Federal inspectors found that San Rafael Nursing and Rehabilitation had not included hypertension medications in the care plan for Resident #17, a patient who had been taking the blood pressure drug Lisinopril daily since May. The 10-milligram medication came with specific instructions to hold the dose if the resident's blood pressure dropped below 110/60.
But nursing staff had no way of knowing about these monitoring requirements. The care plan, last updated in May, made no mention of the antihypertension medication despite the resident's active diagnosis of high blood pressure and heart disease.
The oversight persisted for months. Resident #17, who had intact cognitive function, continued receiving the medication while his care plan remained outdated and incomplete.
When confronted during the September inspection, the facility's MDS nurse acknowledged the error. "The care plan should have been updated to reflect Resident #17's use of hypertensive medications," she told inspectors. She admitted uncertainty about how the medication had been missed but accepted responsibility for the clinical portion of care plan updates.
The nurse explained the stakes clearly. "If care plans were not updated accurately, residents may not get the care they needed."
The Regional MDS Coordinator agreed that blood pressure medications required care planning. "Hypertensive medications should be care planned so staff are aware to monitor for signs and symptoms of hypertension," she said. Despite daily care plan reviews and quarterly audits, she could not explain why Resident #17's medications had been overlooked.
The facility's Director of Nursing shifted responsibility back to the MDS nurse during her interview. She emphasized that care plans provided staff with "the most up to date and accurate information regarding a resident's care."
Yet the facility's own policies demanded exactly what had not happened. The comprehensive care plan policy, dating to December 2016, required incorporation of "identified problem areas" and "risk factors associated with identified problems." It mandated that care plans "reflect currently recognized standards of practice for problem areas and conditions."
The policy specifically stated that care plans must be "revised as information about the residents and the residents' conditions change."
Resident #17's medication order had been in place since May 7. His quarterly assessment from that period showed both intact cognition and an active hypertension diagnosis. The care plan initiated eight days later on May 15 contained none of this medication information.
The violation represented a breakdown in the facility's medication management system. Blood pressure medications like Lisinopril require careful monitoring because they can cause dangerous drops in blood pressure, particularly in elderly patients. The "hold" parameters on Resident #17's order acknowledged this risk.
Without proper care planning, nursing assistants and other staff members would have no guidance about watching for signs of hypotension. They would lack instructions about when to check blood pressure or what symptoms might indicate the medication was working too well.
The facility conducts daily care plan reviews, according to staff interviews. The Regional MDS Coordinator told inspectors that comprehensive audits occur every three months. Yet this medication had been missing from the care plan for at least four months when inspectors discovered the problem.
The MDS nurse's admission that she was "not sure how or why it got missed" suggested systemic problems beyond this single case. If the person responsible for clinical care plan updates could not identify how a routine medication order had been overlooked, similar oversights likely affected other residents.
Federal regulations require nursing homes to develop comprehensive, person-centered care plans that address each resident's medical needs. These plans serve as roadmaps for daily care, ensuring that all staff members understand a resident's conditions, treatments, and monitoring requirements.
When care plans fail to reflect current medications, the consequences extend beyond paperwork violations. Staff members making critical decisions about a resident's care lack essential information. They cannot properly assess changes in condition or recognize medication-related complications.
Resident #17 continued taking his blood pressure medication throughout this period, trusting that nursing home staff understood his medical needs and monitoring requirements. The care plan failure meant that trust was misplaced, even as his medication continued without apparent incident.
The facility's own policy acknowledged that "assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change." For Resident #17, that revision never came.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Rafael Nursing and Rehabiliation from 2025-12-01 including all violations, facility responses, and corrective action plans.
Additional Resources
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