Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marin Post Acute during CMS and state inspections, most recent first.
A resident with pelvic fractures was improperly denied visits and phone contact with a daughter and son-in-law after staff relied on another daughter’s request and the resident’s profile instructions. The MD had documented that the resident had capacity to make health care decisions, but the SSD found no record that the resident refused contact, no court order, and no clinical or safety reason for the restriction. The resident stated she wanted ongoing communication and visits with all of her family members, and the DON acknowledged the restriction was not authorized by the advance directive.
Nursing staff failed to implement a timely, person-centered nutrition care plan and did not follow ordered weekly weights for a resident with dysphagia, muscle wasting, Wernicke's encephalopathy, and moderate cognitive impairment. Despite RD assessment and goals for stable weight and adequate intake, staff missed an ordered weight, then documented a significant weight loss without verifying the weight, notifying the physician or RD, or initiating a change of condition report. The care plan for high nutritional risk was initiated late and did not address the resident’s need for assistance with eating, monitoring meal intake percentages, or meal refusals, even though CNAs and an LN reported the resident sometimes refused to eat and required encouragement.
Two residents were not adequately supervised near unsecured exits, leading to one resident in a wheelchair leaving the building unnoticed through unlocked front doors and traveling down a steep, uneven driveway to a lower parking lot, where paramedics later found the resident unresponsive, and another cognitively impaired resident with gait and vision issues wandering alone in a second-floor common area adjacent to unlocked doors to a wet deck, steep incline, and parking lot. The front lobby reception desk, which the DON stated was responsible for monitoring residents and intervening if they attempted to leave, was repeatedly observed to be unstaffed, and staff acknowledged that no one was actively monitoring the front doors. The eloped resident had a history of suicidal ideation, a care plan requiring continuous monitoring and hourly checks, and a physician order limiting outings to passes with a responsible party for medical appointments only, while the second resident was supposed to be supervised by activity staff who could not see her from their location. Facility policies on wandering, elopement, and safety required identification of at-risk residents and targeted interventions, including adequate supervision and locked doors, but these measures were not effectively implemented at the time of the incidents.
A resident was found slumped over in a wheelchair in the facility’s lower parking lot, and 911 was called. Paramedics performed CPR, pronounced the resident dead in the driveway, and then notified on-duty nurses. The Administrator stated he did not report the death to the Department because he did not consider it an unusual occurrence and had not completed his investigation or staff interviews. However, the DSD and DON both stated that the sudden death was an unusual occurrence that should have been reported. The facility’s Unusual Occurrence Reporting policy required reporting deaths from unnatural causes and submitting a written report within 48 hours, but this was not done for this event.
A resident’s assessments were not accurately completed, leading to incorrect documentation of cognitive status and an incomplete fall risk evaluation. The BIMS score recorded in the quarterly assessment was 1, despite the DSD and MDS nurse stating the resident was alert, oriented, and capable of making decisions, and a POLST form signed by the resident indicating capacity. The MDS nurse reported that social services staff had completed and mis-scored the BIMS. Additionally, a fall risk assessment documented a high-risk score but was not fully completed, even though it was signed by the MDS nurse. Elopement and wandering risk assessments showed the resident could propel in a wheelchair with some assistance, had no communication, hearing, or vision deficits, and had expressed plans to leave, with documentation that care plan interventions for unsafe wandering or elopement had been initiated or updated.
Nursing staff left medications at the bedside for four residents with varying cognitive abilities and complex medical conditions, without staying to ensure the medications were taken. Facility leadership confirmed this practice was not allowed and contradicted policy requiring staff to remain with residents until all medications were ingested.
A resident with severe cognitive impairment was physically struck in the face by another resident with no cognitive impairment in the hallway near the nurse's station. The incident was witnessed by the HRD, immediately intervened, and confirmed by video surveillance. This event demonstrated a failure to protect a resident from abuse as required by facility policy.
