San Rafael Nursing And Rehabiliation
San Rafael Nursing and Rehabiliation in Corpus Chrisit, TX — inspection on October 27, 2025.
Found 4 citations. 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 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/27/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
San Rafael Nursing and Rehabiliation
3050 Sunnybrook Rd Corpus Chrisit, TX 78415
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/27/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
San Rafael Nursing and Rehabiliation
3050 Sunnybrook Rd Corpus Chrisit, TX 78415
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/27/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
San Rafael Nursing and Rehabiliation
3050 Sunnybrook Rd Corpus Chrisit, TX 78415
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: