Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 The Tamalpais during CMS and state inspections, most recent first.
The facility did not ensure an RN was on duty for eight consecutive hours each day, as required, with multiple days lacking RN coverage for skilled nursing. The Administrator confirmed gaps in RN scheduling and a lack of awareness regarding the requirement for consistent RN coverage.
The facility did not have a full-time infection preventionist (IP) dedicated solely to the SNF, as required by state law. Instead, the IP's responsibilities were divided among the SNF, assisted living, and independent living areas, and the time spent in the SNF was not documented. The administrator confirmed that the IP was not exclusively assigned to the SNF.
A multidose vial of PPD diagnostic antigen remained in the medication refrigerator beyond the facility's 30-day discard policy. The DON confirmed the vial was not discarded as required, and both facility policy and FDA guidelines state that such vials should be discarded after 30 days.
A resident with multiple medical conditions was discharged without a physician's discharge order or discharge summary in the EMR. Staff interviews confirmed that required documentation was not completed or provided to the resident or their primary care provider, contrary to facility policy.
A resident with a femur fracture and Alzheimer's Disease was placed on Enhanced Barrier Precautions (EBP), but staff failed to include EBP in the care plan or document its initiation and rationale. Staff were observed providing high-contact care without required gloves and gowns, and there was no facility policy or procedure for EBP, despite facility policy requiring comprehensive care plans for all resident needs.
Two residents did not receive care as ordered by their physicians: one resident with dementia was found without a required wanderguard device and lacked a timely elopement risk assessment, while another high fall-risk resident did not have floor mats placed on both sides of the bed as ordered. Staff confirmed these omissions, which were contrary to facility policy and physician orders.
A staff member with facial hair was observed cooking food without a beard net, in violation of both facility policy and FDA Food Code requirements for hair restraints. This lapse was confirmed by the DDS and indicated a failure to maintain safe and sanitary kitchen practices.
Staff failed to follow infection control protocols by not wearing required PPE while providing high-contact care to a resident on Enhanced Barrier Precautions and by not cleaning or disinfecting a reusable blood pressure cuff between use on two residents. These actions were inconsistent with facility policy and CDC guidelines.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours a day, seven days a week, from January 2025 to August 2025 for all residents. Review of the Payroll Based Journal (PBJ) Staffing Data Report for Quarter 2 of 2025 revealed that there were no RN hours recorded on several Sundays, specifically 1/5/2025, 2/2/2025, 2/16/2025, 3/2/2025, and 3/30/2025. Additional review of the facility's Skilled Daily Staffing assignment reports for 8/17/2025 and 8/31/2025 also indicated no RN coverage for skilled nursing on those dates. During interviews, the Administrator confirmed the absence of RN coverage on the dates identified in the PBJ report and acknowledged that there were additional dates not listed where no RN was scheduled. The Administrator further stated that the facility was unaware that RN coverage was specifically required for the skilled nursing facility and confirmed that no RN coverage was scheduled for every other Sunday. No specific details about individual residents or their medical conditions at the time of the deficiency were provided in the report.
Lack of Dedicated Full-Time Infection Preventionist for SNF
Penalty
Summary
The facility failed to employ a dedicated full-time infection preventionist (IP) solely for the skilled nursing facility (SNF) as required by California Assembly Bill 2644 and outlined in All Facility Letter (AFL) 20-85. The IP was responsible for infection surveillance, tracking and trending infections, staff training, and participating in infection control and QAPI activities. However, the IP's duties were divided among three levels of care within the Continuing Care Retirement Community (CCRC): independent living, assisted living, and the SNF. The IP reported that her time was not exclusively devoted to the SNF and that she did not document the amount of time spent in the SNF specifically. During interviews and record reviews, the administrator confirmed that the IP was not solely assigned to the SNF but also served as the IP for the other levels of care within the CCRC. The facility's policy and job description indicated compliance with state and federal regulations but did not specify that the IP's full-time role was dedicated only to the SNF. AFL 20-85 and AB 2644 require a full-time IP for the SNF, a requirement not met by the facility's current staffing arrangement.
Expired PPD Antigen Vial Not Discarded per Policy
Penalty
Summary
A multidose vial of PPD diagnostic antigen was found in the medication refrigerator with an opening date that exceeded the facility's 30-day discard policy. During an observation with the DON, it was verified that the vial had been opened more than 30 days prior and had not been discarded as required. The DON confirmed that the facility's policy is to label multidose vials with the date opened and to discard them after 30 days, in accordance with manufacturer guidelines and facility procedures. Review of the facility's policy and the FDA guidelines for APLISOL also confirmed that vials in use for more than 30 days should be discarded.
