San Rafael Healthcare & Wellness Center, Lp

1601 5th Avenue
San Rafael, CA 94901
Marin County
Phone: 415-456-7170
Provider Number: 055331
Last Inspection: 11/10/2015

About the Nursing Home About the Staff

Number of Beds
Number of
Beds
54
Number of Residents
Number of
Residents
46
Number of Beds Available
Beds Available
8
Percent Occupancy
Percent Occupancy
85%
Accepts Insurance
Insurance Accepted
Medicare & Medicaid
Types of Councils
Types of Councils
Resident
Type of Ownership
Type of Ownership
For profit - Corporation
Within a Hospital?
Within Hospital?
NO

State Inspection Deficiencies About State Inspection Deficiencies

Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home. We suggest you use our Nursing Home Checklist to help evaluate the nursing homes you plan to visit.


Deficiency Ratings what is a deficiency rating?
By Region


  • Facility
  • County
  • CA
  • USA
  • 47
  • 30
  • 31
  • 20
Lower Numbers are Better

Deficiency Ratings what is a deficiency rating?
By Year


  • 2015
  • 2015
  • 2014
  • 47
  • 47
  • 33
Lower Numbers are Better

Details by Inspection Date

 

11/10/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Pattern : Minimal 4 12/21/2015
Failed To: Provide housekeeping and maintenance services. Isolated : Minimal 3 11/18/2015
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 12/31/2015
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 1/8/2016
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 1/8/2016
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 1/8/2016
Failed To: Ensure that residents are safe from serious medication errors. Widespread : Minimal 5 1/8/2016
Failed To: Hire a qualified dietician. Isolated : Minimal 3 11/30/2015
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 1/7/2016
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Immediate 6 1/8/2016
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 12/13/2015
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Isolated : Minimal 3 1/8/2016
 

1/9/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Isolated : Minimal 3 2/25/2015
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 2/25/2015
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 2/25/2015
Failed To: Honor a residents' rights as a residents of the nursing home, free of coercion and reprisal, and as citizens or residents of the United States. Isolated : Minimal 3 2/25/2015
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 2/25/2015
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 2/25/2015
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 2/25/2015
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 2/25/2015
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 2/25/2015
Failed To: Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. Isolated : Minimal 3 2/25/2015
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 2/25/2015
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 2/25/2015
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Pattern : Minimal 4 2/25/2015
 

1/31/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 4/14/2014
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 4/14/2014
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Isolated : Minimal 3 4/14/2014
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Isolated : Minimal 3 4/14/2014
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 4/14/2014
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 4/14/2014
Failed To: Keep clinical record information safe. Widespread : Minimal 5 4/14/2014
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Widespread : Minimal 5 4/14/2014
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Isolated : Minimal 3 4/14/2014


 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

 

7/28/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 8/27/2015
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Isolated : Minimal 3 8/27/2015
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Isolated : Minimal 3 8/27/2015
 

2/19/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 3/10/2015
 

7/7/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 12/10/2015
 

3/14/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Minimal 3 4/11/2014
Failed To: Provide care for each resident in a way that maintains or improves their quality of life. Isolated : Minimal 3 4/11/2014
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 4/11/2014
 

1/8/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 5/22/2014
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 5/22/2014
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 5/22/2014
 

10/7/2013 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 2/13/2014
 

4/28/2013 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 5/27/2014

 

About The Staff About the Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg CA State Avg
Number of Residents 46 66.33 84.73
Registered Nurses 4.30 1.29 0.87
Licensed Practical / Vocational Nurses 0.77 0.72 0.98
Certified Nursing Assistants 2.48 2.80 2.61
Total Staff Hours 7.55 4.82 4.46

About the Residents About the Staff

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% CA State Avg%
High Risk Long Stay Residents With Pressure Ulcers 11 7 6
Long Stay Residents Experiencing One or More Falls with Major Injury 8 2 1
Long Stay Residents Who Have Depressive Symptoms 0 2 1
Long Stay Residents Who Lose Too Much Weight 6 6 6
Long Stay Residents Who Received an Antipsychotic Medication 12 17 13
Long Stay Residents Who Self Report Moderate to Severe Pain 7 5 5
Long Stay Residents Who Were NOT Assessed and Appropriately Given the Pneumococcal Vaccine 0 7 5
Long Stay Residents Who Were NOT Assessed and Appropriately Given the Seasonal Influenza Vaccine 8 2 5
Long Stay Residents Who Were Physically Restrained 0 0 1
Long Stay Residents Whose Need for Help with ADLs has Increased 16 15 11
Long Stay Residents with a Catheter Inserted and Left in Their Bladder 4 3 3
Long Stay Residents With a Urinary Tract Infection 7 4 3
Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 69 41 44
Short Stay Residents Who Newly Received an Antipsychotic Medication 4 2 1
Short Stay Residents Who Self Report Moderate to Severe Pain 22 12 12
Short Stay Residents Who Were NOT Assessed and Appropriately Given the Pneumococcal Vaccine 16 18 18
Short Stay Residents Who Were NOT Assessed and Appropriately Given the Seasonal Influenza Vaccine 27 8 18
Short Stay Residents With Pressure Ulcers That Are New or Worsened 2 0 0