A resident struck another resident in the face during a hallway altercation witnessed by the HRD, who separated them and notified nursing leadership. Despite the incident being captured on video and observed by management, there was no documentation in the residents' records or care plans, and the event was not reported to the Department as required by policy. The failure to report and document the incident prevented timely investigation by authorities.
Infection prevention and control failures were observed with contaminated pill crushers on medication carts, an LPN checking a resident’s vital signs in an EBP room without a gown, and nebulizer tubing that had not been changed weekly for a resident using daily nebulizer treatments. Staff stated the pill crushers were dirty with medication residue, the gown should have been worn for EBP care, and the nebulizer tubing should have been changed.
Overfilled Sharps Container in Shower Room: A sharps container in Unit 2, Shower Room A was observed overfilled with razors sticking out of the opening. An LVN stated that housekeeping and nursing staff were responsible for emptying the container, and the facility policy required designated individuals to seal and replace sharps containers when they were 75% to 80% full.
A resident’s indwelling urinary catheter collection bag was observed positioned above the bladder instead of below it. An LVN stated the bag was not positioned correctly for drainage, and the resident’s care plan and facility policy both directed staff to keep the bag and tubing below bladder level. The DON stated this placement is intended to prevent back flow.
Unsafe room conditions and improper fall pad placement: A portable space heater was observed on the floor in a shared room used by two residents, and staff were aware it was there even though facility policy prohibited portable space heaters in resident areas. In addition, a resident at risk for falls did not have the ordered floor pad placed beside the bed; instead, it was stored upright next to the nightstand, despite staff stating it should have been on the floor and the DON confirming the order required proper placement every shift.
Unlocked Medication and Treatment Carts: A medication cart was observed unlocked and unattended near the Beauty Shop, and a treatment cart was also observed unlocked and unattended. An LVN and an RN each stated the carts should have been locked when not in use to prevent unauthorized access, and the DON confirmed the facility policy requires medication and treatment carts to be locked when unattended.
A resident with severe cognitive impairment and bed confinement was physically struck in the face with a hanger by another resident with moderate cognitive impairment and Parkinson's disease. The incident resulted in new scratches on the victim's cheek, and staff interviews confirmed the event and the facility's responsibility to prevent such abuse.
A resident with hemiplegia and hemiparesis did not receive restorative nursing services as ordered by her physician, receiving therapy only twice weekly instead of three times. This occurred because the RNA responsible for these services was frequently reassigned to CNA duties due to staffing shortages, with no replacement provided, resulting in missed restorative care for multiple residents.
A licensed nurse left a cup of nine pills unattended on a resident's bedside table without a physician's order for self-administration. The resident, who had hemiplegia and hemiparesis but no memory impairment, reported the incident and noted a medication was missing. Facility policy and staff confirmed that no residents had orders for self-administration, and that leaving medications unattended was not permitted.
Two residents experienced significant delays in call light response, with one resident's call light going unanswered for 25 minutes while she waited for a missing medication, and another reporting frequent waits of up to an hour-and-a-half. Both residents, who had no memory impairment and required staff assistance, described feeling neglected due to these delays. Facility policy required prompt call light response, but staff failed to meet this standard.
A resident with a history of hemiplegia and hemiparesis was not kept free from significant medication errors when a nurse administered morning medications more than an hour late, left the medications unattended at the bedside, and omitted a required dose of metformin that was to be given with breakfast. The nurse later confirmed the errors, and facility policy indicated that such deviations from scheduled administration times are considered medication errors.
The facility employed two Social Service Directors who did not meet federal qualification requirements, with one holding a degree in communications and the other lacking a college degree, and neither having documentation of the required credentials in their personnel files.
