South Marin Health & Wellness Center

Inspectors wroteBased on interviews and record reviews, the facility failed to send a notice of discharge to the Office of the State Long-Term Care Ombudsman (an independent, impartial official that mediates complaints in the long-term care setting) at the same time the notice was given to one resident (Resident 1) of three sampled residents. This failure decreased the facility's potential to ensure Resident 1 was not unsafely discharged .

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure licensed nurses administered significant medication (a medication that increased the risk of harm when not taken) to one resident (Resident 1) of three sampled residents on 10/15/25 because they did not reorder the medication prior to it running out. This failure decreased the facility's potential to ensure Resident 1 received medication as ordered and decreased Resident 1's risk of developing a blood clot.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the dignity of three sampled residents (Resident 27, Resident 76 and Resident 52), when the residents reported missing clothing and personal items to the facility and the facility did not respond according to their Facility Policy and Procedure for Theft and Loss. This failure to follow their Policy and Procedure for theft and loss resulted in a loss of dignity and respect for the residents when they did not have access to clothing from home that felt familiar as well as personal item that were important to their day-to-day life in the facility. During an observation at the nurses' station, on 12/3/25 at 12:42 p.m., a binder titled THEFT /LOSS / GRIEVANCE, not dated, indicated there were no completed documents or forms for any residents. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to follow the physician's orders for three out of three sampled residents (Residents 11, 63 and 68) when: 1. Residents 11 and 63 did not received their insulin before meals as ordered. 2. Resident 68 received pain medication that was ordered to relieve mild pain only when Resident 68 was complaining of severe pain. This failure could result in:1. Inappropriate Diabetes management, which could result in blood sugar spike (hyperglycemia) followed by a potential delayed low blood sugar (hypoglycemia) several hours later. 2. increased pain and suffering.

Inspectors wroteBased on observations, interviews and record reviews, the facility:A. did not implement Enhanced Barrier Protection (EBP, an infection control intervention, primarily used in nursing homes, that involve the use of gowns and gloves during high-contact resident care activities to reduce the transmission of Multidrug-Resistant Organisms (MDROs, microorganisms, primarily bacteria, that are resistant to one or more classes of antimicrobial agents) ) for one out of three sampled residents (Resident 53) when Resident 53s surgical thoracic wound was treated using Negative Pressure Wound Therapy (NPWT/wound vac, a treatment that uses a sealed dressing, connected to a vacuum pump to apply continuous or intermittent suction to a wound). B. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an antibiotic use protocol in addition to a system to effectively monitor the use of antibiotics. This failure can result in inappropriate use of antibiotics that can lead to the development of antibiotic-resistant organisms, difficulty treating infections and severe health complications.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident's code status (defines what life-sustaining treatments (like CPR (cardiopulmonary resuscitation), intubation, shocks) a medical team should provide if a patient's heart stops or they stop breathing, guiding emergency care to match the patient's wishes) was accurately clarified, consistently documented, and incorporated into the resident's goals of care for one of six residents sampled for Advance Directives (Resident #5). This failure resulted in conflicting information regarding Resident #5's code status and had the potential to result in the resuscitation of a resident who wished to have a natural death. [...]

Inspectors wroteBased on interview and records review, the facility failed to provide a copy of the notice of discharge to the Office of the State Long-Term Care Ombudsman for one (Resident 74) of three sampled discharged residents. This failure had the potential for inappropriate and unsafe discharge and deprived Resident 74 of access to an advocate who can provide information of her options and rights.

Inspectors wroteBased on interview and records review, the facility failed to develop a plan of care to prevent the development of a pressure ulcer on one (Resident 24) of 19 sampled residents when Resident 24 developed pressure ulceration under the oxygen tubing over his left ear. This failure led to staff not having an individualized plan to follow to regularly monitor and ensure the oxygen tubing with ear protector is kept in place to prevent skin ulceration.

