RAFAEL CONVALESCENT HOSPITAL - SAN RAFAEL, CA

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Staff Information

Quality Measures

Complaint Deficiency

Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for: Some (Potential for minimal harm)

Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident: Few (Minimal harm or potential for actual harm)

Allow residents to easily view the results of the nursing home's most recent survey: Many (Potential for minimal harm)

1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents: Some (Minimal harm or potential for actual harm)

Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property: Some (Minimal harm or potential for actual harm)

Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality: Some (Minimal harm or potential for actual harm)

Reasonably accommodate the needs and preferences of each resident: Few (Minimal harm or potential for actual harm)

Provide a safe, clean, comfortable and homelike environment: Some (Minimal harm or potential for actual harm)

Allow the resident the right to participate in the planning or revision of the resident's care plan: Few (Minimal harm or potential for actual harm)

Maintain 15 months of resident assessments in the resident's active clinical record: Some (Potential for minimal harm)

Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents: Few (Immediate jeopardy to resident health or safety)

Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so: Few (Minimal harm or potential for actual harm)

1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being: Few (Minimal harm or potential for actual harm)

Store, cook, and serve food in a safe and clean way: Few (Minimal harm or potential for actual harm)

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards: Some (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Some (Minimal harm or potential for actual harm)

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms: Some (Potential for minimal harm)

Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space: Few (Minimal harm or potential for actual harm)

Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility: Many (Minimal harm or potential for actual harm)

Keep accurate, complete and organized clinical records on each resident that meet professional standards: Few (Minimal harm or potential for actual harm)

Keep clinical record information safe, so that it will not be lost, destroyed or used by the wrong person: Some (Minimal harm or potential for actual harm)

Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents: Many (Minimal harm or potential for actual harm)

Approved construction type or materials: Few (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Some (Minimal harm or potential for actual harm)

Proper stairway enclosures and vertical shafts: Few (Minimal harm or potential for actual harm)

Smoke barrier doors that can resist smoke for at least 20 minutes: Few (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Few (Minimal harm or potential for actual harm)

Did not have a written emergency evacuation plan: Few (Minimal harm or potential for actual harm)

Record of quarterly fire drills for each shift under varying conditions: Few (Minimal harm or potential for actual harm)

Automatic sprinkler systems that have been maintained in working order: Some (Minimal harm or potential for actual harm)

Portable fire extinguishers: Many (Minimal harm or potential for actual harm)

Proper medical gas storage and administration areas: Few (Minimal harm or potential for actual harm)

Weekly inspections and monthly testing of generators: Some (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Some (Minimal harm or potential for actual harm)

Properly installed hallway dispensers for alcohol-based hand rub: Few (Minimal harm or potential for actual harm)

Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for: Many (Potential for minimal harm)

Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality: Some (Minimal harm or potential for actual harm)

Make sure services provided by the nursing facility meet professional standards of quality: Some (Minimal harm or potential for actual harm)

Post nurse staffing information/data on a daily basis: Many (Potential for minimal harm)

Store, cook, and serve food in a safe and clean way: Some (Minimal harm or potential for actual harm)

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards: Some (Minimal harm or potential for actual harm)

Approved construction type or materials: Some (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Some (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Some (Minimal harm or potential for actual harm)

A fire alarm system that can be heard throughout the facility: Few (Minimal harm or potential for actual harm)

Automatic sprinkler systems that have been maintained in working order: Few (Minimal harm or potential for actual harm)

Portable fire extinguishers: Some (Minimal harm or potential for actual harm)

Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed: Some (Minimal harm or potential for actual harm)

Exits that are free from obstructions and can be used at all times: Few (Minimal harm or potential for actual harm)

Properly installed hallway dispensers for alcohol-based hand rub: Some (Minimal harm or potential for actual harm)

Provide access to a telephone for resident to use in private: Some (Minimal harm or potential for actual harm)

Reasonably accommodate the needs and preferences of each resident: Some (Minimal harm or potential for actual harm)

Conduct initial and periodic assessments of each resident's functional capacity: Few (Minimal harm or potential for actual harm)

Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured: Few (Minimal harm or potential for actual harm)

Make sure services provided by the nursing facility meet professional standards of quality: Few (Minimal harm or potential for actual harm)

Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients: Few (Minimal harm or potential for actual harm)

Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature: Some (Minimal harm or potential for actual harm)

Approved construction type or materials: Few (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Few (Minimal harm or potential for actual harm)

Properly maintained smoke detectors: Few (Minimal harm or potential for actual harm)

Automatic sprinkler systems that have been maintained in working order: Few (Minimal harm or potential for actual harm)

Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed: Some (Minimal harm or potential for actual harm)

Properly protected cooking facilities: Few (Minimal harm or potential for actual harm)

Weekly inspections and monthly testing of generators: Few (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Few (Minimal harm or potential for actual harm)

Other nearby nursing homes

• COUNTRY VILLA SAN RAFAEL HEALTHCARE CENTER (1.13 miles)
• SUTTER VISITING NURSE ASSOCIATION (0.98 miles)
• NORTHGATE CARE CENTER (1.23 miles)
• NORTHGATE DIALYSIS CENTER (1.28 miles)
• PINE RIDGE CARE CENTER (1.18 miles)
• KINDRED TRANSITIONAL CARE AND REHAB - SMITH RANCH (1.28 miles)
• VILLA MARIN (1.41 miles)