Improper Restriction of Family Visitation and Communication
Penalty
Summary
The facility failed to ensure that a resident was provided immediate access to family members of her choosing when it restricted visits and telephone communication from one daughter and a son-in-law based only on another daughter's designation as health care decision maker. The resident had been admitted with pelvic fractures, and a physician documented on a resident capacity statement that she had the capacity to make health care decisions. The facility did not verify the resident's wishes before restricting contact, and there was no documented court order, clinical reason, or safety justification for the restriction. A family member reported that nursing staff refused to allow her to speak with the resident after being told by other family members, who were listed as health care agents, that she and her husband were not permitted to contact the resident. A progress note showed an LPN denied the husband’s request to visit and bring food because the restriction was listed in the resident’s profile. The LPN stated she relied on the profile information and was told the restriction came from an email from the resident’s daughters. The SSD confirmed the facility had restricted communication and visitation from the daughter and son-in-law, but found no documentation that the resident had refused contact with them. The SSD also stated she had never interviewed the resident about her wishes. During interview, the resident stated she wanted to continue communicating and visiting with all of her family members, including the daughter and son-in-law, and expressed distress about not knowing why contact had been restricted. The DON acknowledged at least two incidents of improper restriction and confirmed the resident’s advance directive did not authorize limiting access to those family members.
Failure to Implement Person-Centered Nutrition Care Plan and Respond to Significant Weight Loss
Penalty
Summary
Nursing staff failed to initiate and implement a comprehensive, person-centered care plan within seven days of admission and did not follow physician orders for weight monitoring for one resident. The resident was admitted with diagnoses including dysphagia, cerebrovascular disease, muscle wasting and atrophy, and Wernicke's encephalopathy, and was assessed as needing assistance with eating and having moderate cognitive impairment. An RD nutritional assessment identified chewing/swallowing problems, set an ideal and goal weight range, and recommended weights per facility protocol with goals of no significant weight changes and monitoring weight trends and meal intake over 65%. Despite a physician order for weekly admission weights for four weeks, nursing staff did not obtain the ordered weight on the first scheduled date. Subsequent documentation showed a significant weight decrease from the admission weight of 128.1 lbs to 116 lbs within approximately 12 days, triggering an electronic warning of more than a 5% weight change. There was no documentation in the progress notes that the physician or RD were notified of this weight loss, and no evidence that the weight change was verified or retaken as required by facility policy. Staff interviews confirmed that significant weight changes should have prompted retaking the weight, notifying the physician and RD, and initiating a change of condition report, but this was not done. The resident’s care plan for high nutritional risk was not initiated until after the period of weight loss and did not address the resident’s need for assistance with eating, monitoring meal intake percentages, or any meal refusals, despite prior assessments indicating the need for assistance and staff reports that the resident sometimes refused to eat and required encouragement. Facility policies required that any weight change of 5% or more be rechecked the next day, with verified changes immediately reported to the dietician, and that individualized care plans be developed and revised based on ongoing assessments and changes in condition. The DON acknowledged the resident’s weight loss variance and confirmed there was no documented evidence of physician or IDT notification or care plan revision in response to the weight change.
