San Rafael Nursing And Rehabiliation

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

sure the care plan was updated. The DON stated care plans were updated so staff had the most up to date and accurate information regarding a resident's care. 2.Record review of Resident #17's face sheet dated 09/24/25 reflected a [AGE] year-old-male with an original admission date of 09/17/21. Diagnoses included heart disease, hypertension (high blood pressure), and type two diabetes (insufficient insulin production in

the body). Record review of Resident #17's physician orders dated 05/07/25 reflected: Lisinopril oral tablet 10 MG by mouth one time a day for hypertension. Hold if blood pressure is less than 110/60. Record review of Resident #17's care plan initiated on 05/15/25 did not reflect the use of antihypertension medications.

Record review of Resident #17's quarterly MDS dated [DATE REDACTED] reflected a BIMS of 13 (cognition intact) and

an active diagnosis of hypertension. In an interview on 09/25/2025 at 3:15 pm, the MDS nurse stated the care plan should have been updated to reflect Resident #17's use of hypertensive medications. The MDS nurse stated she was not sure how or why it got missed but she was ultimately responsible for updating the clinical portion of the care plan, so it reflected the most current information. The MDS nurse stated if care plans were not updated accurately, residents may not get the care they needed. In an interview on 09/25/25 at 3:26 pm, the RMDS stated hypertensive medications should be care planned so staff are aware to monitor for signs and symptoms of hypertension. The RMDS stated care plans were reviewed daily but were audited approximately every 3 months. The RMDS could not state why Resident #17's hypertensive medications had not been care planned. In an interview on 09/25/2025 at 3:40 pm, the DON stated the MDS nurse updated the clinical portion of the comprehensive care plan and ultimately it was the MDS nurse's responsibility to make sure the care plan was updated. The DON stated care plans were updated so staff had the most up to date and accurate information regarding a resident's care. Record review of facility's Care Plans, Comprehensive Person-Centered dated December 2016 reflected: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7.

The comprehensive, person-centered care plan will: G. Incorporate identified problem areas; H. incorporate risk factors associated with identified problems; K. reflect treatment goals, timetable and objectives in measurable outcomes; O. reflect currently recognized standards of practice for problem areas and conditions. 8. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 12. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

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

12/01/2025

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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on Interviews and record reviews, the facility failed to ensure the director of nursing did not serve as

a charge nurse when the facility had an average daily occupancy of 60 or higher for 4 days (08/03/25, 08/11/25, 09/08/25, and 09/14/25) reviewed for DON staffing in the last 2 months. The facility failed to ensure the DON did not work as a charge nurse for 4 different shifts in August and September 2025 while

the average census was above 60. This failure could lead to dividing the DON's attention, preventing them from performing duties assigned to the DON leading to possible harm to a resident. The findings included:Record review of the daily clinical staff schedules revealed the DON was scheduled to work as charge nurse from 2:00 PM - 6:00 PM on 08/03/25 in the 100 hall, 6:00 AM - 6:00 PM on 08/11/25 in the 300 hall, 6:00 AM - 6:00 PM on 09/08/25 in the 100 hall, and 6:00 AM - 6:00 PM on 09/14/25 in the 300 hall. Record review of the resident census data from the facility revealed the daily census for 08/03/25 was 118, 08/11/25 was 121, 09/08/2025 was 116, and 09/14/25 was 116. In an interview with ADON B on 09/25/25 at 1:50 PM, ADON B stated a charge nurse was a nurse that was in charge of residents on a hall.

ADON B stated there multiple charge nurses working at a time. ADON B stated there were typically 5 charge nurses working during the 6:00 AM - 6:00 PM shift and 3 charge nurses for 6:00 PM - 6:00 AM.

ADON B stated the DON had come in and worked as a charge nurse when they were short-staffed. ADON B stated she had seen the DON working as a change nurse. ADON B stated the DON was used as a last resort to fill in as a charge nurse if they could not find anyone else. In an interview with the ADM on 09/25/25 at 3:09 PM, the ADM stated the DON has filled in as a charge nurse on the halls a few times. The ADM stated the DON was the last person on the list to call when a charge nurse was needed. The ADM stated they did not schedule the DON to work as a charge nurse ahead of time, but that he only ever filled

in for another nurse. The ADM stated if the DON was scheduled on a daily basis to work as a charge nurse

they would not be able to perform their DON duties effectively. In an interview with the DON on 09/25/25 at 3:28 PM, the DON stated he had worked as a nurse on the floor at the facility approximately four times in

the past 2 months. The DON stated when he worked as a floor nurse he was not able to perform all of his responsibilities as a DON. The DON stated he was never scheduled to work on the floor ahead of time. The DON stated he would find out he was needed to fill in as a floor nurse about an hour before he was needed to be at the facility. A facility policy was requested from the ADM on 9/25/25 at 3:40 PM regarding the DON working as a charge nurse but the ADM stated the facility did not have a policy covering that.

