San Rafael Nursing And Rehabiliation

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

E stated while the administrator was present, that she requested the administrator to be present during the interview. LVN E stated when Resident #5 returned to the facility roughly after lunch around 12:30pm-1:30pm on 09/17/2025. LVN E stated she recalled Resident #5 entering the facility on a stretcher and noticed he had a beige colored dressing/covering on Resident #5's arm but could not recall which arm.

LVN E stated she worked at least 4-5 days between 09/17/2025-09/24/2025 and asked on 09/17/2025 and 9/18/2025 to observe what was underneath the bandage/dressing, but Resident #5 was resistant to care.

LVN E stated in-hindsight she should have advocated to see what was under the bandage/dressing as not only part of her professional scope of practice but also to ensure there were no negative or immediate concerns for skin irregularities. LVN E stated her concern with Coban dressings was if the dressing was too tight, there could be a loss of blood circulation, skin irritation, and/or possible wound, but reiterated Resident #5 never expressed or exhibited any sign or symptoms of distress or concern. LVN E stated she should have conducted a more thorough head-to-toe assessment to ensure there were no concerning irregularities; however verbalized Resident #5 did not exhibit or express anything of a compromising nature regarding any skin irregularities. LVN E stated going forward; she will advocate in a more assertive manner when conducting a head-to-toe assessment as a precautionary intervention, to ensure the well-being of all her patients. LVN E stated she attended an in-service regarding removing Coban dressing upon all assessments. LVN E stated roughly after 09/22/2025 she observed Resident #5 with slight redness to his forearm and reiterated going forward; she will complete a thorough head-to-toe assessment for any newly admitted /readmitted resident. During an interview on 10/25/2025 at 4:00PM, the DON stated LVN E should have completed a thorough head-to-toe assessment when Resident #5 was readmitted into the facility. The DON stated these types of thorough assessments are to ensure there are no concerning skin irregularities and if any skin irregularities are observed, the facility would enact a plan to mitigate any progression of those skin irregularities. The DON stated all staff members have been in-serviced and educated regarding

the facility's expectation that all clinical nursing staff members are to observe and assess underneath all dressings and Coban dressings as a preventative measure to ensure the well-being and skin integrity of all residents. The DON stated had the dressing been too tight, or if there was a skin irregularity under the dressing, there could be a loss of circulation, a wound progression or formation of infection, however reiterated there the well-being of Resident #5 was intact, and there was never any concern for Resident #5's skin integrity.Record reviewed the facility's Abuse &Neglect; removal of tourniquet/Coban in-service dated 09/25/2025 was reviewed.Record reviewed the facility's in-service regarding bands are to be removed on all new admissions and readmissions. If a resident refuses, make sure the nurse is notified-so

it can be documented and care planned dated 10/17/2025 was reviewed. Record review of the facility's Pressure Ulcer/Skin Breakdown-Clinical Protocol revised dated April 2018 documented, the staff/practitioner will examine the skin of newly admitted resident for evidence of existing pressure ulcers or other skin conditions.

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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

10/27/2025

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, interview and record review the facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access for 1 of 2 wound treatment carts on hall 100 reviewed for storage.The 100 hall wound care treatment cart was found unlocked.This failure could place residents at risk of access and ingestion of medications or supplies not intended for them and/or misappropriation. Findings were:Observation on 10/21/2025, at 11:24 a.m., a wound care treatment cart was found unlocked in front of

the 100 hall nursing station. The observation of items inside the wound care cart included: betadine solution, hydrogen peroxide, triple antibiotic ointment, nystatin cream, diclofenac sodium gel, iodoform packing strips, lidocaine cream, and a variety of bandages used for wound care treatment.During an

interview on 10/21/2025 at 11:30 a.m., LVN A verbalized the treatment cart was an extra cart and was not assigned to any staff member. LVN A verbalized she was unsure who used the cart last, but it is policy for

the cart to be locked. LVN A stated if a resident accessed the items in the cart they could ingest or use the items in the cart. During an interview on 10/27/2025 at 9:50 a.m., the Director of Nursing (DON) stated it is

