San Rafael Healthcare: Resident Left With Wander Monitor - CA
The resident, identified in inspection records as Resident 1, left the facility on December 10, 2025 for a home visit. He arrived at his responsible party's house still wearing his wander management monitor, the electronic bracelet facilities use to trigger alarms when memory-impaired residents approach exits unsupervised. The next day, in her kitchen, she watched him pick up a pair of scissors and cut it off.
She told inspectors what she saw. The monitor was gone. Nobody from the facility had called to ask about it.
The complaint inspection, conducted December 23, 2025, turned up a straightforward account of what went wrong. A staff member told inspectors he did not hear the wander management monitor alarm. That was the extent of the explanation, at least the part that made it into the record.
The facility's own policy on wandering and elopement, last revised January 31, 2023, says the facility will identify residents at risk for elopement upon admission, in order to enhance the safety of residents. Resident 1 had been identified as exactly that kind of resident. The monitor on his wrist was the evidence. He left wearing it anyway.
A second policy, governing residents going out on a pass, spells out that the resident or their responsible party will verbally notify a licensed nurse before leaving and will sign out on a form called the Resident Out On Pass Log. Whether that happened, and what the log showed, the inspection record does not say. What it does say is that Resident 1 arrived at a private home in an unknown location still tethered, at least nominally, to a safety system his facility was no longer monitoring.
The Centers for Medicare and Medicaid Services classified the harm level as minimal harm or potential for actual harm, and noted that only a few residents were affected. Those classifications carry regulatory weight, but they don't fully capture what the responsible party described: watching an elderly man, apparently cognitively impaired enough to require a wander monitor, calmly pick up scissors and free himself from the device in her kitchen while she looked on.
She didn't say whether she called the facility. The record doesn't say whether the facility called her. What's documented is that the monitor left the building on a resident's wrist, an alarm either didn't sound or wasn't heard, and the facility's awareness of the situation appears to have begun when inspectors arrived thirteen days later.
Wander management monitors are a last line of defense, not a first one. They exist because other safeguards, staff awareness, sign-out procedures, communication between nurses and family, have already failed or aren't sufficient on their own. When a monitor leaves the facility on a resident rather than stopping him at the door, it means every layer above it came apart first.
The responsible party's account is the clearest window into what the inspection found. She wasn't describing a near-miss she learned about secondhand. She was describing something she watched happen in her own home, a man who needed a device to stay safe in a memory care setting, now sitting in a kitchen with scissors, and no one from the facility on the phone asking where the monitor was.
Inspectors rated the deficiency under the federal tag for resident elopement and wandering protections. The facility's census and ownership structure are not detailed in the inspection record. San Rafael Healthcare & Wellness Center, LP operates at 1010 D Street in San Rafael.
The monitor, as of the inspection record, had not been returned to the facility. Whether Resident 1 went back is not documented. What the responsible party saw in that kitchen on December 11th is.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Rafael Healthcare & Wellness Center, Lp from 2025-12-23 including all violations, facility responses, and corrective action plans.
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 24, 2026 · Our methodology
SAN RAFAEL HEALTHCARE & WELLNESS CENTER, LP in SAN RAFAEL, CA was cited for violations during a health inspection on December 23, 2025.
The resident, identified in inspection records as Resident 1, left the facility on December 10, 2025 for a home visit.
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.