Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Redwoods, A Community Of Seniors during CMS and state inspections, most recent first.
A resident with a medically complex condition had conflicting information between their signed POLST form and the MDS assessment, with the MDS indicating full treatment and artificial nutrition while the POLST specified DNR, selective treatment, and no artificial nutrition. The MDS coordinator and DON confirmed the inaccuracy, and it was noted that the facility lacked a policy for MDS assessment completion.
The facility did not establish or maintain an infection prevention and control program, as required, resulting in a lack of systematic measures to prevent, identify, and control infections among residents and staff.
The facility did not provide written notice to the LTC Ombudsman when two residents were transferred to the hospital, as required by policy and regulation. Multiple staff members, including the DSD, Admin, LNs, and SSD, were unaware of the requirement and confirmed that no notifications were made for these transfers.
Two residents at risk for falls in an LTC facility experienced multiple falls due to inadequate supervision and ineffective care plans. One resident suffered two hip fractures, while the other fell seven times in four months. The facility failed to update care plans with appropriate interventions and did not increase supervision, despite the residents' high fall risk.
The facility failed to track mandatory training compliance, resulting in overdue trainings for a licensed nurse and a CNA. Additionally, an unlicensed staff member worked with an expired BLS certification for 4.5 months, and was observed not following infection control protocols. The DSD admitted to not having a system to track certifications, contrary to facility policy.
The facility did not post daily nursing staffing information as required, with the posting from the previous Friday still displayed on Monday. The Staffing Coordinator was responsible for weekday postings, but on weekends, charge nurses were tasked with this duty, which was not consistently fulfilled. This failure contradicted federal regulations requiring daily postings at the beginning of each shift.
The facility did not ensure timely responses to the Pharmacist's Drug Regimen Review reports, affecting all residents receiving medications. Reviews for May and June lacked follow-up, and earlier months showed incomplete documentation. The Consulting Pharmacist had to seek physician responses, and the DON admitted to not following through on recommendations, despite policy requiring action within 30 days.
A resident with dementia and no documented aggression was prescribed Seroquel without proper justification or monitoring. The facility failed to document aggression or attempt non-pharmacological interventions before administering the medication. The prescribing physician did not respond to the pharmacist's recommendation to discontinue Seroquel, and the facility did not adhere to its policy on psychotropic medication use.
The facility failed to maintain proper medication storage conditions, with a refrigerator consistently at 28°F instead of the required 36-46°F, affecting medications for two residents. The medication room door was found propped open, risking unauthorized access, and an expired medication was stored with active ones in a cart. The DSD confirmed these issues, indicating a need for staff education on proper procedures.
A resident with a history of falls and Alzheimer's Disease suffered multiple falls resulting in major injuries due to inaccurate fall risk assessments. The assessments failed to accurately reflect the resident's condition, including her fall history, need for supervision, incontinence, and the number of medications increasing fall risk. This led to inadequate care planning and interventions.
The facility failed to follow its Infection Control and QAPI policies by not tracking chronic UTIs among residents. Licensed Staff A admitted to not maintaining surveillance data, leaving the chronic infections section blank for several months. Specific cases included residents with multiple UTIs, yet no data was captured for root cause analysis, contrary to the facility's policies.
A staff member failed to follow Enhanced Barrier Precautions and Hand Hygiene policies while providing care to a resident who was incontinent of stool. The staff member did not wear an isolation gown or perform hand hygiene after care, despite facility policies requiring these measures for high-contact activities. This lapse was acknowledged by the staff member and confirmed by a licensed staff member, highlighting the risk of infection spread.
The facility failed to provide adequate annual training in abuse and dementia care for three CNAs. Unlicensed Staff N received only one hour of abuse training and no dementia training, while Unlicensed Staff O and P received one hour each of abuse and dementia training. The facility's assessment required at least 12 hours of training annually, but only about 5 hours were provided, as confirmed by the DSD.
