Marin Post Acute

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of four sampled residents (Resident 1) when Resident 2 entered his room and struck him with a hanger.This failure had the potential to result in serious physical injury to Resident 1.Findings:A review of Resident 1's admission record indicated he was last admitted in 5/25 with diagnoses of severe obesity and bed confinement.A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), 6/18/25, indicated he had severe cognitive impairment.A review of Resident 1's Social Services note, dated 7/25/25, indicated the Social Services Director (SSD) had spoken to him and he confirmed a female resident had entered his room and hit him.A nursing note, dated 7/25/25 and written by Licensed Nurse 1 (LN 1), indicated Resident 1 had been assessed by her and found to have had two 1-centimeter (cm- a unit of measurement) scratches on his left cheek.A review of Resident 2's admission record indicated she was admitted in 2/25 with the diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).A review of Resident 2's MDS, dated [DATE], indicated she had moderate cognitive impairment.A review of Resident 2's Social Services note, dated 7/25/25, indicated Resident 2 had informed the SSD that on the previous day, she had entered Resident 1's room with a hanger and hit him with it because she was upset with his yelling.

During an interview on 8/12/25 at 11:44 a.m. with Resident 1, Resident 1 stated a female resident had entered his room and struck him in the face with a hanger. Resident 1 could not recall her name and stated it was a while back. Resident 1 stated he had a couple of scratches on his face.

During an interview on 8/12/25 at 12:17 p.m. with Resident 2, Resident 2 acknowledged she had entered Resident 1's room with a hanger.

During an interview on 8/12/25 at 12:50 p.m. with the SSD.

The SSD confirmed Resident 2 had reported the incident with Resident 1 to him, agreed it was the facility's responsibility to protect residents from other residents and being hit with a hanger was abusive.

During an interview on 8/12/25 at 3:28 p.m. with LN 1, LN 1 stated she had completed a head-to-toe assessment on Resident 1 on 7/25/25, found two superficial scratches on his left cheek and confirmed the scratches were new injuries for him.

During an interview on 8/12/25 at 4:11 p.m. with the Director of Nursing (DON), the DON stated she was aware of the incident between Resident 1 and Resident 2.

The DON agreed Resident 1 had been physically abused by Resident 2 and it was the facility's responsibility to protect residents from all types of abuse.During a review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 2001, the policy stipulated, Residents have the right to be free from abuse.This includes.physical abuse.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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