Marin Post Acute
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
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 REDACTED], 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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
MARIN POST ACUTE in SAN RAFAEL, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN RAFAEL, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MARIN POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.