Failure to Provide Discharge Order and Summary for Discharged Resident
Penalty
Summary
A deficiency occurred when a resident was discharged without a physician's discharge order or a discharge summary being maintained in their medical record. The resident, who had a history of atrial fibrillation, myocardial infarction, asthma, hypertension, and elevated liver enzymes, was admitted to the facility and later discharged. Upon review of the resident's electronic medical record (EMR), it was confirmed by the MDS Registered Nurse, Medical Director, Director of Nursing, and Social Worker that neither a discharge order nor a discharge summary was present in the EMR or provided to the resident at the time of discharge. Interviews with facility staff revealed that it was the responsibility of the discharging physician to provide both a discharge order and a discharge summary, which should have been given to the resident and forwarded to the primary care provider for continuity of care. The facility's policies required a written physician order for discharge and completion of a discharge summary within 14 days, including details about the resident's medical condition, current status, treatments, and medications. These requirements were not met for the resident in question.
Failure to Develop and Implement Care Plan for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement a care plan addressing Enhanced Barrier Precautions (EBP) for a resident admitted with a femur fracture and Alzheimer's Disease. Observation revealed that EBP signage was posted outside the resident's room, indicating specific infection control measures, including the use of gloves and gowns for high-contact care activities. However, staff were observed repositioning the resident in bed without wearing the required personal protective equipment. Interviews with staff confirmed a lack of understanding regarding when to use gloves and gowns for residents on EBP, and the Infection Preventionist acknowledged that moving a resident in bed is considered high-contact care requiring such precautions. Record review showed no documentation in the resident's interdisciplinary notes regarding the initiation or rationale for EBP, nor was EBP included in the resident's baseline or comprehensive care plan. The Infection Preventionist confirmed the absence of EBP documentation and care planning, and stated that the facility did not have a policy or procedure for EBP. The facility's own care planning policy requires comprehensive care plans to address individual resident needs and to be updated as conditions change, but this was not followed in the case of EBP for this resident.
Failure to Follow Physician Orders for Wanderguard and Fall Prevention Devices
Penalty
Summary
Two deficiencies were identified involving the care and services provided to two residents. For one resident with a diagnosis of dementia, there was a physician's order for a wanderguard device to be placed on the right wrist, with instructions to check the battery daily and the placement every shift. However, during observation, the resident was found without the wanderguard device on either wrist or wheelchair. Staff interviews confirmed the absence of the device, despite active orders and a history of the resident attempting to leave the unit. Additionally, the elopement risk assessment was not completed prior to the initial placement of the wanderguard, contrary to facility policy, which requires such assessments upon admission, change of condition, and annually. For another resident with a history of cerebral infarction and muscle weakness, and identified as high risk for falls, physician's orders specified that floor mats should be placed on both sides of the bed. During observation, only one mat was in place, while the other was found rolled up and not in use. Staff confirmed that both mats should have been positioned on the floor as a precautionary measure, in accordance with the resident's care plan and physician's orders. The facility's policy requires licensed nurses to implement physician orders, which was not followed in this instance. These findings were based on direct observation, staff interviews, and review of medical records and facility policies. The failures to follow physician orders and facility protocols had the potential to adversely affect the physical and psychosocial well-being of the residents involved.
Failure to Ensure Kitchen Staff Wore Required Beard Net
Penalty
Summary
A staff member with facial hair was observed cooking food in the kitchen without wearing a beard net, as required by facility policy and the FDA Food Code. This observation was confirmed by the Director of Dining Services during a concurrent interview. A review of the facility's Uniform Dress Code policy indicated that all facial hair must be restrained with a beard net or restraint. The FDA Food Code also mandates that food employees wear hair restraints, including beard restraints, to prevent hair from contacting food. The failure to follow these requirements resulted in the kitchen preparation area not being maintained in a safe and sanitary manner.
Failure to Follow Infection Control Practices for PPE and Equipment Disinfection
Penalty
Summary
Two deficiencies in infection prevention and control practices were identified during observations, interviews, and record reviews. In the first instance, two certified nursing assistants (CNAs) provided care to a resident with a femur fracture and Alzheimer's Disease who was under Enhanced Barrier Precautions (EBP) due to a leg dressing. Despite a posted EBP sign instructing staff to wear gloves and gowns for high-contact care activities, both CNAs repositioned the resident in bed without donning the required personal protective equipment (PPE). One CNA stated that staff did not need to wear a gown or gloves when repositioning a resident in bed, which was contradicted by the facility's Infection Preventionist and CDC guidelines, both of which classify moving a resident in bed as high-contact care requiring PPE. In the second instance, a registered nurse (RN) used a reusable blood pressure machine and cuff on two different residents without cleaning or disinfecting the equipment between uses. The RN acknowledged that the equipment should have been cleaned and disinfected after each use, and the Infection Preventionist confirmed that failure to do so could result in microbe transmission between residents. The facility's policy also required reusable items to be cleaned and disinfected between residents, but this protocol was not followed during the observed care.
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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) |
|---|---|---|---|---|
| South Marin Health & Wellness Center | 0.6 mi | — | 19 | 0 |
| San Rafael Healthcare & Wellness Center, Lp | 2.1 mi | — | 1 | 0 |
| The Redwoods, A Community Of Seniors | 3.6 mi | — | 0 | 0 |
| Marin Post Acute | 4 mi | — | 24 | 0 |
| Villa Marin | 4.1 mi | — | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.