Marin Post Acute: Resident Hit With Hanger - CA
The incident, documented in a complaint inspection conducted on August 12, 2025, resulted in a citation against the facility for failing to protect a resident from physical abuse by another resident. Inspectors reviewed records, interviewed the two residents involved, and spoke with the Social Services Director, a licensed nurse, and the Director of Nursing. Every one of them confirmed what had happened. None of them disputed it was abuse.
The man, identified in inspection records only as Resident 1, was admitted to Marin Post Acute in May 2025 with severe obesity and is confined to his bed. A federally mandated assessment completed in June 2025 documented that he has severe cognitive impairment. He cannot leave his room on his own. He cannot get up.
The woman who entered his room, identified as Resident 2, was admitted to the facility in February 2025 with a diagnosis of Parkinson's disease, a progressive neurological condition that causes tremor, muscular rigidity, and slow, imprecise movement. Her own assessment indicated she had moderate cognitive impairment.
According to a Social Services note dated July 25, 2025, Resident 2 told the Social Services Director that the day before, she had gone into Resident 1's room carrying a hanger and hit him with it. She said she did it because she was upset with his yelling.
He confirmed it himself.
The Social Services Director spoke with Resident 1 on the same day, July 25, and Resident 1 told him a female resident had entered his room and hit him. A licensed nurse, identified in the report as Licensed Nurse 1, assessed Resident 1 that day and found two scratches, each measuring about one centimeter, on his left cheek. She confirmed in an interview with inspectors on August 12 that the scratches were new injuries, ones he had not had before.
When inspectors sat down with Resident 1 on August 12 at 11:44 in the morning, he told them the same thing he had told staff weeks earlier: a female resident had come into his room and struck him in the face with a hanger. He said he had a couple of scratches on his face. He could not remember her name, and he said it was a while back.
Forty-five minutes later, at 12:17 p.m., inspectors spoke with Resident 2. She acknowledged she had entered Resident 1's room with a hanger.
The Social Services Director, interviewed at 12:50 p.m., told inspectors that Resident 2 had reported the incident to him. He agreed it was the facility's responsibility to protect residents from other residents. He agreed that being hit with a hanger was abusive.
The Director of Nursing, interviewed at 4:11 p.m., said she was aware of the incident. She agreed Resident 1 had been physically abused by Resident 2. She agreed it was the facility's responsibility to protect residents from all types of abuse.
What the inspection report does not document is what the facility did, after July 25, to make sure it would not happen again.
The facility's own abuse prevention policy, dated 2001, states that residents have the right to be free from abuse, including physical abuse. A bedridden man with severe cognitive impairment was struck in the face with a hanger by another resident. Two people with cognitive impairments were living in close enough proximity that one could walk, uninvited, into the other's room. The facility's nursing director knew. The Social Services Director knew. The licensed nurse who found the scratches knew.
The inspection was triggered by a complaint, not by the facility's own reporting up a regulatory chain that resulted in scrutiny. Inspectors arrived on August 12, more than two weeks after the July 24 incident. The citation covers one of four residents whose records were sampled during the inspection.
Resident 1 is bedridden. He cannot leave. He depends entirely on the staff and the structure of the facility to keep him safe from harm. On or around July 24, that structure failed him. A woman came through his door with a hanger and hit him in the face, and he was left with scratches on his cheek and, weeks later, telling a federal inspector that it happened a while back and he couldn't quite remember her name.
The facility's abuse policy has been on the books since 2001. It did not prevent this.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marin Post Acute from 2025-08-12 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
MARIN POST ACUTE in SAN RAFAEL, CA was cited for violations during a health inspection on August 12, 2025.
Every one of them confirmed what had happened.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.