Marin Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable homelike environment for nine of thirteen sampled residents (Resident's 1,2,4,5,6,7,8,9,12), when room temperatures reached above 81degrees ( ) Fahrenheit (F) during a summer heat wave. This failure resulted in residents feeling hot and uncomfortable and increased the potential for heat-related illnesses such as heat stroke, dehydration and impaired skin integrity in an already vulnerable population. On 7/30/26, the department entered the facility to investigate a complaint related to power outages in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Social Service Director (SSD) met the minimum qualifications of their position per federal regulations for a census of 135, when the SSD did not have a Bachelor's degree in Social Work or in a Human Services field. This failure decreased the facility's potential to meet the social service needs of the residents. A review of the facility's license, dated 6/1/26 to 5/31/27, indicated the facility had 168 beds. During an interview on 6/25/26 at 9:02 a.m. with the SSD, the SSD stated she had a Bachelor's Degree in Communications. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to receive written notice of a room change for two of four sampled residents reviewed for resident rights (Resident 1 and Resident 2) when the residents were notified of a room change verbally and not in writing. This failure resulted in the residents feeling upset, angry and confused about the change of rooms.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was provided the right to immediate access by family members, as required when the facility restricted Resident 1 from receiving visits and telephone communication from one of her daughters (DTR 3) and her son in law (SIL 1), based solely on another daughter's (DTR 1) designation as health care decision maker. The facility did not verify Resident 1's wishes, and there was no clinical, legal, or safety justification for restricting contact. This failure resulted in Resident 1 being denied communication and visitation with family members of her choosing, with the potential for psychosocial harm. [...]

Inspectors wroteBased on staff interviews and record review, the nursing staff failed to initiate and implement a person-centered care plan within seven days of admission and notify the physician and Registered Dietician (RD) for one resident (Resident 1) of three sampled residents, when Resident 1 was not weighed as ordered by the physician and lost 7 pounds in 13 days. This failure resulted in a significant loss of weight for Resident 1 and decreased the facility's potential to ensure accurate communication among its care team.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide adequate supervision for two of three sampled residents (Resident 1 and Resident 2), when:Resident 1 was able to leave the facility unnoticed by staff (elope), through the front doors in his wheelchair on [DATE], making it down a steep hill before being found deceased on the sidewalk in front of the building and next to a busy street, being discovered by a passerby who notified paramedics, who in turn notified facility staff, who was not aware Resident 1 had left the facility. Resident 2 was observed unsupervised and wandering around an area next to unlocked doors that led to a wet deck, a steep decline and a parking lot. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an event of unknown source which resulted in a resident's death, when one resident (Sampled Resident 1) was found deceased by paramedics in the facility's driveway on [DATE], within the mandatory timelines.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure accuracy of assessments when one of three sampled resident's (Resident 1) assessments did not reflect his correct status mental capacity status, and his fall risk assessment was not completed. These failures had the potential for lack of coordination of care with the health team and not providing the care and services necessary to ensure residents were safe and achieving their highest level of day-to-day life.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow professional standards of practice when nursing staff left medications at the bedside for four residents (Resident 1, Resident 2, Resident 3, and Resident 4) of four sampled residents. This failure had the potential to increase the risk of medication errors, misuse and/or accidental ingestion of medication by the resident or others. A review of Resident 1's admission record indicated admission to the facility on 1/24/25 with diagnoses including Amyotrophic Lateral Sclerosis (ALS - a progressive disease affecting the nerve cells in the brain and spinal cord that control voluntary muscles), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), neuropathy (nerve pain), and chronic pain syndrome. [...]