the expectation of the facility for all staff to lock all carts including the wound care carts. The DON stated depending on the items in the cart the residents could have ingested or utilized the items in the cart. The DON stated the cart was not assigned to any staff member(s) as the cart was an extra wound care treatment cart.During an interview on 10/27/2025 at 9:55 a.m., the Administrator stated all carts should be locked and all items on the cart should be put away. The Administrator stated, depending on what is in the cart it would depend on what happens to a resident if they access a cart, but a resident could open an item and ingest it. The Administrator also stated it is not necessarily neglect or abuse, but it is against the policy and procedure to leave any carts unlocked.A review of the medication policy dated 2001 Medpass (revised November 2020) revealed #1 Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity control. Only persons authorized to prepare, and administer medications have access to locked medication, #2 The nursing staff is responsible for maintaining medication storage, and preparation areas in a clean, safe and sanitary manner, and #6 Compartments, including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biologicals are locked when not in use.

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

10/27/2025

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 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

Honeyo All dietary and direct care staff in-serviced on the requirement of a nurse checking the tray cards versus what is on the tray prior to CNA's serving them. The CNA's need to be the second check prior to service residents' tray to verify it matches.o All dietary staff and Charge Nurses in-serviced on process not allowed to give food to staff for a resident unless the nurse is the one who comes and asks for it.o When and how to do the Heimlich.o All direct care staff in-serviced on Code Blue and what to do when there has been a Change of Condition.*Anyone hired after 10/16/2025 will not work the floor until education has been received 6. Ad Hoc QAPI conducted with IDT team and Medical Director.7. Menu reviewed to remove hot dog, sausage, grapes, raw carrots, cherry tomatoes, hard candy, nuts, and peanut butter. Dietitian informed of changes. Monitoring Actions: -Admin/DON/ or ADON will audit breakfast, lunch, and dinner service weekly to ensure process is being followed.-Admin/DON/or ADON will review tray cards weekly to ensure

they match physician orders. Record review of in-service dated 10/17/2025 revealed 112 staff in-serviced.

In-service topics: tray ticket auditing, facility will no longer serve hotdogs, all food items will be served by dietary, Charge nurses to check tray tickets prior to passing out trays and performing the Heimlich maneuver. Record review of in-service dated 10/17/2025 revealed 14 dietary staff in-serviced. In-service topics: meal trays are to be signed/initialed after the nurse has verified that the diet, texture and liquid consistency is correct, if a resident is requesting anything extra from the kitchen, the nurse will have to request it. If a resident is requesting an alternative: a) the nurse will have to request the alternative, b) verify

the diet, texture and liquid consistency, and sign/initial the tray ticket when the alternative has been verified.

Observation of lunch and dinner service on 10/23/2025 revealed kitchen staff matching tray tickets to the diet type listed on meal tickets for the 100 hall, nurses verified and initialed all meal trays on the cart for the 100 hall, and one pureed diet tray sent back to the kitchen upon request for an alternative meal and nurse verified by initialing meal ticket that a pureed diet was provided to the resident by matching the ticket with

the food type.

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

10/27/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

diameter. LVN F stated she did not observe any other discoloration to Resident #5 extremities. LVN F stated

she did not place the details of what she saw in the note as she did not think to document it in a note. LVN F stated details like measurements, would help her assessment to ensure skin irregularities were not getting worse. LVN F stated by documenting her assessment findings, this documentation would aid in avoiding infections and ensure the safety and well-being of all her residents. LVN F stated she is more vigilant now, and thoroughly intentional with her observation documentation. LVN F stated there was no negative outcome to her lack of documentation for Resident #5.During an interview on 10/25/2025 at 4:00PM the DON stated, LVN E should have documented her observation of Resident #5's bandage on 09/17/2025, and furthermore LVN F should have documented her 09/25/2025 detailed assessment regarding Resident #5 skin impairment. THE DON stated the expectation of the facility was to document and detail all observational findings with as much detail including measurement and descriptive verbiage.

The DON stated documentation should include measurements, description of injury, any odors, color, and if skin is blanchable. The DON stated documentation is an effort to ensure the safety of all residents and a way to monitor any irregularities. The DON stated the clinical staff, in no way, compromised the wellbeing of Resident #5, but going forward the staff have been in-serviced on the facility's expectation to document all

observational findings.Record review of the facility's documentation, refusals, measurements, and description of skin integrity in-service dated 09/25/2025 was reviewed.Record review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol revised April 2018 documented, 2. In addition, the nurse/physician shall describe and document/report the following: a. Full data collection of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.

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Facility ID:

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