South Marin Health & Wellness Center

Name: South Marin Health & Wellness Center
Address: 1220 SOUTH ELISEO DRIVE, Greenbrae, CA, 94904, US
Telephone: 4154619700

1220 South Eliseo Drive, Greenbrae, CA 94904 · Marin County · 72 certified beds · avg 63 residents/day · certified since Mar 20, 1969

Part of chain: ASPEN SKILLED HEALTHCARE (35 facilities, chain avg rating 3.7★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.48

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (37)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jan 23, 2026	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint
Jan 23, 2026	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Dec 4, 2025	E · Potential for harm, repeated	The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings.
Dec 4, 2025	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Dec 4, 2025	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 4, 2025	E · Potential for harm, repeated	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Dec 4, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Dec 4, 2025	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Nov 22, 2024	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Nov 22, 2024	E · Potential for harm, repeated	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Nov 22, 2024	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Nov 22, 2024	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Nov 22, 2024	E · Potential for harm, repeated	The facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Nov 22, 2024	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 22, 2024	E · Potential for harm, repeated	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Nov 22, 2024	E · Potential for harm, repeated	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Nov 22, 2024	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Nov 22, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jun 12, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Mar 18, 2024	E · Potential for harm, repeated	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
May 17, 2022	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
May 17, 2022	E · Potential for harm, repeated	The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
May 17, 2022	E · Potential for harm, repeated	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
May 17, 2022	E · Potential for harm, repeated	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
May 17, 2022	E · Potential for harm, repeated	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
May 17, 2022	E · Potential for harm, repeated	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
May 17, 2022	E · Potential for harm, repeated	The facility did not have enough support staff to safely and effectively run its food and nutrition service.
May 17, 2022	D · Potential for harm, one-off	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
May 17, 2022	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 17, 2022	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
May 17, 2022	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
May 17, 2022	D · Potential for harm, one-off	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 11).

Year	Citations	Worst severity that year
2022	12	E
2024	12	E
2025	11	E
2026	2	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.48	4.31	3.95	top 29% in California; top 23% in the U.S.
Registered Nurse hours	0.93	0.61	0.69	top 13% in California; top 19% in the U.S.
Weekend total nurse staffing	3.92	3.90	3.50	top 38% in California; top 25% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.75	0.51	0.48	top 13% in California; top 13% in the U.S.
Total nursing staff turnover (%)	37.8	36.7	45.8	bottom 45% in California; top 31% in the U.S.
RN turnover (%)	28.6	38.1	42.9	top 33% in California; top 26% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.42, RN 0.92, weekend 3.86. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Agse LLC	Organization	Direct Ownership Interest	NOT APPLICABLE	12/20/2018
Aspen Skilled Healthcare INC	Organization	Indirect Ownership Interest	NOT APPLICABLE	12/20/2018
Bradshaw, Peter	Individual	Indirect Ownership Interest	NOT APPLICABLE	07/07/2023
Elsner, Eric	Individual	Indirect Ownership Interest	NOT APPLICABLE	12/20/2018
Kirkwood, Jared	Individual	Indirect Ownership Interest	NOT APPLICABLE	01/01/2019
Orgill, Craig	Individual	Indirect Ownership Interest	NOT APPLICABLE	01/01/2019
Parti, Rajesh	Individual	Indirect Ownership Interest	NOT APPLICABLE	12/20/2018
Parti, Shruty	Individual	Indirect Ownership Interest	NOT APPLICABLE	12/20/2018
Paxman, Marcus	Individual	Indirect Ownership Interest	NOT APPLICABLE	04/01/2022
Sequoia Healthcare Group LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	01/01/2023
SKBM LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	12/20/2018
Agse LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	12/20/2018
Agse LLC	Organization	ADP of the SNF	NOT APPLICABLE	12/20/2018
Aspen Healthcare Services LLC	Organization	ADP of the SNF	NOT APPLICABLE	01/01/2023
Bradshaw, Jeffrey	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	10/24/2025
Bradshaw, Jeffrey	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023
Brady, Vern	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023
Case, Ryan	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2023
Castro, Madelene	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2020
Castro, Madelene	Individual	ADP of the SNF	NOT APPLICABLE	09/01/2020

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"How do you train staff to treat residents with dignity, and how do you protect residents' personal belongings?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
"How are residents and families included in care plan meetings, and how often do those meetings happen?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
The Tamalpais	0.6 mi	Greenbrae, CA	★★★★★	4/5
San Rafael Healthcare & Wellness Center, LP	2.1 mi	San Rafael, CA	★★☆☆☆	2/5
The Redwoods, a Community of Seniors	3.5 mi	Mill Valley, CA	★★☆☆☆	2/5
Villa Marin	4.1 mi	San Rafael, CA	★★★★★	4/5
Marin Post Acute	4.2 mi	San Rafael, CA	★★☆☆☆	2/5	abuse
Pine Ridge Care Center	4.6 mi	San Rafael, CA	★★★★★	3/5
Northgate Postacute Care	4.6 mi	San Rafael, CA	★★☆☆☆	2/5	abuse
Professional Post Acute Center	4.7 mi	San Rafael, CA	★★★☆☆	2/5
Smith Ranch Skilled Nursing & Rehabilitation Cente	5.2 mi	San Rafael, CA	★★★☆☆	2/5
Richmond Post Acute Care	10.3 mi	Richmond, CA	★★★★☆	4/5
Shields Richmond Nursing Center	10.4 mi	Richmond, CA	★★★★☆	2/5
Novato Healthcare Center	10.7 mi	Novato, CA	★☆☆☆☆	1/5	abuse

Compare this facility with the 3 closest →

All facilities in Greenbrae →

Facility data as of CMS processing date 2026-08-01. CCN 055093.

The Care File

Visit checklist — South Marin Health & Wellness Center

1220 South Eliseo Drive, Greenbrae, CA 94904 · 4154619700

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "How do you train staff to treat residents with dignity, and how do you protect residents' personal belongings?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
☐ "How are residents and families included in care plan meetings, and how often do those meetings happen?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 055093 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)