San Rafael Nursing And Rehabilitation Center

Penalties

• Oct 27, 2025 — Fine ($17,345)
• Aug 21, 2025 — Fine ($16,421)
• Dec 14, 2023 — Fine ($10,036)

Inspection findings

1. May 28, 2026 Fire Safety · 15 findings
   • Not serious Scope/severity F

     E0007 Emergency Preparedness Deficiencies

     Address patient/client population and determine types of services needed.

     CMS fire safety

   • Not serious Scope/severity D

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     CMS fire safety

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Jul 9, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     CMS fire safety

   • Not serious Scope/severity F

     K0331 Smoke Deficiencies

     Construct fire resistant interior walls.

     CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     CMS fire safety

   • Not serious Scope/severity F

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     CMS fire safety

   • Not serious Scope/severity D

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     CMS fire safety

2. Dec 1, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Dec 3, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0727 Nursing and Physician Services Deficiencies

     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.

     Corrected Dec 3, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Dec 3, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Dec 3, 2025 · CMS health inspection

3. Oct 27, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Nov 10, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Nov 10, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0805 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

     Corrected Oct 17, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Nov 10, 2025 · CMS health inspection

4. Aug 21, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Aug 22, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Aug 22, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Aug 22, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Aug 22, 2025 · CMS health inspection

5. Mar 6, 2025 Health · 20 findings
   • Not serious Scope/severity D

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0801 Nutrition and Dietary Deficiencies

     Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

     Corrected Mar 31, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 7, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Mar 13, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Mar 25, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected May 5, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected May 5, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 5, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 5, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected May 5, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected May 5, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected May 5, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected May 5, 2025 · CMS fire safety

6. Feb 6, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Feb 7, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from the wrongful use of the resident's belongings or money.

     Corrected Feb 7, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Feb 7, 2025 · CMS health inspection

7. Jan 16, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 20, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Jan 20, 2025 · CMS health inspection

8. Sep 6, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Sep 27, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Sep 27, 2024 · CMS health inspection

9. Jun 30, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Jul 25, 2024 · CMS health inspection

10. Jun 7, 2024 Health · 1 finding
    • Not serious Scope/severity E Complaint

      F0921 Environmental Deficiencies

      Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

      Corrected Jul 22, 2024 · CMS health inspection

11. Dec 23, 2023 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected Dec 24, 2023 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Dec 23, 2023 · CMS health inspection

12. Dec 14, 2023 Health · 13 findings
    • Not serious Scope/severity E

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Dec 15, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0584 Resident Rights Deficiencies

      Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

      Corrected Jan 28, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Dec 15, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0759 Pharmacy Service Deficiencies

      Ensure medication error rates are not 5 percent or greater.

      Corrected Dec 15, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0760 Pharmacy Service Deficiencies

      Ensure that residents are free from significant medication errors.

      Corrected Dec 15, 2023 · CMS health inspection

    • Not serious Scope/severity F Complaint

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Jan 22, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0842 Resident Assessment and Care Planning Deficiencies

      Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

      Corrected Dec 15, 2023 · CMS health inspection

    • Not serious Scope/severity F Complaint

      F0908 Environmental Deficiencies

      Keep all essential equipment working safely.

      Corrected Jan 22, 2024 · CMS health inspection

    • Not serious Scope/severity D

      K0222 Egress Deficiencies

      Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

      Corrected Dec 20, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0355 Smoke Deficiencies

      Properly select, install, inspect, or maintain portable fire extinguishes.

      Corrected Dec 20, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Dec 20, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0741 Miscellaneous Deficiencies

      Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

      Corrected Dec 20, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Dec 20, 2023 · CMS fire safety

13. Nov 26, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Dec 20, 2023 · CMS health inspection

14. Oct 6, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0690 Quality of Life and Care Deficiencies

      Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

      Corrected Oct 7, 2023 · CMS health inspection

15. Sep 29, 2023 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Sep 30, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0908 Environmental Deficiencies

      Keep all essential equipment working safely.

      Corrected Sep 30, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BYERS, RONALD — adp of the snf, NOT APPLICABLE, since 07/31/2023
• HOOVER, SHAWN — corporate director, NOT APPLICABLE, since 11/01/2021
• NOWOTNY, STEVEN — adp of the snf, NOT APPLICABLE, since 12/01/2024
• SCHINDELE, WILLIAM — operational/managerial control, NOT APPLICABLE, since 11/01/2021
• BILLY SCHINDELE 2020 IRRV TR — adp of the snf, NOT APPLICABLE, since 11/01/2021
• BOOKER HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 11/01/2021
• SAN RAFAEL LEASING LLC — adp of the snf, NOT APPLICABLE, since 11/01/2021
• SAN RAFAEL OPERATIONS INC. — operational/managerial control, NOT APPLICABLE, since 11/01/2021
• SHERRY SCHINDELE IRRV TR — adp of the snf, NOT APPLICABLE, since 11/01/2021
• TRIDENT LTC, INC. — adp of the snf, NOT APPLICABLE, since 11/01/2021
• TRIDENT ONE LEASING LLC — adp of the snf, NOT APPLICABLE, since 11/01/2021