A facility failed to document a resident's advance directives and POLST, despite the resident's serious medical conditions. Staff interviews revealed reliance on verbal communication and manual chart checks, which led to the oversight. The facility's policies required documentation of these directives, but they were not followed.
A facility failed to create a resident-centered care plan for a resident with a stage 4 pressure ulcer. The care plan lacked specific treatments ordered by the physician and included only generalized interventions. This deficiency was confirmed by the DSD, highlighting a failure to meet the facility's policy for comprehensive care plans.
Inaccurate MDS Assessment Due to POLST Discrepancy
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a medically complex condition. The resident's MDS assessment, specifically section S which documents Physician Orders for Life-Sustaining Treatment (POLST), indicated that the resident had chosen to receive full treatment, including resuscitation and a trial period of artificial nutrition via feeding tube. However, a review of the resident's signed POLST form revealed that the resident had actually chosen Do Not Resuscitate (DNR), selective treatment, and no artificial means of nutrition, including feeding tubes. This discrepancy was confirmed during interviews with the MDS coordinator and the Director of Nursing (DON), both of whom acknowledged that the MDS assessment did not accurately reflect the resident's documented wishes as indicated on the POLST form. Further investigation revealed that the facility did not have a policy or procedure in place regarding the completion of MDS assessments. The DON confirmed that the information in section S of the MDS should be transcribed directly from the signed POLST form, and that any mismatch would render the MDS assessment inaccurate. The lack of an accurate MDS assessment could result in care and treatment that does not align with the resident's documented preferences. The findings were supported by a review of relevant professional guidance, which emphasized the importance of accurate documentation for MDS accuracy.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection prevention and control measures were not established or maintained as required by regulations. The report specifically notes the absence of a comprehensive program designed to prevent, identify, report, investigate, and control infections and communicable diseases among residents and staff.
Failure to Notify Ombudsman of Resident Transfers to Hospital
Penalty
Summary
The facility failed to provide written notice of transfer to the Long-Term Care Ombudsman for two residents who were transferred to the hospital. Interviews with staff, including the Director of Staff Development, Administrator, Licensed Nurses, and Social Services Director, revealed that none were aware of the requirement to notify the Ombudsman when residents were transferred to the hospital. Staff members confirmed that they had not completed notices of transfer nor notified the Ombudsman in such cases. The Director of Nursing verified that no notice was completed and the Ombudsman was not notified for the two residents transferred to the hospital at the end of March 2025. A review of the facility's policy and procedure indicated that the Ombudsman should be notified in all cases of transfer or discharge, in accordance with regulatory requirements. Additionally, an All Facilities Letter specified that notice must be sent to the local LTC Ombudsman for any transfer or discharge initiated by the facility. Despite these requirements, the facility did not notify the Ombudsman for the two residents transferred to the hospital, as confirmed by staff interviews and record review.
Inadequate Supervision and Care Plan Implementation for Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and implement effective care plans for two residents at risk for falls, leading to multiple incidents. Resident 190, with a history of falls and severe cognitive impairment, suffered three falls within a short period, resulting in two hip fractures. The facility did not create a care plan before the first fall and failed to update the care plan with appropriate interventions after subsequent falls. Despite being at high risk for falls, the supervision for Resident 190 was not increased, and the documentation of staff checks was inconsistent. Resident 34, who was completely dependent on staff for daily activities, experienced seven falls over four months. The facility's care plans for Resident 34 lacked specific interventions to prevent falls and did not increase supervision despite the repeated incidents. Documentation of neurological checks and fall risk assessments was incomplete or missing, and the facility did not revise care plans promptly after each fall. The facility's policies on fall prevention and management were not followed, as evidenced by the lack of adequate supervision and failure to update care plans with effective interventions. The Director of Nursing acknowledged the need for improvement in managing falls, including accurate fall risk assessments and documentation of visual checks. The facility's failure to implement and monitor appropriate interventions contributed to the residents' repeated falls and injuries.