Failure to Supervise Residents and Secure Exits Resulting in Elopement and Unsafe Wandering
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a safe environment to prevent accidents, resulting in one resident leaving the building unnoticed and being found deceased outside, and another resident wandering unsupervised near unlocked exterior doors. The facility building is three stories high and located on a hillside, with a steep, uneven asphalt driveway and stairs connecting the main entrance to a lower-level parking lot near a busy street. There were no secured gates to prevent residents from leaving the sitting area outside the front doors and attempting to go down the steep driveway in wheelchairs. On one survey date, the reception desk at the main entrance was observed to be empty, and multiple individuals without visible employee identification entered through the front doors. One resident, admitted with diagnoses including cerebral infarction (stroke), ataxia, dysphagia, major depressive disorder, right above-the-knee amputation, muscle weakness, dysarthria, and anarthria, self-propelled his wheelchair from the second floor via the elevator to the lobby. Video surveillance reviewed by the Administrator and Director of Staff Development showed the resident moving down a long hallway to the front doors, waiting there, and then exiting when visitors opened the unlocked doors. The last video frame showed him leaving the sitting area and heading slowly down the steep driveway. Facility staff were unaware he had left the building until paramedics, called by a passerby who found him slumped over in his wheelchair in the lower parking lot near electric vehicle chargers, arrived around 5 p.m. and requested information. The Administrator acknowledged there was no receptionist at the front desk at the time, despite the usual practice of staffing that area from mid-afternoon to evening, and the Assistant DON confirmed that no one was actively monitoring residents or the front doors. The resident who eloped had a documented history of suicidal ideation. Progress notes indicated that on a prior date he had stated he wanted to die, attempted to go out a ramp door but was redirected, and later went out to a second-floor balcony and said he wanted to leave and would jump off the balcony. Nursing documentation described him as having suicidal thoughts and verbalizing wanting to die and jump off the balcony, after which he said he did not mean it and was upset about his roommate not receiving help. His care plan included a focus on behavior monitoring due to suicidal ideation, with instructions for continuous monitoring for suicidal thoughts and hourly checks per facility protocol. A physician order from admission stated that he may go out on pass with a responsible party for medical appointments only, with no documented end date. The resident’s physician stated he should only have left with a responsible party and that no one should have been able to leave alone, and the DON stated that residents could not “just walk out,” describing the front desk role as monitoring residents in the lobby and intervening if they attempted to leave. A second resident, admitted with dementia with behaviors, muscle weakness, abnormal gait and mobility, and glaucoma, was observed on the second floor in an unattended common area adjacent to unlocked sliding doors leading to a wet deck overlooking a steep incline and unlocked double doors leading to a parking lot via a ramp. This resident was awake, non-communicative, and continuously walking around the area and hallway for approximately 40 minutes, turning lights on and off, opening cabinets, and rearranging furniture without apparent reason, with no staff checking on or monitoring her behavior during that time. The Nurse Consultant stated that both the sliding doors to the deck and the doors to the parking lot ramp were supposed to be locked and acknowledged the risk that the resident could have gone onto the deck and slipped and fallen on wet leaves. He also stated that the resident was being monitored remotely by activity staff in the next room and that those staff were supposed to supervise her, but they could not see her from where they were seated. Facility policies on wandering, elopement, and safety and supervision required identification of residents at risk for wandering or elopement, inclusion of safety strategies in the care plan, and targeted interventions such as adequate supervision to address individual hazards, which were not effectively implemented in these instances. Additional interviews reinforced the lack of effective supervision and control of egress points. The Administrator defined elopement as a resident without capacity leaving without permission and asserted that the eloped resident had capacity, while other staff, including the DON and unlicensed staff, stated that residents could not leave on their own and should only leave with someone for safety. Unlicensed staff reported that the resident left the second floor without being noticed and questioned how he could have navigated the steep, uneven driveway in a wheelchair, describing it as too steep to manage safely. A roommate of the deceased resident described the driveway as steep and dangerous and expressed doubt that the resident could have returned up the hill once he went down. Weather records for the evening of the incident documented cold, rainy, and windy conditions. The facility’s own policies on safety and supervision emphasized an individualized, resident-centered approach, analysis of assessment information to identify accident risks, and targeted interventions including adequate supervision, which contrasted with the observed absence of monitoring at the front entrance and the unlocked access to hazardous exterior areas near wandering residents.
