Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Marin Health & Wellness Center during CMS and state inspections, most recent first.
The facility failed to send a required copy of a facility-initiated discharge notice to the State LTC Ombudsman at the same time it notified a resident’s representative. The resident’s spouse received written notice on the day the resident was expected to leave, but facility records showed the Ombudsman was not faxed the notice until 22 days after the discharge. The SSD, who was responsible for sending such notices, acknowledged that the Ombudsman should have been notified before the discharge. The facility’s own P&P required that a copy of any transfer or discharge notice be sent to the State LTC Ombudsman before the transfer or discharge, but this was not done in this case, and the family reported they had not requested the discharge and wanted the resident to remain.
A resident with chronic pulmonary embolism and atrial fibrillation had a physician’s order for daily rivaroxaban, but nursing staff failed to reorder the medication when the bubble pack indicated a low supply, resulting in the drug being unavailable and not administered on a scheduled day. The MAR reflected the missed dose due to unavailability, and an LPN confirmed the supply had run out and was not available in the E-Kit, requiring the resident to wait for the next pharmacy delivery. The DON stated nurses were responsible for reordering when the bubble pack turned blue and that facility policies required timely reordering and administration of medications as prescribed.
The facility failed to ensure medication carts and the medication room were free of expired medications and supplies. Expired Latanoprost was found in a medication cart, and the medication room contained expired syringes, syringe caps, an insulin syringe, and COVID-19 tests. A medication cart also contained a resident's medication after discharge. The facility's policy requires immediate removal of outdated medications.
The facility failed to follow the prescribed recipe for pureed rice, as observed when a staff member did not add margarine and thickener, using a recipe meant for pureed salads instead. This was confirmed by the staff and acknowledged by the RD and DM, who stressed the importance of following recipes to ensure consistent meal quality and nutritional value.
The facility failed to serve food that was palatable, attractive, and at an appetizing temperature. Observations revealed that food temperatures were below policy requirements, and the food was unappealing and bland. Residents confirmed the food was dry and tasteless, and the dietary manager acknowledged the deficiencies.
The facility failed to properly label and date food items, including a pitcher of tea and vegan chicken nuggets, and did not separate a dented can of vanilla pudding from intact cans. These oversights, confirmed by the dietary manager and registered dietician, posed potential health risks to residents due to the possibility of serving expired or contaminated food.
A facility failed to follow its policy on labeling food items brought by family or visitors, as a resident's refrigerator contained six unlabeled food containers. Staff, including LNs, the IP, and the DON, confirmed the oversight, emphasizing the importance of labeling to prevent serving spoiled food. The resident had a history of hypertension and hyperlipidemia, highlighting the need for strict food safety measures.
The facility failed to maintain proper infection control practices, including processing soiled linens at the correct temperature, ensuring hand hygiene before meals, and adhering to enhanced barrier precautions for a resident with MRSA. Additionally, kitchen utensils were stored wet, increasing the risk of bacterial growth.
A facility failed to provide hot water in shared bathrooms of certain rooms, with temperatures below the required 105 degrees. A resident reported inconvenience and safety concerns due to the cold water, which could deter handwashing and increase infection risk. Staff confirmed the issue, and observations verified the deficiency, with water temperatures recorded between 84 and 87 degrees.
The facility's ineffective pest control program resulted in flies being present, posing health risks to residents. Flies were observed landing on food and residents, with staff acknowledging the potential for disease spread. Two residents with moderate cognitive impairment were notably affected, with flies landing on their food and clothing. The facility's pest control policy was outdated, and staff confirmed the health risks associated with the presence of flies.
Two LNs in an LTC facility failed to follow professional standards, leading to potential medication errors and inaccurate blood glucose tests. One LN left medications at a resident's bedside without a physician's order, allowing the resident's wife to administer them, contrary to facility policy. Another LN did not follow protocol when performing a blood glucose check, using the first drop of blood after cleaning with alcohol, which may alter test results.
A resident with COPD and muscle weakness, identified as high risk for falls, experienced four falls over ten months due to inadequate supervision and ineffective interventions. Despite being at high risk, the facility did not increase supervision or implement new preventive measures after each fall, as revealed by interviews with the DON and a CNA. The facility's falls management policy was not effectively followed.