Inspectors wroteBased on observation and interview, the facility failed to protect one resident (Resident 5) of six sampled residents from physical abuse when Resident 6 hit Resident 5 in the face. This failure had the potential to cause physical injury and emotional distress for Resident 5. A review of Resident 5's admission record indicated admission to the facility on 1/16/25 with diagnoses including atrial fibrillation (a type of irregular heart rhythm) and delirium (a sudden, severe change in mental status). A review of Resident 5's Minimum Data Set (MDS- an assessment tool) dated 10/9/25 indicated Resident 5 had severe cognitive impairment with a BIMS score of 3. A review of Resident 6's admission record indicated admission to the facility on 8/12/25. Resident 6 was admitted with a diagnosis of malignant neoplasm of colon (colon cancer). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to report an allegation of abuse and failed to submit the results of their investigation to the California Department of Public Health (the Department) within the required timeframe. This failure impeded the ability of the Department to conduct a timely investigation and ensure the safety and well-being of the residents. A review of Resident 1's admission record indicated admission to the facility on 1/24/25 with diagnoses including Amyotrophic Lateral Sclerosis (ALS - a progressive disease affecting the nerve cells in the brain and spinal cord that control voluntary muscles), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), neuropathy (nerve pain), and chronic pain syndrome. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when:1. 3 of 3 pill crushers contained a white and black colored powder-like substances.2. The licensed staff did not wear a gown while checking vital signs (measurement of body functions) for Resident 36, who was in an isolation room that had signage posted on his room door to indicate Enhanced Barrier Precautions (EBP- gown and glove use, required during high contact resident care activities, designed to reduce transmission of organisms). 3. Resident 17's nebulizer tubing (used to inhale medication) was not changed weekly. These failures had the potential to result in the spread of infectious diseases for the facility's residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment when one sharps container (a specially made box used to safely discard sharp items) was overfilled in Unit 2, Shower Room A.This failure had the potential to cause harm to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 30 sampled residents (Resident 8) care plan interventions were implemented when Resident 8's indwelling urinary catheter (a flexible tube that drains urine from the bladder) collection bag was not positioned below the bladder. This failure placed Resident 8 at risk for urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remained free of accident and hazards for 3 of 30 sampled residents (Residents 4, 17, and 53) when:1. A portable space heater was on the floor in the middle of Resident 4,17, and 53's shared room. This failure had the potential to result in a fire and tripping hazard for the residents.2. Resident 53's, who was at risk for falls, floor pad was not on the floor as ordered. This failure had the potential to result in significant injuries for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store drugs and supplies in accordance with acceptable standards of practice when: 1. One medication cart (Medication Cart A) was left unlocked and unattended.2. One treatment cart (Treatment Cart A) was left unlocked and unattended. These failures had the potential for residents and staff to have unauthorized access to medications and treatments.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of four sampled residents (Resident 1) when Resident 2 entered his room and struck him with a hanger. This failure had the potential to result in serious physical injury to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure rehabilitative services were provided for one resident (Resident 2) of three sampled residents when restorative nursing services (nursing interventions that focus on helping residents maintain and improve their ability to function independently in activities of daily living and mobility) were not performed according to physician ' s orders. This failure decreased the facility ' s potential to ensure residents attained their highest practicable level of physical and functional well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident 2) of three sampled residents received care which met professional standards when a Licensed Nurse B (LN B) left a cup of medications by the Resident 2 ' s bedside, unattended, without a physician ' s order. This failure decreased the facility ' s potential to safely administer medications to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights for two residents (Resident 1 & Resident 2) of three sampled residents were answered promptly when the Surveyor observed Resident 2 ' s call light ringing for 25 minutes before intervening. This failure decreased the facility ' s potential to provide prompt assistance to residents and resulted in Resident 2 feeling neglected.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident 2) of three sampled residents was kept free of significant medication errors, when Licensed Nurse B ( LN B) administered her morning medications more than one hour late, left her medications by the resident ' s bedside unattended, and missed an important morning medication that was required to be administered with breakfast. These findings increased the potential to result in elevated blood pressure, elevated glucose levels, and harm to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Social Service Director's (SSD) met the minimum qualifications of their positions per federal regulations, when one SSD did not have a Bachelor's Degree, and the other SSD did not have a Bachelor's degree in Social Work or in a Human Services field. This failure decreased the facility's potential to meet the social service needs of the residents.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #134) of 2 sampled residents reviewed for choices was assessed to self-administer their medication before the licensed nurse left the medication(s) with the resident to administer on their own.

Inspectors wroteBased on interviews, record review, document review, and facility policy review, the facility failed to ensure their grievance policy revealed who the Grievance Official was, their contact information, and the contact information for independent entities to whom grievances may be files. The facility further failed to ensure there was documentation of a resident's grievance to include, the receipt of the grievance, a summary statement of the grievance, the steps taken to investigate the grievance , a summary of the pertinent findings/conclusion, any corrective action taken, whether the grievance was confirmed or not, and the date the written decision was issued to the resident for 1 (Resident #19) of 6 sampled residents reviewed for personal property.

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure 1 (Resident #22) of 1 sampled resident reviewed for abuse, was not physically abused by another resident.

Inspectors wroteBased on interviews, record reviews, document review, and facility policy review, the facility failed to timely report an allegation of physical abuse to the state agency that involved 1 (Resident #22) of 1 sampled resident reviewed for abuse.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a Level II mental health evaluation was completed for 1 (Resident #56) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR).

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #57) of 3 sampled residents reviewed for accidents was assessed for smoking.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to ensure the medication error rate was 5% or less. There were two medication errors out of 29 opportunities, which yielded a medication error rate of 6.89%. This deficient practice was affected 2 (Resident #54 and Resident #75) of 8 residents observed for medication administration.

Inspectors wroteBased on Observation, interview and record review, the facility failed to provide sufficient staffing for basic care needs for two acute rehabilitation Residents (Resident 1) and (Resident 2). This failure resulted in the potential for injury for Resident 1 to endure Skin breakdown and Resident 2 to suffer a fall.

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to prevent pressure ulcers for one of two residents (Resident 54) at risk for pressure ulcers. This failure resulted in Resident 54 developing a Stage 2 Pressure Ulcer on her coccyx.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and manage the pain of one of 27 sampled residents (Resident 76), in accordance with his tolerable level of pain, monitor if pain intervention was effective, and communicate with the providing physician when pain management intervention was not effective. This failure resulted in Resident 76 suffering through severe and debilitating pain, thus making him miserable and irritable.