Failure to Report Unusual Resident Death to State Authorities
Penalty
Summary
The facility failed to timely report an event of unknown source that resulted in a resident’s death to the state Department, as required by regulation and by its own policy on unusual occurrence reporting. A resident was found slumped over in his wheelchair in the lower parking lot, and someone called 911. Paramedics arrived, performed CPR, and then pronounced the resident dead in the facility’s driveway. The Administrator stated that the facility first became aware of the resident’s death only after paramedics had completed CPR, pronounced the resident, and notified the nurses working in the facility. The Administrator further stated that he did not report this resident death to the Department because he did not consider it to be an unusual occurrence and believed he did not have to report it. The Administrator also stated he had not concluded his investigation and did not have interviews with staff who responded to the incident, and therefore did not report the event. In contrast, the Director of Staff Development stated that the resident’s death was an unusual occurrence and should have been reported to the Department. The DON stated that she understood an unusual occurrence to include events such as a fire, flood, or the sudden death of a resident, and confirmed that this resident’s death was definitely an unusual occurrence that should have been reported. The facility’s written policy on Unusual Occurrence Reporting specified that the death of a resident due to unnatural causes (e.g., suicide, homicide, accidents) must be reported to appropriate agencies, with a written report sent within 48 hours of reporting the event, but this process was not followed for this resident’s death in the driveway.
Inaccurate Cognitive and Incomplete Fall Risk Assessments for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate resident assessments for one of three sampled residents. The Director of Staff Development reported that, during an investigation into this resident’s death, he reviewed the resident’s Brief Interview of Mental Status (BIMS) score and found the last quarterly summary showed a score of 1, which he could not understand because, as a licensed nurse familiar with the resident, he believed the resident was alert and oriented. In a concurrent interview and record review, the MDS nurse stated that when she assessed the resident during the last quarter, she would have scored the BIMS at 3, and on review of the documented BRIEF INTERVIEW FOR MENTAL STATUS form, she noted it showed a score of 1 and stated that social services staff had completed and scored it incorrectly. She further stated the resident had capacity to make his own decisions and was his own responsible party. A Physician Orders for Life-Sustaining Treatment (POLST) form in the record, signed by the resident, indicated that the patient had capacity. Record review also showed that the resident’s fall risk assessment was incomplete. A NURSING - FALL RISK OBSERVATION / ASSESSMENT form for the resident indicated a score of 18, which corresponded to high risk, but the assessment had not been completed and was signed by the MDS nurse. Additional documentation titled NURSING - ELOPEMENT AND WANDERING RISK OBSERVATION ASSESSMENT indicated the resident was able to move or propel himself in a wheelchair with some assistance, had no communication, hearing, or vision deficiencies, and that the care plan had been initiated or updated to reflect interventions aimed at reducing the risk of unsafe wandering or elopement. A subsequent elopement and wandering risk assessment documented that the resident had expressed plans to leave but had not attempted to leave the facility, again noting no communication, hearing, or vision deficiencies and that interventions were reflected in the care plan.
Medications Left Unattended at Bedside by Nursing Staff
Penalty
Summary
Nursing staff failed to follow professional standards of practice by leaving medications at the bedside for four residents. Observations and interviews revealed that medications, including oxycodone and gabapentin, were left in cups on residents' tray tables without supervision. Residents reported that nurses sometimes left pills on their tables and did not always return to ensure the medications were taken. One nurse confirmed dropping off medications for a resident without staying to observe ingestion, and there was no order for self-administration for that resident. Facility policy required staff to remain with residents until all medications were taken. The residents involved had varying degrees of cognitive impairment and complex medical histories, including conditions such as ALS, diabetes, neuropathy, cerebral ischemia, chronic hepatitis, heart failure, chronic kidney disease, acute respiratory failure, dementia, and hyperlipidemia. Interviews with facility leadership confirmed that leaving medications at the bedside was not permitted and contradicted both facility policy and staff training.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of delirium was physically struck in the face by another resident who had no cognitive impairment. The incident took place in the hallway near the nurse's station, where the resident with cognitive impairment was in her wheelchair and was cut off by the other resident, also in a wheelchair, who then hit her. The event was witnessed by the Human Resource Director (HRD), who immediately separated the two residents and notified the appropriate staff. The altercation was also captured on facility video surveillance, confirming the physical abuse. The facility's policy on abuse prevention requires protection of residents from abuse by anyone, including other residents. Despite this policy, the physical altercation occurred, resulting in a failure to protect the resident from abuse. Interviews with both residents and the HRD confirmed the incident, and the video evidence corroborated the sequence of events. The resident who was struck did not recall the incident, while the resident who struck her stated it was in self-defense, though he could not recall the exact date.