A resident with dysphagia was given ice chips by a CNA, contrary to the prescribed dysphagia diet of puree food and honey-thick liquids. The CNA was not informed of the resident's dietary changes, leading to a potential risk of aspiration pneumonia. The facility's RD and DON confirmed the importance of adhering to diet orders, and the attending physician expected compliance with care plans.
The facility failed to report allegations of a staff-to-resident verbal altercation and an incident between two residents within the required two-hour timeframe. These delays in reporting were confirmed during a review of records and interviews with the Administrator and DON, risking physical, mental, or psychosocial harm to the residents involved.
Failure to Timely Notify State LTC Ombudsman of Facility-Initiated Discharge
Penalty
Summary
The facility failed to provide a timely notice of discharge to the Office of the State Long-Term Care Ombudsman for one resident. A written Notice of Transfer or Discharge for Resident 1, dated 10/21/25, showed that the resident’s spouse received the discharge notice on the same day the resident was expected to leave the facility. The notice itself stated that the facility must send a copy of the notice to a representative of the Office of the Long-Term Care Ombudsman. Facility records, including a fax transmission report, showed that the notice was not sent to the Office of the State Long-Term Care Ombudsman until 11/11/25 at 10:01 a.m., which was 22 days after the resident had been discharged. During interviews, the Social Services Director (SSD) acknowledged responsibility for sending transfer or discharge notices to the Ombudsman at the time of this event and confirmed that Resident 1’s discharge was facility-initiated. The SSD also stated she understood that the Ombudsman advocates for residents and that the notice should have been sent before the resident’s discharge. In a separate interview, Resident 1’s family member reported that the family did not request the discharge and wanted the resident to remain at the facility. The facility’s policy and procedure titled “Transfer or Discharge Notice,” dated December 2016, required that a copy of the transfer or discharge notice be sent to the Office of the State Long-Term Care Ombudsman, with notice to be provided as soon as practicable but before the transfer or discharge under certain circumstances. This policy requirement was not followed for Resident 1.
Failure to Reorder and Administer Anticoagulant as Prescribed
Penalty
Summary
The facility failed to ensure that licensed nurses administered a significant medication as ordered for one resident when they did not reorder the medication before the supply ran out. The resident was admitted with diagnoses including wedge compression fracture, chronic pulmonary embolism, atrial fibrillation, and muscle weakness, and had a physician’s order for rivaroxaban 15 mg orally once daily for thromboembolism related to chronic atrial fibrillation. Review of the October 2025 Medication Administration Record showed that on 10/15/25 the rivaroxaban dose was marked with the number 8, which staff stated indicated the medication was not available to be administered that day. During interviews, a licensed nurse reported that on 10/15/25 she did not administer the rivaroxaban because the supply had run out and, if the medication was not available in the emergency medication supply kit, the resident had to wait until the next day for the pharmacy delivery. The DON explained that the medication bubble pack background turned blue at medication number 4 to indicate the supply was low and needed to be reordered, and that nurses were responsible for reordering medications when the supply became low. Facility pharmacy policy required medications to be reordered five days in advance of need to ensure an adequate supply, and the general medication administration policy required medications to be administered safely, in a timely manner, and as prescribed. These policies were not followed, resulting in the missed dose of rivaroxaban on 10/15/25.
Expired Medications and Supplies Found in Facility
Penalty
Summary
The facility failed to ensure that medication carts and the medication room were free of expired and outdated medications and medical supplies. During an observation, a medication cart for Station 2 was found to contain Latanoprost 0.005% with an expiration date of 11/15/24, which was confirmed by a Licensed Nurse (LN) F. The nurse stated that the Infection Preventionist and Director of Staff Development were responsible for weekly checks of the medication carts for expired medications. Additionally, the Director of Nursing (DON) confirmed the presence of more than 10 expired syringes and syringe caps, as well as an expired insulin syringe and COVID-19 tests in the medication room. Further observations revealed that a medication cart for Station 3 contained a bottle of collagen tablets belonging to a resident who had been discharged a week prior. The Director of Staff Development stated that Licensed Nurses were responsible for checking their assigned medication carts for expired medications, while the central supply department was tasked with checking the medication room once a month. The facility's policy on medication storage, last revised in April 2008, indicated that outdated or deteriorated medications should be immediately removed from stock and disposed of according to procedures.