Inspectors wroteBased on observation, interview and records review, the facility failed to monitor and ensure proper placement of oxygen tubing and ear protector to prevent the development of pressure ulcer on one (Resident 24) of 19 sampled residents. This failure led to Resident 24 developing a pressure ulcer behind his left ear from oxygen cannula tubing pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly administer tube feeding to one of one resident sampled for tube feeding (Resident #8) when Resident #8 was found laying flat during tube feeding administration. This failure had the potential to result in aspiration (inhaling foreign substances like food, liquids, saliva, or stomach contents into the lungs, which can lead to pneumonia, a lung infection) of the tube feeding formula, difficulty breathing, aspiration pneumonia, and hospitalization. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure two out of four sampled residents' (Residents 5 and 68) pain was adequately and timely addressed. These failures left Resident 5 distressed, tearful, feeling like she was dying and experiencing 12/10 (Twelve out of Ten), severe pain for 30 minutes before receiving her narcotic (strong but addictive pain medicine) pain medication and Resident 68 feeling frustrated and enduring pain while having to wait for over an hour to receive his routine narcotic medication.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure:only medications that were prescribed by the physician were administered for two out of four sampled residents (Residents 2 and 45). 2. two out of four sampled residents (Residents 2 and 45) were allowed to keep medications at bedside without safe administration assessment and physician order. These failures had the potential to put residents at high risk for masking of serious medical condition and adverse drug reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three medication carts (Medication cart for Station 2 and medication cart for Station 3), in addition to the medication room, were free of expired and outdated medications and medical supplies for residents. This failure had the potential to result in inadvertently using these products on residents, which could have caused them harm and infections.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to follow the recipe for pureed rice. This failure could lead to potential food safety issues, inconsistent quality of meals for residents, and nutritional deficiencies.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure residents were served with food that was palatable, attractive and at an appetizing temperature. These failures could put the residents at risk for illness, injury, malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things), and poor nutritional status.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure: 1A. two food items in the freezer were clearly labeled to identify what it was, when it was opened and when to discard the food item. 1B. one pitcher of tea was discarded by the use by date of 11/16/24. 2. one dented can (might contain bacteria that can make you sick, or even produce a toxin that can be deadly) was not separated from intact cans. These failures could put the residents at risk for: 1A. allergic reactions, health complications and food poisoning (infection or irritation of your digestive tract that spreads through foods). 1B.consuming tea that might contain bacteria which can cause abdominal pain, vomiting, diarrhea (three or more loose stools per day), and fever. 2. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to follow their policy on foods brought by family/ visitors when the food stored in resident's refrigerator by the nursing station did not have a use by date per their policy. This failure could lead to residents potentially consuming food that has gone past its safe consumption window, increasing the risk of foodborne illness due to bacteria growth, as well as potential issues with food quality and taste deterioration, which could impact resident nutrition and well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Process soiled linens to prevent the spread on infection. 2 A. Offer hand hygiene (HH) to eight of nine residents (Resident 59, Resident 225, Resident 61, Resident 121, Resident 40, Resident 5, Resident 49, and Resident 120) before meals. 2 B. Perform HH prior to donning new gloves by one dietary staff , [NAME] E. 3. Use enhanced barrier precautions (A set of infection control measures that reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) when two nursing assistants working with Resident 33 who had a history of Methicillin-resistant Staphylococcus aureus (MRSA-A type of bacteria resistant to a certain type of antibiotics), did not follow the precautions. 4. Air dry kitchen utensils prior to storing in the kitchen drawers. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure hot water was available for use to the shared bathrooms in rooms (rms) 26-28 and 27-29 when the hot water temperature in these rooms were below 105 degrees. This failure resulted in Resident 48 who was in RM [ROOM NUMBER] complaining of inconvenience and unpleasantness of using cold water to wash her hands for over a week. This failure also put the residents at risk for not washing their hand due to discomfort, residents could then get sick and spread infection (invasion and growth of germs in the body) to others.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to maintain an effective pets control program when flies were observed in the facility, bothering two residents, Resident 38 and Resident 21. This failure posed a health risk to residents as flies carries and spread diseases like food poisoning, salmonella (food poisoning caused by infection (invasion or growth of germs in the body) with the salmonella bacterium), Escherichia coli (E. coli, a sickness you get from the E.coli bacteria that causes a lot of diarrhea (3 or more loose stool per day) related illnesses) and staphylococcus (group of bacteria that causes skin infection). Flies could also contaminate food and could infest (present in large numbers) open wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four Licensed Nurses (Licensed Nurse (LN) H and Licensed Nurse (LN) O ) followed professional standards of practice when: 1. LN H left medications by Resident 67's bedside without a physician order. 2. LN O did not follow facility policy when performing a blood glucose (Blood sugar) check for Resident 170. These failures had the potential to result in medication administration errors and inaccurate blood glucose tests which could have caused harm to the residents involved.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seventeen sampled residents (Resident 21) had intervention and supervision implemented to prevent falls. As a result, Resident 21 sustained four falls with minor injuries (Skin tears and bruises) in a period of ten months. This failure had the potential to result in further falls with injuries for Resident 21.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that one of two sampled residents, Resident 1, received care in accordance with his comprehensive person-centered care plan based on his comprehensive assessment and per his doctor's orders regarding Resident 1's medical diagnosis of dysphagia (difficulty swallowing), when on 5/24/24, Certified Nursing Assistant A (CNA A) offered Resident 1 ice chips (considered as Transitional Food- Food that starts at one texture (e.g. firm solid) and changes into another texture specifically when moisture (e.g. water or saliva) is applied or, when a change in temperature occurs (e.g. heating). This failure had the potential to result in aspiration pneumonia (Aspiration pneumonia occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) to Resident 1. Findings. [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of a staff to resident (Resident 1) verbal altercation, and an incident between residents (Resident 2 and Resident 3) within two hours of the incidents. This failures had the likelihood for incidents of potential abuse to not get prevented, corrected, or investigated in a timely manner, and can result to physical, mental, or psychosocial harm to residents.