Deficiencies in Staff Training and Competency Tracking
Penalty
Summary
The facility was found to lack a system for tracking staff compliance with mandatory training requirements, leading to overdue trainings for two out of four sampled employees. Specifically, one licensed nurse and one certified nursing assistant (CNA) had not completed their annual mandatory trainings on time. The Director of Staff Development (DSD) confirmed that there was no tracking system in place to ensure these trainings were completed annually, which is a requirement according to the facility's Employee Benefits document and the DSD's job description. Additionally, the facility failed to ensure that a competent Director of Staff Development was in place to enforce training and verify competencies for nursing staff. This was evidenced by the fact that an unlicensed staff member's Basic Life Support (BLS) certification had been expired for 4.5 months while they were working at the facility. The DSD was unaware of this expiration and admitted that it was her responsibility to track current competencies and certifications, not the payroll department as she initially stated. Furthermore, during an observation, the unlicensed staff member was seen providing care without following proper infection control protocols, such as wearing a gown or washing hands after providing care to a resident. This incident, along with the expired BLS certification, highlighted the facility's failure to maintain sufficient and competent staffing as per their policy and procedure, which requires all staff to be appropriately trained and certified to perform their duties.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nursing staffing information was posted in a conspicuous place, as required, on one of the five days surveyed. On 7/08/24, it was observed that the staffing information posted was from the previous Friday, 7/05/24, indicating that the information had not been updated over the weekend. The Director of Staff Development confirmed this finding during an observation and interview, noting that the unit clerk was typically responsible for posting the information daily around 10:00 a.m. Further interviews revealed that the Staffing Coordinator was responsible for creating and posting the daily staffing information on weekdays, usually by 8:30 a.m. However, on weekends, this task was delegated to charge nurses, who did not always post the information if they were busy. The facility's policy required posting within three hours of each shift's start, but this contradicted federal regulations, which mandated daily posting at the beginning of each shift. This discrepancy led to the failure to post updated staffing information on 7/06/24 and 7/07/24, potentially impacting the ability of residents, visitors, and staff to review and advocate for appropriate staffing levels.
Failure to Act on Pharmacist's Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely responses from physicians and the Medical Director to the Pharmacist's Drug Regimen Review (DRR) reports, which are monthly summaries of each resident's medication irregularities. This deficiency was identified during a review of the monthly Drug Regimen Review binder, which revealed that for the months of May and June, there were no follow-up responses to the recommendations made by the Consulting Pharmacist. Additionally, previous months' reports from February, March, and April also showed incomplete documentation of physician responses or follow-through on the pharmacist's recommendations. Interviews conducted with the Consulting Pharmacist and the Director of Nursing (DON) highlighted the lack of timely follow-up and documentation. The Consulting Pharmacist noted that she had to actively seek out physicians for responses, although there had been some improvement with a new Medical Director. The DON acknowledged her oversight responsibility and admitted to not following through with the pharmacist's recommendations. The facility's policy, dated September 2018, requires that recommendations be acted upon within 30 days, but this was not adhered to, placing all residents receiving medications at risk for negative clinical outcomes.
