General Information: ALDERSLY SKILLED NURSING FACILITY
Nursing home name ALDERSLY SKILLED NURSING FACILITY
Address326 MISSION AVENUE
SAN RAFAEL, CA 94901
Phone number (415) 453-5686
Located within a hospital No
Type of ownership For profit - Corporation
Owner operates multiple homesNo
Accept Medicare or Medicaid Medicare and Medicaid
Continue Care Retirement CommunityYes
Resident and family councils Resident
Certified number of beds 20
Total number of residents 14
Perc of occupied beds 70
Sprinkler status Yes
Number of Facility Reported Incidents0
Number of Substantiated Complaints0
Number of Fines0
Total Amount of Fines$0
Total Number of Penalties0
Total Number of Penalties0
Ratings Summary: ALDERSLY SKILLED NURSING FACILITY
Overall rating 5
5
Nursing Home Staffing 5
5
Registered Nurses only 5
5
Health Inspections 5
5
Quality Measures 5
5
Nursing Home Staffing Info: ALDERSLY SKILLED NURSING FACILITY
National AverageCalifornia AverageALDERSLY SKILLED NURSING FACILITY
Overall staff rating NA NA 5
5
Registered Nurses only rating NANA 5
5
Total Number of Residents NA NA 14
Total Number of Nurse Staff Hours per Resident per Day 4.11 hours 4.49 hours 4.82 hours
Total Number of Licensed Nurse Staff Hours per Resident per Day 1.64 hours 1.8 hours 2.5 hours
Registered Nurses Hours per Residents per Day 0.81 hours 0.88 hours 1.42 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 0.83 hours 0.92 hours 1.08 hours
Certified Nursing Assistants Hours per Residents per Day 2.47 hours 2.69 hours 2.32 hours
Physical Therapy Staffing Hours per Resident Per Day 0.1 hours 0.14 hours 0.05 hours
Health Survey: ALDERSLY SKILLED NURSING FACILITY
Heath Survey Summary on 2013-09-06
Total Number of Health Deficiencies 2
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Heath Survey Summary on 2012-08-31
Total Number of Health Deficiencies 2
Scope and Severity of most Severe Health Deficiency Widespread/Potential for minimal harm
Heath Survey Summary on 2011-06-20
Total Number of Health Deficiencies 3
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Health Survey Details: ALDERSLY SKILLED NURSING FACILITY
Inspection Results: 09/06/2013
Corrected Deficiency Scope and Severity
10/28/2013 Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated/Minimal harm or potential for actual harm
10/28/2013 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated/Minimal harm or potential for actual harm
Inspection Results: 08/31/2012
Corrected Deficiency Scope and Severity
09/24/2012 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Widespread/Potential for minimal harm
09/24/2012 Post nurse staffing information/data on a daily basis. Widespread/Potential for minimal harm
Inspection Results: 06/20/2011
Corrected Deficiency Scope and Severity
08/10/2011 Store, cook, and serve food in a safe and clean way. Pattern/Minimal harm or potential for actual harm
08/10/2011 Keep all essential equipment working safely. Widespread /Minimal harm or potential for actual harm
08/10/2011 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated/Minimal harm or potential for actual harm

