Smith Ranch Skilled Nursing & Rehabilitation Cente
SMITH RANCH SKILLED NURSING & REHABILITATION CENTE in SAN RAFAEL, CA — inspection on May 16, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of the facility's Order Listing Report, dated 5/15/25, the Order Listing Report indicated there are a total of 22 Residents currently receiving RNA services.
During an interview on 5/16/25 at 11:16 a.m. with the Director of Nursing (DON) and Director of Rehabilitation (DOR), The DOR stated the DON oversees the RNA program because it falls under nursing and the DOR is only responsible for training staff and putting in RNA orders.
The DOR further stated she does not complete any auditing for the RNA program.
The DON stated he quickly scans the RNA weekly progress notes but does not verify the treatment provided against the orders.
The DON and the DOR both confirmed they were unaware of any issues with the RNA program not fulfilling the physician orders.
During a concurrent interview and record review on 5/16/25 at 1:01 p.m. with the Administrator (Admin) and the DON, the QAPI Meeting Minutes dated October 2024 to April 2025 were reviewed.
The minutes indicated no focus on the RNA program.
The Admin confirmed QAPI did not identify any concerns with the RNA program.
During a review of the Facility's Quality Assurance Performance Improvement Plan (QAPIP), undated, the QAPIP indicated, Segments of Care .
Inpatient Rehabilitation .
Services Rendered .
Provide appropriate levels of rehabilitation to the inhouse Residents and coordinate with their MD's [Medical Doctor] .
Clinical care will be measured through: Consultant evaluations and feedback of practice, MDS-QI [Minimum Data Set Quality Improvement- an assessment tool used to guide resident care] scores, Family/Resident survey scores, QAPI tools .
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.