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

12/01/2025

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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Record review of Resident #16's face sheet dated 09/25/25 reflected a [AGE] year-old-male with an original admission date of 10/16/20. Diagnoses included acute chronic kidney failure, hypertension (high blood pressure), congestive heart failure (long-term condition in which the heart cannot pump blood well enough to meet the body's needs), and type two diabetes (insufficient insulin production in the body). Record review of Resident #16's care plan dated 12/12/23 reflected: Resident #16 had hypertension. Interventions included: Give anti-hypertensive medications as ordered. Record review of Resident #16's physician orders dated 03/06/25 reflected: Clonidine HCI oral tablet 0.1 by mouth every 6 hours as needed for a systolic greater than 160 and a diastolic greater than 100. Record review of Resident #16's blood pressure log reflected: 9/20/2025 08:20 164 / 66 mmHg; 9/20/2025 06:48 164 / 66 mmHg. Record review of Resident #16's September 2025 MAR reflected Clonidine HCI oral tablet 0.1 MG was not given for any days in September. In an interview on 09/25/25 at 9:23 am, LVN C stated sometimes when he administered blood pressure medication, the previous blood pressure was populated, and he would not change it. LVN C stated

he would check resident's blood pressure prior to administration but sometimes would not record it. LVN C stated if blood pressure medication was not given as ordered, the resident's blood pressure could decline,

the resident could become dizzy or hypotensive (low blood pressure), and experience headaches or fainting. In an interview 09/25/25 at 10:00 am, Resident #16 stated he would get his blood pressure checked daily but could not say if he got his blood pressure medication as needed. In an interview on 09/25/2025 at 2:02 pm, ADON B stated it was important to document blood pressures accurately to understand where the resident was at. ADON B also stated it was important to see if the blood pressure medication needed to be held, if Resident #16 needed any additional medications, or if the physician needed to be contacted in case the blood pressure was out of parameters. ADON B stated Resident #16 could experience a possible stroke, hypertension or death if Resident #16's was given the blood pressure medication outside of parameters. ADON B stated there was no current process for auditing blood pressure. In a phone interview on 09/25/25 at 2:28pm, MA E stated she was new to the facility and worked at another facility where their computers were bigger, and she was simply not used to this facility's small computers. MA E stated if Resident #16's blood pressure was out of parameters then she would have given

the medication. MA E stated if Resident #16's blood pressure was not documented then she did not know what to say. MA E stated she always took blood pressure on the residents that required them. MA E stated

she did not use the same blood pressure as before, and if they were the same blood pressures, then that's what they were. MA E stated she did not know what else to say as she had always taken residents blood pressures and documented accurately. In an interview on 09/25/2025 at 3:55 PM, the DON stated nurses should always recheck an elevated blood pressure and administer any prn blood pressure medication the resident had. The DON also stated if a blood pressure was already elevated, and medication was not administered as ordered, the blood pressure could have continued to rise, and the resident could have had

a stroke. Record Review of the facility's Administering Medications policy, dated December 2012, reflected: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. 3.

Medication must be administered in accordance with the orders, including any required time frame. 4.

Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals). Refer to Liberalized Medication Pass Policy if used. 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

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

12/01/2025

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

pressure. LVN C did not have a reason why Resident #16's blood pressure was not accurately recorded.

LVN C stated it was important to update and record each blood pressure to ensure correct medication administration. In an interview 09/25/25 at 9:40 am, Resident #16 stated he would get his blood pressure checked daily but could not state if he was getting his medication as needed. In an interview on 09/25/2025 at 10:00 am, the DON stated Resident #16's blood pressure should have been taken and accurately documented to assess vitals and see where the patient was at. The DON stated Resident #16's blood pressure could have fluctuated, and the medication needed would not have been given. In an interview on 09/25/2025 at 2:02 pm, ADON A stated it was important to document blood pressures accurately to understand where the resident was at and to see if the medication needed to be held or if the physician needed to be contacted incase the blood pressure was out of parameters. ADON A stated Resident #16 could experience a possible stroke, hypertension or death if given the blood pressure medication outside of parameters. ADON A stated there was no current process for auditing blood pressures. ADON A stated the blood pressure usually fluctuated and would not typically be the same in the morning and in the evening. In

a phone interview on 09/25/25 at 2:28pm, MA E stated she was new to the facility and worked at another facility where their computers were bigger. MA E stated she was not used to the facility's small computers.

MA E stated if Resident #16's blood pressure was not documented then she did not know what to say as

she would have documented and gave medication as ordered. MA E stated she always took blood pressures on the residents that required them. MA E stated she did not use the same blood pressure previously recorded and if the blood pressures were recorded the same, then they were the same. MA E kept stating she just started at the facility and had vision problems. MA E stated she did not know what to say as she always took resident blood pressures and documented what the blood pressures were at that time. Record review of the facility's Charting and Documentation dated July 2017 reflected: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in

the resident medical record: b. Medications administered; c. Treatments or services performed 3.

Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; e. whether the resident refused the procedure/treatment;

Event ID:

Facility ID:

If continuation sheet