Inspectors wroteBased on interview and record review, the facility staff failed to respond to call lights timely when five of 16 sampled residents had to wait up to one hour for staff to respond when residents pressed their call lights for assistance. This failure resulted in residents sitting in soiled briefs.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow up on a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) level 2 referral (determines if mental illness needs of a the individual can be met in a nursing facility) for 1 out of 16 sampled residents (Resident 27) and five unsampled residents (Resident 64, Resident 7, Resident 16, Resident 65 and Resident 66). This failure had the potential risk of Resident 27 missing out on specialized services and obtaining additional resources.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide two of three sampled residents (Resident 8 and Resident 18) scheduled weekly showers, who depended on staff to assist. This failure to provide the necessary care resulted in residents looking unkempt and had the potential for residents having body odors, dry/broken skin not being assessed, and/or an infection, further negatively impacting the resident's physical and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with or at risk for developing pressure ulcers (PUs - injury to skin and underlying tissue resulting from prolonged pressure on the skin caused by staying in one position too long) for two of three sampled residents (Resident 18 and Resident 267) were provided treatment consistent with professional standards to promote healing of a pressure ulcer when Resident 18 and Resident 267 were not being turned and repositioned per the facility's policy/procedure, nursing staff did not document turning and repositioning, inconsistent skin documentation and Resident 18's heels were not being floated (offloading by using pillow(s) under resident's calves) per physician order. [...]

Inspectors wroteBased on interview and record review, the facility's consultant licensed pharmacist failed to detect and report 62 medication errors involving the administration of insulin (a hormone which regulates the amount of glucose in the blood) at bedtime to one of 16 sampled residents (Resident 53). Over a four-month period, from January to April 2022, Resident 53 was administered the wrong dose of bedtime insulin 62 out of 118 nights. The wrong doses were documented in Resident 53's medication administration record. The facility's consultant licensed pharmacist reviewed Resident 53's medication administration record monthly during January and April 2022 but did not detect or report these drug errors. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 53) was free of significant medication errors when Resident 53 received the wrong dose of insulin (a hormone produced in the pancreas which regulates the amount of glucose in the blood) at bedtime 70 times over a period of 130 days from January 2 to May 11, 2022. These failures resulted in Resident 53 receiving up to four times the ordered bedtime dose of insulin during that period, placing Resident 53 at risk of a potentially dangerous drop in blood sugar/hypoglycemia (low blood sugar).

Inspectors wroteBased on observation, interview and record review, the facility failed to employ sufficient dietary personnel when the facility's food and nutrition services was short of one dietary aide and one cook. This failure resulted in the facility's Director of Food Services (DFS) performing the duties of dietary support personnel, such as processing food deliveries, assembling resident lunch trays, and transporting resident food carts, which resulted in perishable foods being left unrefrigerated outdoors and prevented the DFS from managing and overseeing the facility's food and nutrition service.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure residents were aware of the facility's Grievance Process for seven out of 16 residents. This failure had the potential risk of unresolved grievances or concerns.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan with interventions to meet the needs of one of 16 sampled residents (Resident 267) when Resident 267 was assessed to be immobile and at high risk for pressure ulcers and the facility did not include in her care plan the intervention of turning and repositioning Resident 267 every two hours. This failure had the potential for Resident 267 to develop pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow medication safety measures when licensed staff administered twice the ordered dose of a medication to a resident, Resident 57. This failure could potentially lead to further medication errors and cause harm to vulnerable residents.

Inspectors wroteBased on observation, interviews and record review, the facility failed to change the nasal cannula (NC) weekly for one out of 16 sampled residents (Resident 48 ). Staff did not change Resident 48's NC tubing (device used to deliver supplemental oxygen or increased airflow to a patient in need of respiratory help) per the facility's policy policy. This failure had the potential risk of Resident 48 acquiring an infection and or not receiving the correct amount of prescribed oxygen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared and stored in sanitary manner when perishable food intended for residents was left unrefrigerated outdoors for over 1.5 hours and one of four dietary support personnel did not have their hair fully restrained/covered while preparing resident food. These failures created the potential for foodborne illness in a vulnerable resident population and for food to become contaminated and improper for resident consumption.