Marin Post Acute

In the surveyor’s words

From the most serious findings on record at Marin Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 8, 2026

  Based 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. […]

• Actual harm, isolatedF689May 16, 2022

  Based on interview and record review, the facility failed to initiate effective interventions and supervision to keep one of three sampled residents (Resident 1) safe, when: 1) Resident 1 was admitted to the facility at high risk for falls, and no high fall risk interventions, nor supervision, were initiated to keep her free from falls at the facility. This caused Resident 1 to suffer a fall with injury hours after she was admitted , and; 2) After Resident 1's fall at the facility, she started to exhibit symptoms of decline, and although these symptoms were observed by the Licensed Nurse A, assigned to her care, he failed to notify the physician immediately. […]

• Actual harm, isolatedF686May 7, 2021

  Based 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. Findings: A review of Resident 54's Admission Record indicated she was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 54's Admission Record did not indicate a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review on Resident 54's record indicated, on 12/8/20, the day after admission, the facility assessed Resident 54's risk for pressure ulcers using the Braden Scale (a standardized tool for predicting a patient's risk for developing pressure ulcers). […]

• Actual harm, isolatedF697May 7, 2021

  Based 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. Findings: During observation in Resident 76's room and concurrent interview on 05/04/21 at 9:14 AM, Resident 76 was seated on his bed hunched over and grimacing in pain. He slowly and agonizingly stated, in a low faint voice, he had pain on his whole right side of the body. […]

• No harm, potential for more than minimal, widespreadF850Mar 13, 2025

  Based 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. Findings: A review of the facility's license, dated 2/3/25 to 5/31/25, indicated the facility had 168 beds. During an interview on 3/13/25 at 11:11 a.m., the Human Resource Director (HRD) stated Social Services Director A (SSD A) worked on Unit One and Social Services Director B (SSD B) worked on Unit Two. […]