Failure to Timely Report and Document Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report an allegation of abuse and did not submit the results of their investigation to the California Department of Public Health within the required timeframe. This deficiency was identified through observation, interviews, and record review, which revealed that an incident occurred where one resident struck another in the face while both were in their wheelchairs in a hallway. The incident was witnessed by the Human Resource Director (HRD), who immediately separated the residents and notified the floor nurse, DON, and Administrator. However, there was no documentation of the incident in the progress notes or care plans for either resident, and the event was not reported to the Department as required. The residents involved had significant medical histories: one had severe cognitive impairment and was unable to recall the incident, while the other admitted to hitting in self-defense but could not remember the date. The HRD confirmed the incident was captured on video and occurred on Halloween, but neither the DON nor the Director of Staff Development (DSD) were aware of the event until interviewed by surveyors. The DON stated that staff were expected to separate residents, report the incident, and follow up with assessments and monitoring, but these steps were not documented or completed. A review of facility records and Department logs confirmed that no abuse allegations were reported during the relevant period, and the facility's policy required timely identification, investigation, and reporting of abuse allegations. The management team, including the Administrator, DON, and others, were present in the facility on the day of the incident, yet the required reporting and documentation did not occur, impeding the Department's ability to conduct a timely investigation.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when three pill crushers on medication carts were observed with white and black powder-like residue. During observations, an RN used the pill crusher on the blue medication cart to administer medication for Resident 21, and two LVNs observed that the pill crushers on the purple and green medication carts were also dirty with medication residue. The RN and LVNs stated the residue appeared to be medication dust or buildup, and one LVN stated the pill crusher should be clean to prevent cross-contamination. The Infection Preventionist stated the pill crushers should have been cleaned once per shift and as needed, and the manufacturer’s instructions indicated the crusher should be cleaned with a damp cloth, detergent and water, then dried. The facility also failed to follow Enhanced Barrier Precautions for Resident 36 and to change Resident 17’s nebulizer tubing weekly. Resident 36 had EBP signage posted on the room door, and while the resident was lying in bed, an LVN checked vital signs without wearing a gown. The LVN stated a gown should have been worn because the resident was on EBP due to a urinary catheter. In addition, Resident 17’s nebulizer tubing was observed dated nine days earlier even though the resident reported using the nebulizer daily and said the tubing had not been changed. An LVN confirmed the tubing should have been changed, and the Infection Preventionist stated nebulizer tubing should be changed weekly or as needed.
Overfilled Sharps Container in Shower Room
Penalty
Summary
A sharps container in Unit 2, Shower Room A was observed overfilled, with razors sticking out of the opening during a concurrent observation and interview with an LVN. The LVN stated that housekeeping and nursing staff were responsible for emptying the sharps container. Review of the facility's Sharps Disposal policy, dated January 2012, showed that designated individuals were responsible for sealing and replacing containers when they were 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container.
Urinary Catheter Bag Positioned Incorrectly
Penalty
Summary
The facility failed to ensure that the care plan intervention for Resident 8’s indwelling urinary catheter was implemented when the catheter collection bag was observed positioned above the bladder. During a concurrent observation and interview, an LVN stated the bag was not positioned correctly to allow urine to drain into the collection bag and should have been placed below the resident’s bladder. The resident’s care plan, dated 1/30/25, directed staff to position the catheter bag and tubing below the level of the bladder. The DON stated the urinary catheter collection bag should be placed below the level of the bladder to prevent back flow that can lead to infection. The facility policy titled Catheter Care, Urinary, dated 8/2022, also stated the drainage bag should be positioned lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.