Inspectors wroteBased on observation and interview, the facility failed to respect the right of two of 27 sampled residents (Resident 294 and 109) and two unsampled residents (Unsampled Residents 38 and 13) to refuse care, when staff checked vital signs at night despite Resident 294 informing staff he did not want vital signs checked at night. This failure resulted in residents having their sleep disturbed.

Inspectors wroteBased on interview and record review, the facility failed to honor the bath and shower preferences of two of 27 sampled residents, Resident 109 and Resident 242. This failure had the potential to affect residents' quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make the facility's survey results accessible to residents, when eight out of eight residents at a resident council interview (Residents 9, 14, 42, 43, 66, 101, 122, 125), and one sampled resident (Resident 129), did not know the location of the binder containing the results, which was on the first floor, and not easily accessible to those who lived on the second floor. This failure was a violation of the residents' right to have survey results readily available to them for review.

Inspectors wroteBased on interview and record review, the facility failed to create a comprehensive care plan which met the needs of residents, for four of four residents (Residents 30, 39, 48 and 76). This failure had the potential for Residents 30, 39, 48 and 76 not having their care needs met.

Inspectors wroteBased on interview and record review, the facility failed to provide Restorative Nursing Assistant (RNA) services, as ordered, to three of 27 sampled residents (Residents 109, 127 and 33). This failure could potentially lead to residents' functional decline and contracture (loss of range of motion in a joint) development in a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide enough staff to meet the needs of three of 27 sampled residents (Residents 76, 109, and 129) and eleven unsampled residents (Residents 13, 14, 16, 24, 26, 42, 43, 71, 92, 119 and 192). This failure caused delays in resident care, long waits while residents were soiled, residents missing scheduled sessions with Restorative Nursing Assistants, missed showers, missed medication, and caused residents to be cared for by staff who were, irritated, and threatening.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards of food safety, (1) when the hand washing station, used by dietary staff in the kitchen, lacked soap and paper towels and, (2) when one of the two ice machines, used to supply ice to the kitchen and the residents, was stored in a room with spider webs and a spider. These failures had the potential for food not to be prepared and served to residents in a sanitary manner, resulting in gastrointestinal illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly, when there was kitchen trash scattered on the ground behind the trash disposal bins. This failure had the potential to attract pests to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. Residents and staff in the common room did not maintain six feet distance from each other while not wearing masks; 2. A staff member passing lunch trays did not perform hand hygiene; 3. One out of two residents sampled for tube feeding did not have a label on their tube feeding set; and, 4. Staff failed to ensure visitors complied with Transmission-based Precautions, when four out of five visitors were not wearing gowns properly in residents' rooms in the Yellow Zone (designated area to quarantine newly-admitted residents to rule out COVID-19). These failures could potentially spread infectious agents, including SARS-COV-2, throughout a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a functioning call system, when three of 27 sampled residents and two unsampled residents (Sampled Residents 109 and 129) and Unsampled Residents 13, 14 and 71) stated their call lights were not functioning properly. This failure caused delays in meeting residents' needs and one resident to feel hopeless.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, and comfortable environment for ten residents: (1) when the bed light string for Resident 295 was broken, (2) the window blinds in Resident 19's room were broken and bent, (3) the window screens in the rooms and bathroom of Residents 19, 39, 73, 98, 99, 133, 293, 294, 295 and 296, were not properly fitted to the window frames, with gaps through which insects and pests could enter facility and resident rooms. These failures prevented the residents from having a safe, functional, and comfortable environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to inform two of three reviewed residents (Resident 43 and Resident 13), that Medicare would not pay for other items or services, the facility offered, that the resident would be required to pay for. This failure had the potential to cause confusion and anxiety for patients who did not understand why they were charged for services they expected Medicare to pay.

Inspectors wroteBased on interview and record review, the facility failed to create a baseline care plan within 48 hours of admission, for one of two residents at risk for pressure ulcers (Resident 54). This failure had the potential for Resident 54 not to receive treatment and care to prevent pressure ulcers. One week after admission, Resident 54 developed a Stage 2 Pressure Ulcer.

Inspectors wroteOn 05/06/21 at 3:03 PM, a review of Resident 76's pain medication orders, pain assessment records and care plans was done with the Director of Nursing (DON). Reviewed records showed there were no changes in the physician orders. Pain assessments prior to scheduled pain medication administration were documented, but there were no pain assessments after medication administration of scheduled and as needed pain medications. The Progress Notes of Nurse J were reviewed. No documentation of pain assessments on her shift report could be found. There was also no mention of calling the ordering physician to request resumption of a discontinued medication as was mentioned by the Administrator on 5/5/21. The DON could not find any other documentation of pain assessment after pain medication administration. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer two sampled residents (Residents 109 and 43) and three unsampled residents (Residents 119, 122, and 108) a choice of an alternate meal when they did not want to eat what they were served on their tray. This failure could potentially affect residents' nutritional status or quality of life.