Fire Safety Survey: ALDERSLY SKILLED NURSING FACILITY
Fire Safety Survey Summary on 2013-09-11
Total Number of Fire SafetyDeficiencies 7
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2012-08-28
Total Number of Fire SafetyDeficiencies 10
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2011-06-24
Total Number of Fire SafetyDeficiencies 7
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey: ALDERSLY SKILLED NURSING FACILITY
Fire Safety Survey Results: 09/11/2013
Corrected Deficiency Severity
09/30/2013 Approved construction type or materials. Isolated/Minimal harm or potential for actual harm
09/30/2013 Record of quarterly fire drills for each shift under varying conditions. Widespread/Potential for minimal harm
09/30/2013 A fire alarm system that can be heard throughout the facility. Isolated/Minimal harm or potential for actual harm
09/30/2013 Automatic sprinkler systems that have been maintained in working order. Pattern/Minimal harm or potential for actual harm
09/30/2013 Exits that are free from obstructions and can be used at all times. Pattern/Minimal harm or potential for actual harm
09/30/2013 Proper construction of ducts through walls designed to prevent smoke passage. Isolated/Minimal harm or potential for actual harm
09/30/2013 Weekly inspections and monthly testing of generators. Widespread/Potential for minimal harm
Fire Safety Survey Results: 08/28/2012
Corrected Deficiency Severity
09/20/2012 Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Widespread/Potential for minimal harm
09/20/2012 Properly installed electrical wiring and equipment. Isolated/Minimal harm or potential for actual harm
09/20/2012 Restrictions on the use of highly flammable decorations. Isolated/Minimal harm or potential for actual harm
09/20/2012 Exits that are free from obstructions and can be used at all times. Isolated/Minimal harm or potential for actual harm
09/20/2012 Properly installed hallway dispensers for alcohol-based hand rub. Pattern/Minimal harm or potential for actual harm
09/20/2012 Automatic sprinkler systems that have been maintained in working order. Isolated/Minimal harm or potential for actual harm
09/20/2012 A fire alarm system that can be heard throughout the facility. Isolated/Minimal harm or potential for actual harm
09/20/2012 Walls that prevent smoke from passing through and would resist fire for at least one hour. Isolated/Minimal harm or potential for actual harm
09/20/2012 Approved construction type or materials. Isolated/Minimal harm or potential for actual harm
09/20/2012 Corridor and hallway doors that block smoke. Isolated/Minimal harm or potential for actual harm
Fire Safety Survey Results: 06/24/2011
Corrected Deficiency Severity
07/12/2011 Corridor and hallway doors that block smoke. Pattern/Minimal harm or potential for actual harm
07/12/2011 Walls that prevent smoke from passing through and would resist fire for at least one hour. Isolated/Minimal harm or potential for actual harm
07/12/2011 An approved automatic sprinkler system connected to the fire alarm system. Isolated/Minimal harm or potential for actual harm
07/12/2011 Automatic sprinkler systems that have been maintained in working order. Pattern/Minimal harm or potential for actual harm
07/12/2011 Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Isolated/Minimal harm or potential for actual harm
07/12/2011 Properly installed electrical wiring and equipment. Isolated/Minimal harm or potential for actual harm
07/12/2011 Properly installed hallway dispensers for alcohol-based hand rub. Pattern/Minimal harm or potential for actual harm

Resident Complaints: ALDERSLY SKILLED NURSING FACILITY
Not available

Quality Measures: ALDERSLY SKILLED NURSING FACILITY
Quality Measures National Average California Average ALDERSLY SKILLED NURSING FACILITY
Overall quality rating NA NA 5
5
Long-Stay Residents
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased 15.4% 11.7% 9.4%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain 8.3% 5.9% 0.0%
Percent of High Risk Long Stay Residents With Pressure Ulcers 6.1% 6.2% 0.0%
Percent of Long Stay Residents Who Lose Too Much Weight 7.2% 5.8% 0.0%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 43.9% 45.3% %
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3.2% 3.3% 10.3%
Percent of Long Stay Residents With a Urinary Tract Infection 6.2% 5.3% 2.9%
Percent of Long Stay Residents Who Have Depressive Symptoms 6.3% 1.8% 10.0%
Percent of Long Stay Residents Who Were Physically Restrained 1.4% 2.1% 0.0%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury 3.2% 1.6% 0.0%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine 92.7% 92.3% 100.0%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 94.3% 94.6% 100.0%
Percent of Long Stay Residents Who Received an Antipsychotic Medication 20.7% 16.5% 18.4%
Short-Stay Residents
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain 19.2% 16.9% 2.7%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened 1.2% 0.9% 0.0%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine 83.4% 81.1% 100.0%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 82.4% 79.8% 100.0%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication 2.6% 2.0% 0.0%

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