Failure to Follow Pureed Rice Recipe
Penalty
Summary
The facility failed to adhere to the prescribed recipe for pureed rice, which is a critical component of ensuring that residents receive meals that meet their nutritional needs. During an observation, it was noted that a staff member did not add margarine and thickener to the pureed rice as required by the recipe. This deviation from the recipe was confirmed during an interview with the staff member, who admitted to using the wrong recipe intended for pureed salads instead of the one for pureed rice. The Registered Dietician and Dietary Manager both emphasized the importance of following recipes to maintain consistent quality and nutritional value of meals served to residents. The facility's policy and procedure on food preparation mandates the use of approved and standardized recipes to meet the dietary needs of residents. However, the staff's failure to follow the correct recipe for pureed rice could lead to inconsistent meal quality and potential nutritional deficiencies for the residents. The Dietary Manager acknowledged that using the incorrect recipe could result in improper portion control and meals not meeting the dietary requirements of the residents.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that residents were served food that was palatable, attractive, and at an appetizing temperature, as observed during a survey. The dietary manager (DM) did not sample the food prepared, and the food served was found to be unappealing and unappetizing. The temperatures of the food items on the test tray were below the facility's policy requirements, with rice and chicken at 130 degrees and a burger patty at 118 degrees, while the policy required hot foods to be held at 140 degrees or above. The chicken with lemon and thyme was described as dry and bland, lacking the taste of lemon, and both the rice and chicken were lukewarm when sampled. Interviews with residents confirmed the observations, with one resident stating that the chicken was dry and lacked flavor, and another resident describing the chicken as dry as straw and tasteless. Both residents noted that the food was lukewarm upon receipt. The DM acknowledged that the food temperatures were not appetizing and verified that the food did not appear appealing. The facility's policy and procedure for food preparation emphasized the importance of conserving nutritive value, flavor, and appearance, and required that prepared food be sampled to ensure satisfactory flavor and consistency.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in their storage areas, which could lead to potential health risks for residents. During an observation, it was noted that a pitcher of tea in the refrigerator was not discarded by its use-by date, and a bag of vegan chicken nuggets in the freezer was not labeled or dated. The dietary manager confirmed these oversights and acknowledged the potential risks of serving expired or unidentified food items, which could lead to allergic reactions or gastrointestinal illnesses among residents. Additionally, the facility did not separate a dented can of vanilla pudding from intact cans, posing a risk of bacterial contamination. The dietary manager and registered dietician both confirmed that dented cans should be stored separately to prevent accidental use, as they could harbor bacteria that might cause illness if consumed by residents. The facility's policy requires proper storage and labeling of food items, including the separation of dented cans, but these procedures were not followed. Interviews with staff, including the registered dietician and another staff member, reiterated the importance of labeling and dating food items to ensure the safety and dietary compliance for residents. The failure to adhere to these protocols was identified as a safety risk, as it could lead to the consumption of spoiled or inappropriate food items, potentially causing health issues for the residents.
Failure to Label Food Items Brought by Family
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling of food items brought by family or visitors for residents. During an observation, it was noted that a resident's refrigerator by the nursing station contained six food containers, including chilis, meatloaf, egg salad, and potato salads, none of which had a use-by date as required by the facility's policy. This policy mandates that all containers be labeled with the resident's name, the item, and the use-by date to ensure food safety and prevent the consumption of spoiled food. Multiple staff members, including licensed nurses, the Infection Preventionist, and the Director of Nursing, confirmed that the policy was not followed. They acknowledged the importance of labeling food with a use-by date to prevent serving spoiled food, which could lead to foodborne illnesses. The resident involved had a medical history of essential hypertension and hyperlipidemia, which underscores the importance of maintaining strict food safety standards to protect their health and well-being.
