The nurse, identified as LVN E in inspection records, told federal investigators she noticed Resident #5 had a beige-colored dressing on his arm when he returned to San Rafael Nursing and Rehabilitation on September 17, 2025. She couldn't recall which arm.
But for the next week, she never looked under it.
LVN E worked four to five shifts between September 17 and September 24. On September 17 and 18, she asked to observe what was underneath the bandage but said the resident was "resistant to care."
She stopped asking.
"In hindsight she should have advocated to see what was under the bandage/dressing as not only part of her professional scope of practice but also to ensure there were no negative or immediate concerns for skin irregularities," according to the October 27 inspection report.
The nurse expressed particular concern about Coban dressings, a type of self-adhesive elastic wrap. If applied too tightly, she told inspectors, "there could be a loss of blood circulation, skin irritation, and/or possible wound."
Yet she never verified whether the dressing was cutting off circulation.
LVN E told investigators that Resident #5 "never expressed or exhibited any sign or symptoms of distress or concern." She said she should have conducted a more thorough head-to-toe assessment but that the resident "did not exhibit or express anything of a compromising nature regarding any skin irregularities."
The rationalization continued through her interview. She acknowledged she should have been more assertive when conducting assessments "as a precautionary intervention, to ensure the well-being of all her patients."
Around September 22 — five days after the resident's return — LVN E finally observed "slight redness" to his forearm.
By then, potential damage could have been developing for nearly a week.
The facility's Director of Nursing confirmed during an October 25 interview that LVN E should have completed a thorough head-to-toe assessment when Resident #5 was readmitted. Such assessments, the director explained, "are to ensure there are no concerning skin irregularities and if any skin irregularities are observed, the facility would enact a plan to mitigate any progression of those skin irregularities."
The stakes were significant. The Director of Nursing acknowledged that if the dressing had been too tight or if there was a skin irregularity underneath, "there could be a loss of circulation, a wound progression or formation of infection."
The facility's own clinical protocol, revised in April 2018, required staff to "examine the skin of newly admitted resident for evidence of existing pressure ulcers or other skin conditions."
LVN E had violated basic nursing standards.
Following the incident, San Rafael conducted staff education. On September 25, the facility held an in-service on "Abuse & Neglect; removal of tourniquet/Coban." Three weeks later, on October 17, staff received additional training specifying that "bands are to be removed on all new admissions and readmissions."
The October training included a crucial instruction: "If a resident refuses, make sure the nurse is notified — so it can be documented and care planned."
This represented the solution LVN E had failed to implement. When Resident #5 resisted her attempts to examine the dressing on September 17 and 18, she should have documented his refusal and developed a care plan to address it.
Instead, she simply gave up.
The Director of Nursing told investigators that all staff members had now been "in-serviced and educated regarding the facility's expectation that all clinical nursing staff members are to observe and assess underneath all dressings and Coban dressings as a preventative measure to ensure the well-being and skin integrity of all residents."
The training came after the fact. For Resident #5, it was too late to prevent the week of potential risk he faced with an unexamined dressing that could have been compromising his circulation.
LVN E's admission to investigators revealed the depth of the failure. She acknowledged not only that she should have looked under the bandage as part of her professional duties, but that she should have "advocated in a more assertive manner" for the resident's safety.
The word "advocated" appeared repeatedly in her statements to inspectors — a recognition that her role required her to push past patient resistance when medical necessity demanded it.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. But the case illustrated a broader problem: nursing staff failing to follow basic assessment protocols even when they understood the risks.
The Director of Nursing's final comment to inspectors carried an implicit acknowledgment of what could have happened: while "the well-being of Resident #5 was intact" and there was never concern for his skin integrity, the potential consequences of LVN E's inaction could have been severe.
The facility's response — immediate staff training and revised protocols — suggested management recognized the seriousness of the lapse. But for seven days in September, one resident's safety depended on a nurse who admitted she should have done better.
She just didn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Rafael Nursing and Rehabiliation from 2025-10-27 including all violations, facility responses, and corrective action plans.
Additional Resources
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