Unsafe room conditions and improper fall pad placement
Penalty
Summary
The facility failed to ensure the residents' environment remained free of accident hazards for 3 of 30 sampled residents when a portable space heater was observed on the floor in the middle of the shared room used by Residents 4, 17, and 53. During a concurrent observation and interview, Resident 17 stated a CNA had brought the heater to the room about a week earlier because she was cold. An LVN later stated she was aware the portable space heater was on the floor in the middle of the room. The Administrator stated it was the facility's policy for residents not to have space heaters because of fire hazard, and the facility policy titled Electrical Appliances stated portable space heaters are not allowed in resident areas. The facility also failed to ensure Resident 53's floor pad was placed as ordered. During observation, Resident 53 was lying in bed and the floor pad was stored upright next to the nightstand rather than on the floor beside the bed. A CNA stated the floor pad should have been placed on the floor next to the bed to protect Resident 53 in the event of a fall, and another CNA stated Resident 53 was a fall risk and the floor pad should have been placed on the floor next to her bed. The DON reviewed the physician order dated 7/27/24, which directed staff to ensure proper placement of the floor pad every shift for fall risk, and stated it was nursing staff's responsibility to ensure the floor pad was placed on the floor to prevent injury if a fall were to occur.
Unlocked Medication and Treatment Carts
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when Medication Cart A was observed left unlocked and unattended next to the Beauty Shop against the wall on 12/1/25 at 3:31 p.m. During the observation, LVN 2 walked out of room [ROOM NUMBER] toward the cart and confirmed it was unlocked, and stated it should have been locked when unattended to prevent unauthorized access. Treatment Cart A was also observed unlocked and unattended on 12/2/25 at 4:27 p.m., and RN 1 stated it should have been locked when unattended to prevent unauthorized access. During record review on 12/3/25, the DON reviewed the facility policy titled Medication Labeling and Storage, dated 2023, which stated that medications and biologicals are stored in locked compartments, compartments containing medications and biologicals are locked when not in use, and carts are not left unattended. The DON stated medication carts and treatment carts should be locked when unattended to prevent unauthorized access.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe obesity, bed confinement, and severe cognitive impairment was physically abused by another resident who entered his room and struck him in the face with a hanger. The incident was confirmed through interviews and record reviews, including a nursing note documenting two new superficial scratches on the resident's left cheek. The resident who committed the abuse had moderate cognitive impairment and Parkinson's disease, and admitted to entering the other resident's room and hitting him with a hanger due to being upset by his yelling. Staff interviews confirmed awareness of the incident, with the Social Services Director and Director of Nursing both acknowledging the facility's responsibility to protect residents from abuse. The facility's policy on abuse prevention was reviewed and stipulated that residents have the right to be free from abuse, including physical abuse. The failure to prevent this incident resulted in physical harm to the resident and demonstrated a lapse in protecting residents from abuse by others within the facility.
Failure to Provide Ordered Restorative Nursing Services Due to Staffing Reassignments
Penalty
Summary
The facility failed to provide restorative nursing services as ordered by the physician for one resident with hemiplegia and hemiparesis following a cerebrovascular event. The resident was supposed to receive restorative nursing services three times per week, as indicated by an active physician's order, but records showed that she only received these services two times per week during several weeks. The resident herself reported not receiving her regular therapy services, which she needed to prevent stiffness in her affected hand. Interviews with staff revealed that the Restorative Nurse Assistant (RNA) responsible for providing these services was frequently reassigned to work as a Certified Nursing Assistant (CNA) due to staffing shortages, and no replacement RNA was provided on those days. The Director of Rehabilitation confirmed the missed services and stated that he had no control over staffing assignments. The facility's assignment sheets did not clearly document when the RNA was working as a CNA versus providing restorative services, and the RNA estimated that on more than half of his shifts in the relevant month, he was reassigned, resulting in 20 to 22 residents per day not receiving restorative nursing services.