Infection Control Deficiencies in Linen Processing, Hand Hygiene, and Barrier Precautions
Penalty
Summary
The facility failed to properly process soiled linens, as observed during a survey where the washing machine's temperature gauge was malfunctioning, showing 0 degrees Fahrenheit instead of the required 160 degrees Fahrenheit. The laundry staff did not maintain a log of washing machine temperatures, and the facility's policy required washing linens at a minimum of 160 degrees Fahrenheit for high-temperature processing. This failure to maintain proper washing temperatures could lead to the spread of infections due to inadequately sanitized linens. The facility also failed to ensure proper hand hygiene practices among staff and residents. Several residents were not offered or reminded to perform hand hygiene before meals, and a dietary staff member did not perform hand hygiene before donning new gloves. The facility's policy required hand hygiene before and after eating and before donning gloves, but these practices were not consistently followed, increasing the risk of infection transmission. Additionally, the facility did not adhere to enhanced barrier precautions for a resident with a history of MRSA. Staff members were observed not wearing the required gowns and gloves while in close contact with the resident, despite the facility's policy and posted notices indicating the need for such precautions. Furthermore, kitchen utensils were stored while still wet, contrary to best practices that require air drying to prevent bacterial growth. These failures collectively posed a risk of infection transmission to residents.
Deficiency in Hot Water Availability in Shared Bathrooms
Penalty
Summary
The facility failed to ensure that hot water was available in the shared bathrooms of rooms 26-28 and 27-29, with water temperatures recorded below the required 105 degrees. This deficiency was observed over a period of more than a week, during which Resident 48, who was cognitively intact and had conditions such as essential hypertension and anxiety disorder, reported the inconvenience and unpleasantness of using cold water for handwashing. The resident expressed concerns about the safety hazard posed by the lack of hot water, which could deter residents from washing their hands and potentially lead to the spread of infections. Interviews with staff, including a CNA, LN, and the DON, confirmed the absence of hot water and highlighted the importance of having hot water available to encourage proper hand hygiene and prevent infections. The DON and other staff members acknowledged the risk of infection transmission due to inadequate handwashing facilities. Observations by the surveyor and the ADM further verified the insufficient water temperatures, which were significantly below the facility's policy requirement of at least 105 degrees, with recorded temperatures of 84 to 87 degrees.
Ineffective Pest Control Program Leads to Health Risks
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies within the facility, which posed a health risk to residents. Observations and interviews revealed that flies were seen landing on food and residents, which could potentially spread diseases. Specifically, a fly was observed landing on the rim of a cup of pudding belonging to a resident with moderate cognitive impairment and a history of sepsis. This incident was verified by multiple staff members, including a Licensed Nurse, Registered Dietician, Dietary Manager, Infection Preventionist, and Director of Nursing, all of whom acknowledged the health risks associated with flies in the facility. Another resident, also with moderate cognitive impairment and medical diagnoses including COPD and diabetes, was observed with flies on his clothing and hair on multiple occasions. The resident reported that the issue with flies was ongoing. The facility's pest control policy, last revised in 2008, was reviewed, indicating an ongoing pest control program, yet the presence of flies suggests the program was ineffective. The staff, including the Infection Preventionist, acknowledged that flies could spread germs and cause infection control issues.
Failure to Follow Medication and Blood Glucose Testing Protocols
Penalty
Summary
The facility failed to ensure that two licensed nurses adhered to professional standards of practice, resulting in potential medication administration errors and inaccurate blood glucose tests. Licensed Nurse H left medications, specifically Atorvastatin and Melatonin, at Resident 67's bedside without a physician's order, allowing the resident's wife to administer them. This practice was not authorized by the attending physician and was contrary to the facility's medication administration policy, which requires medications to be administered by licensed personnel and within a specific time frame. The medications were administered more than an hour before the scheduled time, indicating a daily medication administration error when the wife was present. Licensed Nurse O did not follow the facility's policy when performing a blood glucose check for Resident 170. The nurse used an alcohol wipe to clean the resident's finger and did not allow it to dry before obtaining a blood sample, using the first drop of blood for the test. This action was against the facility's policy, which states that the first drop should be discarded if alcohol is used, as it may alter the test results. The care plan for Resident 170 did not specify the steps for obtaining a blood sample or indicate that the resident was difficult to bleed, which contributed to the nurse's decision to use the first drop of blood.
