Cycle 1
Health 2025-03-06 · Fire 2025-03-06
24 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Corpus Chrisit, TX
San Rafael Nursing and Rehabiliation
1-star overall rating with 1-star inspections with $88,828 in total fines with 24 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
3050 Sunnybrook Rd, Corpus Chrisit, TX
(361) 853-9981
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
168
Certified beds
Average residents
119
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Booker Hospital District
Operator or chain grouping
Approved since
1997-07-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.15
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.75
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.79
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.35
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.10
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.17
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,946
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.20
Performance 19.95% · Measure score 3.20 · Achievement 3.20 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 6.23% · Performance 8.15% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.99
Baseline 67.31% · Performance 48.23% · Measure score 3.99 · Achievement 3.78 · Improvement 3.99
Adjusted total nurse staffing
0.22
Baseline 2.65 hours · Performance 2.88 hours · Measure score 0.22 · Achievement 0 · Improvement 0.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.56% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 6% · Lower 95% interval 6.18% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.38 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 84.09% |
95.27%
11.2 pts worse
|
Numerator 74 · Denominator 88 |
| Falls with major injury | 2.27% |
0.77%
1.5 pts worse
|
Numerator 2 · Denominator 88 |
| Discharge self-care score | 47.27% |
53.69%
6.4 pts worse
|
Numerator 26 · Denominator 55 |
| Discharge mobility score | 47.27% |
50.94%
3.7 pts worse
|
Numerator 26 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 1.14% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 88 · Adjusted rate 0.85% |
| Healthcare-associated infections requiring hospitalization | 8.15% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 12.2% · Lower 95% interval 4.33% |
| Staff COVID-19 vaccination coverage | 0.83% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 121 |
| Staff flu vaccination coverage | 28.32% |
42%
13.7 pts worse
|
Numerator 64 · Denominator 226 |
| Discharge function score | 41.82% |
56.45%
14.6 pts worse
|
Numerator 23 · Denominator 55 |
| Transfer of health information to provider | 96.3% |
95.95%
0.3 pts better
|
Numerator 26 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25.53% |
25.2%
0.3 pts better
|
Numerator 12 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
97.1%
0.5 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 95.4% · Q4 96.3% · 4Q avg 97.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 79.3% |
97.9%
18.6 pts worse
|
95.5%
16.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 79.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.3%
About the same
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 5.5% · Q4 6.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
2.7%
1.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.0% · Q3 1.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
3.3%
1.3 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.2% · Q3 1.1% · Q4 2.4% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.1% |
18.9%
7.2 pts worse
|
19.6%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 20.4% · Q3 27.8% · Q4 29.7% · 4Q avg 26.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
10.8%
6.1 pts worse
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 16.4% · Q3 16.7% · Q4 18.3% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.8% |
15.4%
2.6 pts better
|
16.3%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 10.7% · Q3 19.0% · Q4 8.0% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
16.1%
0.5 pts better
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 10.7% · Q3 18.9% · Q4 14.8% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
0.8%
0.2 pts worse
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.8% |
15.0%
2.2 pts better
|
19.8%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 16.5% · Q3 0.9% · Q4 24.3% · 4Q avg 12.8% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.2%
1 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.4% · Q3 3.4% · Q4 2.8% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 47.8% |
89.7%
41.9 pts worse
|
81.7%
33.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 55.6% · Q2 49.2% · Q3 48.9% · Q4 34.6% · 4Q avg 47.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.4% |
12.0%
5.4 pts worse
|
12.0%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.4% · Observed 20.5% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.5%
1.4 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q4 4.5% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 45.2% |
88.0%
42.8 pts worse
|
79.7%
34.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 45.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
25.9%
2.2 pts better
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 22.7% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
17 health deficiencies
Top issue: Environmental (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-09-14 · Fire 2022-09-14
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-05
F · Potential for more than minimal harm
2025-03-06
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-03-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-03-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-03-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-03-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-05
F · Potential for more than minimal harm
2023-12-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-12-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-12-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-12-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-12-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-20
F · Potential for more than minimal harm
2022-09-14
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-09-14
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-09-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-13
E · Potential for more than minimal harm
2022-09-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-12-01
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-12-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-12-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-03
J · Immediate jeopardy
2025-10-27
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-10-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-10
J · Immediate jeopardy
2025-08-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-22
G · Actual harm
2025-08-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-22
F · Potential for more than minimal harm
2025-03-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-06
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-03-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-06
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-06
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-03-06
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-02-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-02-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-20
D · Potential for more than minimal harm
2025-01-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-09-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-06
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-06-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-07-22
J · Immediate jeopardy
2023-12-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-12-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-24
F · Potential for more than minimal harm
2023-12-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-22
F · Potential for more than minimal harm
2023-12-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-01-22
E · Potential for more than minimal harm
2023-12-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-12-14
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-01-28
D · Potential for more than minimal harm
2023-12-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-12-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-12-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-12-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-10-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-07
D · Potential for more than minimal harm
2023-09-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-09-29
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-09-30
L · Immediate jeopardy
2023-07-17
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-18
J · Immediate jeopardy
2023-07-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-07-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-07-17
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-04-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-04-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-15
F · Potential for more than minimal harm
2022-09-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-12
F · Potential for more than minimal harm
2022-09-14
F922 · Environmental Deficiencies
Health
Have enough backup water supply for essential areas of the nursing home.
Corrected 2022-10-12
E · Potential for more than minimal harm
2022-09-14
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-10-12
E · Potential for more than minimal harm
2022-09-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-12
E · Potential for more than minimal harm
2022-09-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-10-12
E · Potential for more than minimal harm
2022-09-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-10-12
D · Potential for more than minimal harm
2022-09-14
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-10-12
D · Potential for more than minimal harm
2022-09-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-12
Penalties and ownership
What sits behind the stars
$26,685
2025-10-27
Fine
Fine · fine $26,685
Fine
$24,845
2025-08-21
Fine
Fine · fine $24,845
Fine
$10,036
2023-12-14
Fine
Fine · fine $10,036
Fine
$27,262
2023-07-17
Fine
Fine · fine $27,262
Fine
Ownership
Armstrong, Dwayne
Corporate Officer · Individual
San Rafael Operations Inc.
Operational/Managerial Control · Organization
Schindele, William
Operational/Managerial Control · Individual
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