Unattended Medication Left at Bedside Without Physician Order
Penalty
Summary
A licensed nurse left a cup containing nine pills on a resident's bedside table, unattended, without a physician's order for self-administration. The resident, who had hemiplegia and hemiparesis following cerebrovascular disease but no memory impairment, reported that the nurse left the medications for her to take but noted that one of her prescribed medications was missing. Observation confirmed the unattended medications, and the nurse acknowledged leaving them at the bedside. The Director of Staff Development confirmed that facility policy prohibits leaving medications unattended at a resident's bedside without a physician's order, and that no residents, including the one involved, had such an order. Facility policy and the job description for licensed nurses both require that medications be administered according to established standards and only with proper authorization for self-administration.
Delayed Call Light Response and Missed Medication
Penalty
Summary
The facility failed to ensure that call lights for two residents were answered promptly, as observed and confirmed through interviews and record reviews. One resident, admitted with metabolic encephalopathy and no memory impairment, reported that call lights often took between 30 minutes to an hour-and-a-half to be answered, including instances when she pressed the call light for her roommate who was unable to get out of bed. Another resident, with hemiplegia and hemiparesis following cerebrovascular disease and no memory impairment, was observed to have her call light ringing for 25 minutes without response. This resident had a care plan instructing her to use the call light for assistance with activities of daily living. During the observation, the second resident was found with a cup of medications left unattended on her bedside table, and she reported that a prescribed medication was missing. She had pressed her call light to notify staff of the missing medication and had been waiting for about 25 minutes. The resident stated that staff frequently took up to an hour to respond to call lights and that she had been left wet and soiled for extended periods due to these delays, leading her to feel neglected. The LPN confirmed the missed medication and that the call light could not be seen from the nurses' station. Facility policy required call lights to be answered as soon as possible, and the DON stated the expectation was within 10 minutes.
Significant Medication Errors Due to Late and Improper Administration
Penalty
Summary
A licensed nurse failed to ensure that a resident was free from significant medication errors by administering morning medications more than one hour late, leaving the medications unattended at the resident's bedside, and omitting an important medication that was required to be given with breakfast. The resident, who had a history of hemiplegia and hemiparesis following cerebrovascular disease, was observed with a cup containing nine medications left on her bedside table after 10 a.m., and she reported that one medication was missing. The nurse confirmed both the late administration and the omission of metformin, which was supposed to be given with breakfast. A review of the resident's Medication Administration Record showed that all scheduled morning medications were to be administered at 8 a.m. or 9 a.m., with none scheduled for 10 a.m. or later. The nurse acknowledged that breakfast was served between 8 a.m. and 8:30 a.m., and that the medications, including those requiring administration with food, were given outside the prescribed time window. Facility policy required medications to be administered within one hour before or after the scheduled time, and the Director of Staff Development confirmed that deviations from this protocol constituted medication errors.
Unqualified Social Service Directors Employed
Penalty
Summary
The facility, licensed for 168 beds, failed to ensure that its Social Service Directors (SSDs) met the minimum federal qualifications for their positions. One SSD, assigned to Unit One, held a Bachelor's Degree in communications, which does not meet the requirement for a degree in Social Work or a Human Services field. The other SSD, assigned to Unit Two, did not possess a college degree at all. Personnel files for both SSDs lacked documentation of the required educational qualifications, such as resumes or proof of degrees. The facility's own job description for the Social Services Director position specified a Bachelor's Degree in Social Work or Human Services and two years of supervised social work experience in a healthcare setting, but these requirements were not met by the current SSDs.
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We read the 746 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Rafael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Ridge Care Center | 1.2 mi | ★★★★★ | 24 | 0 |
| Northgate Postacute Care | 1.2 mi | ★★★★★ | 34 | 0 |
| Professional Post Acute Center | 1.2 mi | ★★★★★ | 6 | 0 |
| Smith Ranch Skilled Nursing & Rehabilitation Cente | 1.3 mi | ★★★★★ | 17 | 0 |
| Villa Marin | 1.6 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.