Inadequate Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement adequate interventions and supervision to prevent falls for a resident, identified as Resident 21, who experienced four falls over a ten-month period. Resident 21 was admitted with medical diagnoses including Chronic Obstructive Pulmonary Disease and muscle weakness, and was assessed to have moderately impaired cognition. Despite being identified as high risk for falls through the Morse Fall Risk Screen, the facility did not increase supervision or implement effective interventions after each fall. The first fall occurred when Resident 21 was found on the bathroom floor, unwitnessed, with no injury. The care plan was updated to include continued physical and occupational therapy and assistance during toileting, but supervision was not increased. The second fall happened outside the facility, resulting in minor injuries, and the care plan was revised to remind the resident to have a companion when leaving the facility. However, there was no documentation that this intervention was consistently communicated to or implemented by the staff. The third fall was assisted by a CNA while the resident was standing next to the bed, and the care plan was revised without adding new preventive interventions. The fourth fall was unwitnessed, resulting in a minor injury, and the care plan was updated to ensure items were within reach, but supervision was not increased. Interviews with the DON and a CNA revealed inconsistencies in the understanding and implementation of fall prevention measures, and the facility's policy on falls management was not effectively followed, as evidenced by the lack of increased supervision and new interventions after each fall.
Failure to Follow Dysphagia Diet Orders
Penalty
Summary
The facility failed to provide care in accordance with a resident's comprehensive person-centered care plan and physician's orders. The resident, who had a medical diagnosis of dysphagia, was given ice chips by a Certified Nursing Assistant (CNA), despite being on a prescribed dysphagia diet with specific food and liquid consistencies. The resident had been discharged from the hospital with a history of recurrent aspiration pneumonia and was ordered to follow a Level 4 puree diet with Level 3 honey-thick liquids. The CNA admitted to giving the resident ice chips, which are classified as transitional foods, after not being informed of the resident's updated dietary restrictions. Interviews with facility staff, including the Registered Dietitian (RD) and Director of Nursing (DON), revealed that the CNA was not informed of the resident's dietary changes. The RD confirmed that ice chips do not meet the honey-thick consistency requirement and could lead to aspiration pneumonia. The DON stated that it was the responsibility of the nurse in charge to communicate any changes in diet orders to the CNAs. The attending physician also expected the facility staff to adhere to the prescribed care plans and diet orders. The facility's policy on therapeutic diets emphasizes the importance of following physician-prescribed diets to support the resident's treatment and care plan.
Failure to Timely Report Allegations of Abuse and Resident Incidents
Penalty
Summary
The facility failed to report allegations of a staff-to-resident verbal altercation and an incident between two residents within the required two-hour timeframe. Specifically, an incident between a Certified Nursing Assistant (CNA) and a resident occurred on 3/10/24 at 3:00 PM, but the report was not sent to the Department until 3/11/24 at 0:34 AM. Additionally, an incident between two residents occurred on 3/9/24 at 3:00 AM, but the report was not sent until 3/9/24 at 9:39 AM. These delays in reporting were confirmed during a review of records and interviews with the Administrator and Director of Nursing (DON) on 3/18/24 at 10:42 AM. The facility's policy, effective 1/1/24, mandates that all allegations of abuse be reported to the appropriate agencies within two hours. The Director of Nursing (DON) acknowledged that the incidents were reported late, with one incident being reported by a CNA to a Licensed Nurse at 5:00 AM, who then sent the report. The failure to report these incidents promptly had the potential to prevent timely investigation and correction, thereby risking physical, mental, or psychosocial harm to the residents involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Greenbrae
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Tamalpais | 0.6 mi | — | 20 | 0 |
| San Rafael Healthcare & Wellness Center, Lp | 2.1 mi | — | 1 | 0 |
| The Redwoods, A Community Of Seniors | 3.5 mi | — | 0 | 0 |
| Villa Marin | 4.1 mi | — | 11 | 0 |
| Marin Post Acute | 4.2 mi | — | 24 | 0 |
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