San Rafael Nursing And Rehabiliation

F 0609 Level of Harm - Minimal harm or potential for actual harm

applicable state and federal requirements: Abuse, Neglect, Suspicious injuries of unknown source, and/or Emergency situations that pose a threat to resident health and safety. When to report: Immediately, but not later than two hours after the incident occurs or is suspected.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

San Rafael Nursing and Rehabiliation

3050 Sunnybrook Rd Corpus Chrisit, TX 78415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

there was no specific policy on how or what to report, but he followed the stated and CMS guidelines on how and what to report. In an interview on 07/31/25 at 8:32 AM ADON-S stated she was the one who did fall trending and tracking as well as fall investigations. She stated Resident #1 had only had 1 fall this year, and it was this unwitnessed fall with a major injury. ADON-A stated she completed her report based on the note written by the nurse, and according to the documentation, the nurse called the DON and reported the fall. ADON-A stated she followed up with the resident regarding post-fall questions and the reporting nurse, and LVN-I told her Resident #1 was found in floor, and after assessing Resident #1, LVN-I asked the CNAs to transport Resident #1 to the wheelchair and then to her bed. ADON-A stated LVN-I should not have moved Resident #1 while in severe pain or after noting one leg was longer than the other because it could have meant there was a fracture or major injury, and movement could have caused further injury. In an

interview on 07/31/25 at 11:05 AM, CNA-J stated she heard the male resident say there was a woman on

the floor in his room. She stated no one questioned the male resident as to what happened to Resident#1 and how she ended up on the floor. CNA-J stated LVN-I went and assessed the Resident #1 while she was lying on the floor, and Resident #1 kept moaning and groaning in pain as well as making faces like she was

in severe pain. She stated the LVN-I never said anything to about one leg being longer than the other, so both CNAs assumed it was okay to move Resident #1. CNA-J stated she realized moving a resident with an injury could make it worse.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

San Rafael Nursing and Rehabiliation

3050 Sunnybrook Rd Corpus Chrisit, TX 78415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

been investigated further, and if he would have realized it was an unwitnessed fall with a major injury, he would have reported it within 2 hours. In an interview on 07/31/25 at 8:32 AM ADON-S stated she was the one who did fall trending and tracking as well as fall investigations. She stated Resident #1 had only had 1 fall this year, and it was this unwitnessed fall with a major injury. ADON-A stated she completed her report based on the note written by the nurse, and according to the documentation, the nurse called the DON and reported fall. ADON-A state she followed up with the resident and nurse post fall, and LVN-I told her Resident #1 was found in floor, and after assessing Resident #1, LVN-I asked the CNAs to transport Resident #1 to the wheelchair and then to her bed. ADON-A stated LVN-I should not have moved Resident #1 while in severe pain or after noting one leg was longer than the other because it could have meant there was a fracture or major injury, and movement could have caused further injury. In an interview on 07/31/25 at 11:05 AM, CNA-J stated she heard the male resident say there was a woman on the floor in his room.

She stated no one questioned the male resident as to what happened Resident#1 and how she ended up

on the floor. CNA-J stated LVN-I went and assessed the Resident #1 while she was lying on the floor, and Resident #1 kept moaning and groaning in pain as well as making faces like she was in severe pain. She stated the LVN-I never said anything to about one leg being longer than the other, so both CNAs assumed it was okay to move Resident #1. CNA-J stated she realized moving a resident with an injury could make it worse. Record review of an all-staff in-service dated 04/30/25 revealed a fall is signified as any break in plane regardless of where the patient lands. If a resident fall occurred it must be immediately reported to

the charge nurse so they can assess resident and situation and determine if resident is safe to move or transfer, then incident report must be completed by charge nurse. Record review of the facility's Fall, and Fall Risk, Managing Policy, revised March 2018, revealed Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. The staff will implement a fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

San Rafael Nursing and Rehabiliation

3050 Sunnybrook Rd Corpus Chrisit, TX 78415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

CNA-M stated she had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. In an interview 08/19/125 at 10:55 AM, LVN-Q stated she had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. She stated most of the residents were easily redirected with things such as activities, snacks, television, radio, etc. She stated there was always someone watching

the halls. If both CNAs had to be in a room providing care, the nurse was monitoring the halls, and if the nurse had to step away from the locked unit, the ADON or another nurse would monitor the unit until the nurse returns. In an observation on 08/19/25 at 1:30 PM it was revealed many of the residents on the locked unit were in the dining/common room doing activities with 1 staff from activities. There were 5 residents noted to be wandering in the hallways, but CNA's were monitoring and redirecting them as needed, and the charge nurse was seated at the nurse's station across from the living area where some residents were seated watching television. In an interview on 08/19/25 at 1:45 PM the DON stated there were always 2 CNAs and a nurse on the locked unit, and there was always at least one of the CNAs or nurses in the hallways observing at all times. If the two CNAs were busy providing patient care, the LVN steps forward, and if the LVN had to step off the locked unit, the ADON or another nurse would cover until

they return. The DON stated most of the residents on the locked unit only needed one staff to assist with incontinent or patient care, so it rarely required both CNA's to be in a room together and off the hall at the same time, but if it did, they just notify the charge nurse, and the charge nurse monitored the halls until the CNAs returned. The DON stated staff had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. In an interview on 08/19/25 at 1:45 PM the Administrator stated there was always 2 CNAs and a nurse on the locked unit, and the residents were free to move around the locked unit as they pleased. He stated he would perform random spot checks which would always reveal one of the CNAs or nurses in the hallways observing any residents who may be wandering. The Administrator stated if both CNAs were busy performing patient care, then the charge nurse steps forward to monitor the halls. In an interview on 08/20/25 at 10:55 AM, LVN-R stated there were always at least two CNAs and the charge nurse on the locked unit, and many times during the day there were others such as the person from activities, or the DON or ADON rounding. He stated someone was always watching the hall, and if both CNAs must be in a room providing care, he was the one

on the hall monitoring for residents who wander. He stated he had been in-serviced regarding monitoring and redirecting residents, fall policies and protocols, abuse and neglect, documenting and reporting. The Administrator was informed the Immediate Jeopardy was removed on 08/21/25 at 4:35 PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place.

Event ID:

Facility ID:

If continuation sheet