Inappropriate Use of Psychotropic Medication for a Resident
Penalty
Summary
The facility failed to ensure that Resident 16 was free from unnecessary psychotropic drugs, specifically Seroquel, which was prescribed without proper justification or monitoring for aggression. Resident 16 was admitted with dementia without behavioral disturbance and a history of repeated falls. Despite this, she was prescribed Seroquel for aggression, although there was no documentation or evidence of aggressive behavior in her care plans or medical records. The Director of Staff Development (DSD) confirmed the absence of monitoring for aggression and the lack of evidence for other interventions prior to the administration of Seroquel. During observations, Resident 16 was noted to be pleasant and polite, with no signs of aggression. The prescribing physician, Physician R, was unavailable for an interview but indicated via text that Resident 16 had behavioral issues upon admission and suggested a gradual dose reduction. However, the facility's records did not support the presence of aggression, and the pharmacist had recommended discontinuing Seroquel due to the lack of aggression issues, but received no response from the physician. The facility's policy on psychotropic medications requires that such medications be used only when necessary and with proper documentation of the condition being treated. The policy also mandates that physicians respond to feedback from staff regarding medication use. In this case, the facility did not adhere to its policy, as there was no documented need for Seroquel, and the physician did not respond to the pharmacist's recommendation to discontinue the medication.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to maintain the appropriate temperature for a medication refrigerator, which was consistently recorded at around 28 degrees Fahrenheit, below the required range of 36 to 46 degrees Fahrenheit. This issue persisted for several months, as indicated by the temperature logs dating back to December 2023. Medications stored in this refrigerator, including Lorazepam oral liquid for two residents and an emergency medication kit, were potentially compromised due to improper storage conditions. The Director of Staff Development (DSD) confirmed the findings and acknowledged the need for staff education on maintaining correct refrigerator temperatures. Additionally, the medication room door was found propped open and unattended, contrary to the facility's policy requiring it to be locked at all times. This lapse in security could have allowed unauthorized access to medications. Furthermore, an expired medication was discovered in a medication cart used for the south hall, stored alongside active medications. Licensed Staff I confirmed the presence of the expired medication, which was intended for resident use but was rarely utilized. The facility's policy mandates that outdated medications be returned to the pharmacy or destroyed, highlighting a failure to adhere to established procedures.
Inaccurate Fall Risk Assessments Lead to Resident Injuries
Penalty
Summary
The facility failed to maintain accurate medical records for a resident who suffered multiple falls, resulting in major injuries. The resident, who had a history of falling, Alzheimer's Disease, restlessness, and agitation, was inaccurately assessed as being at low risk for falls after a significant fall that resulted in a hip fracture. The fall risk assessment did not reflect the resident's true condition, including her history of falls, need for supervision with ambulation, incontinence, and the number of medications that increased her fall risk. This inaccurate assessment potentially contributed to inadequate care planning and interventions to prevent further falls. The resident experienced a second fall, resulting in another hip fracture. Although the subsequent fall risk assessment correctly identified the resident as high risk, it still inaccurately documented the number of medications increasing fall risk. The facility's policy on medical record documentation emphasizes the need for factual, complete, and accurate entries, which was not adhered to in this case. The Director of Nursing confirmed the inaccuracies in the fall risk assessments during a review of the resident's records.
Failure to Track and Surveil Chronic UTIs
Penalty
Summary
The facility failed to adhere to its Infection Control and QAPI policies by not tracking and surveilling data for residents with chronic urinary tract infections (UTIs). This deficiency was identified through interviews, observations, and record reviews. Licensed Staff A admitted to not tracking chronic UTIs, which is a critical component of the facility's infection control and QAPI processes. The lack of tracking and surveillance was confirmed during a review of the Infection Control Surveillance Report Tool, where the section for chronic infections was left blank for several months. This oversight was further highlighted by the absence of data for root cause analysis during QAPI and IDT conferences. Specific cases of residents with multiple UTIs were noted, including a resident who experienced three UTIs within three months and another resident with two UTIs in two months. Despite these occurrences, the facility did not capture or analyze data to investigate the root causes of these chronic infections. The facility's policies, including the Infection Control Plan and the QAPI program, emphasize the importance of systematic surveillance and data-driven quality improvement efforts, which were not followed in this instance.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Policies
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions and Hand Hygiene policies, as observed during a survey. A staff member, identified as Unlicensed Staff F, was seen providing hygiene care to a resident who was incontinent of stool without wearing the required isolation gown. This occurred despite the presence of an Enhanced Barrier Isolation Cart outside the resident's room, which contained the necessary personal protective equipment (PPE) such as gloves, masks, and gowns. Furthermore, Unlicensed Staff F exited the resident's room without performing hand hygiene, either by washing hands or using hand sanitizer, after completing the care. During an interview, Unlicensed Staff F admitted to forgetting to wear a gown and to perform hand hygiene after providing care to the resident. Licensed Staff A confirmed that the care provided to the resident was considered a high-contact activity under the facility's Enhanced Barrier Precautions policy, which mandates the use of gowns and gloves, as well as hand hygiene before and after resident care. Licensed Staff A acknowledged the risk of a serious infection outbreak in the facility if such precautions are not followed. The facility's policies on Enhanced Barrier Precautions and Hand Hygiene emphasize the importance of using PPE and practicing hand hygiene to prevent the transmission of infections, including multiple drug-resistant organisms. The Infection Preventionist's role includes ensuring compliance with these procedures. The facility's policies also highlight the importance of treating residents with respect and dignity, and ensuring a safe and sanitary environment to prevent communicable diseases and infections.
