods had been attempted. The Administrator expected that another type of stabilization device should have been tried if the resident was allergic to the adhesive, but this was not documented or actioned, leading to the deficiency.
Failure to Address Pharmacy Recommendations for PRN Medications
Penalty
Summary
The facility failed to address pharmacy recommendations for a resident who was reviewed for unnecessary medications. The resident, admitted on 04/03/2022, had a medical history of schizophrenia and paranoid personality disorder. During a significant change Minimum Data Set (MDS) assessment, it was noted that the resident had moderate cognitive impairment and received multiple medications, including antipsychotics and antianxiety drugs. The resident's medication orders included lorazepam without an end date, despite a pharmacy consulting report recommending a 14-90 day auto-stop date for PRN lorazepam. The medication was administered multiple times without reassessment. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for handling pharmacy recommendations, but the recommendation for a stop date on PRN psychotropic medications was missed. The Consultant Pharmacist confirmed that the facility did not follow the recommendations, and the DON acknowledged the oversight. The Administrator also stated that a 14-day stop date was necessary for reassessment, indicating a lapse in communication and implementation of pharmacy recommendations between the DON, Medical Director, and the Consultant Pharmacist.
Failure to Specify Duration for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that an as-needed (PRN) psychotropic medication order specified the duration of use for a resident with a history of schizophrenia and paranoid personality disorder. The resident was admitted to the facility with a medical history that included these diagnoses and was receiving multiple medications, including antipsychotics and antianxiety drugs. The resident's order summary report showed an active PRN order for lorazepam without an end date, which was against the facility's policy that required PRN psychotropic medications to have a 14-day stop date. Interviews with facility staff, including registered nurses and the Director of Nursing (DON), confirmed that the PRN lorazepam order lacked a stop date, which was necessary for reviewing the medication's effectiveness. The Consultant Pharmacist, who participated in psychotropic medication review meetings, also noted the facility's difficulty in placing stop dates on physician orders, despite recommendations. The facility's failure to follow its policy and the pharmacist's recommendations led to the deficiency, as the PRN lorazepam order for the resident did not comply with the required stop date protocol.
Inaccurate Admission Date Recorded for Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as Resident #190, who was admitted to the facility. The discrepancy arose from conflicting admission dates recorded in the resident's medical records. The Admission Record, Admission Agreement, and the Minimum Data Set (MDS) indicated that the resident was admitted on August 4, 2023. However, interviews with staff, including the Director of Nursing (DON) and the Business Office Manager (BOM), revealed that the resident was actually brought to the facility by a family member on August 5, 2023. The confusion regarding the admission date was further compounded by the actions of the Registered Nurse (RN) #5, who documented the admission summary progress note on the day the resident was physically admitted, which was August 5, 2023. The DON and the Administrator acknowledged that the electronic health record system was updated with the admission date of August 4, 2023, based on initial plans and communications with the hospital, but the resident's actual arrival was delayed by a day. This discrepancy was not corrected in the electronic health record system, leading to inaccurate documentation. Interviews with the MDS Coordinator and the Administrator highlighted that the admission process was initiated on August 4, 2023, in anticipation of the resident's arrival. However, due to the family's decision to bring the resident a day later, the records were not updated to reflect the actual admission date. The facility's policy required accurate and timely documentation of admissions, which was not adhered to in this case, resulting in a deficiency in maintaining accurate medical records for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ferron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission At Community Living Rehabilitation Center | 36.5 mi | — | 0 | 0 |
| Parkdale Health And Rehab | 38.8 mi | — | 0 | 0 |
| Pinnacle Nursing And Rehabilitation Center | 39.5 mi | — | 6 | 0 |
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