Inadequate Training for CNAs in Abuse and Dementia Care
Penalty
Summary
The facility failed to provide adequate annual training in abuse and dementia care for three out of four unlicensed staff members, specifically Certified Nursing Assistants (CNAs) identified as Unlicensed Staff N, O, and P. During an interview and record review with the Director of Staff Development (DSD), it was revealed that Unlicensed Staff N received only one hour of abuse training and no dementia training. Unlicensed Staff O received one hour each of abuse and dementia training, while Unlicensed Staff P also received one hour each of abuse and dementia training. This was confirmed by the DSD during the interview. The facility's document titled 'Facility Assessment' from 2023 indicated that nurse aides are required to receive no less than 12 hours of in-service training annually, which must include dementia management and resident abuse prevention training. However, the DSD stated that the CNAs were provided with only about 5 hours of such training per year. This discrepancy highlights the facility's failure to meet the required training standards, potentially impacting the competency of the staff in providing quality care to residents.
Failure to Document Advance Directives and POLST
Penalty
Summary
The facility failed to ensure that a resident's medical records were updated to reflect discussions and documentation regarding advance directives and Physician Orders for Life-Sustaining Treatment (POLST). The resident, who was admitted with serious medical conditions including pyonephrosis, kidney stones, sepsis, hypokalemia, and dysphagia, did not have an advance directive or executed POLST documented in their medical record. This oversight was identified during a record review, which revealed the absence of these critical documents. Interviews with facility staff, including the Social Services Director and Licensed Staff, highlighted gaps in the process of obtaining and documenting advance directives and POLST forms. The Social Services Director admitted that the process relied on verbal communication and manual checks of resident charts, which failed in this instance. Additionally, Licensed Staff confirmed that the resident's code status was not listed in the electronic medical administrative record, and a manual chart review showed an unexecuted POLST. The facility's policies required that residents be provided with information about their rights to make medical decisions and that POLST forms be completed and signed, but these procedures were not followed for the resident in question.
Deficient Care Plan for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to develop a resident-centered, comprehensive care plan for a resident with a stage 4 pressure ulcer. The resident, who was admitted with a pressure ulcer on the left heel and a history of repeated falls, was observed using a special boot on the left lower leg. A document titled 'Skin Only Evaluation' indicated that the resident had a stage 4 pressure ulcer on the left heel, with specific treatment orders including washing with normal saline, applying Medihoney, and covering with Mepilex dressing. However, the care plan initiated for the resident's pressure wound did not include these specific treatments and instead contained generalized interventions that were not resident-specific or measurable. During a review with the Director of Staff Development, it was confirmed that the care plan lacked specific information tailored to the resident's needs. The facility's policy on care plans emphasized the need for comprehensive, person-centered care plans with measurable objectives, but this was not reflected in the care plan for the resident. The interventions listed were basic and did not address the specific treatments ordered by the physician, leading to a deficiency in providing adequate care for the resident's pressure ulcer.
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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 Mill Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Marin Health & Wellness Center | 3.5 mi | — | 19 | 0 |
| The Tamalpais | 3.6 mi | — | 20 | 0 |
| San Rafael Healthcare & Wellness Center, Lp | 5.6 mi | — | 1 | 0 |
| Marin Post Acute | 7.5 mi | — | 24 | 0 |
| Villa Marin | 7.6 mi | — | 11 | 0 |
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