13 health deficiencies
Top issue: Resident Rights (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Greenbrae, CA
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1220 South Eliseo Drive, Greenbrae, CA
(415) 461-9700
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
72
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aspen Skilled Healthcare
Operator or chain grouping
Approved since
1969-03-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.76
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.94
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
4.24
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
2,024
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.25
Composite VBP score used to determine payment impact.
Payment multiplier
1.0067
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
6.54
Baseline 17.51% · Performance 18.40% · Measure score 6.54 · Achievement 6.54 · Improvement 0
Healthcare-associated infections
4.83
Baseline 6.56% · Performance 6.39% · Measure score 4.83 · Achievement 4.83 · Improvement 0.60
Total nurse turnover
6.29
Baseline 46.75% · Performance 37.97% · Measure score 6.29 · Achievement 6.29 · Improvement 3.51
Adjusted total nurse staffing
3.23
Baseline 4.26 hours · Performance 4 hours · Measure score 3.23 · Achievement 3.23 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.71% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 336 · Observed rate 5.95% · Lower 95% interval 6.73% |
| Discharge to community | 65.65% |
50.57%
15.1 pts better
|
Better than the National Rate · Eligible stays 336 · Observed rate 63.39% · Lower 95% interval 60.29% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.22% |
95.27%
4 pts better
|
Numerator 253 · Denominator 255 |
| Falls with major injury | 0.39% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 255 |
| Discharge self-care score | 69.7% |
53.69%
16 pts better
|
Numerator 69 · Denominator 99 |
| Discharge mobility score | 67.68% |
50.94%
16.7 pts better
|
Numerator 67 · Denominator 99 |
| Pressure ulcers or injuries, new or worsened | 0.39% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 255 · Adjusted rate 0.48% |
| Healthcare-associated infections requiring hospitalization | 6.39% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 233 · Observed rate 5.15% · Lower 95% interval 4.29% |
| Staff COVID-19 vaccination coverage | 26.67% |
8.2%
18.5 pts better
|
Numerator 20 · Denominator 75 |
| Staff flu vaccination coverage | 87.82% |
42%
45.8 pts better
|
Numerator 137 · Denominator 156 |
| Discharge function score | 68.69% |
56.45%
12.2 pts better
|
Numerator 68 · Denominator 99 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 62 · Denominator 62 |
| Transfer of health information to patient | 96.95% |
96.28%
0.7 pts better
|
Numerator 159 · Denominator 164 |
| Resident COVID-19 vaccinations up to date | 47.83% |
25.2%
22.6 pts better
|
Numerator 66 · Denominator 138 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.3
1 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
6.8%
6 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
4.1%
1.9 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
13.7%
6.6 pts worse
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 20.0% · Q3 20.6% · Q4 25.0% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.8% |
14.2%
2.6 pts worse
|
16.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q3 21.4% · Q4 15.4% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.2% |
11.0%
6.8 pts better
|
16.3%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.4% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.7% |
10.7%
6 pts better
|
14.9%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 9.4% · Q3 3.0% · Q4 3.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.2%
0.9 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 5.3% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.6% |
10.9%
6.3 pts better
|
19.8%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.4% · Q3 9.7% · Q4 0.0% · 4Q avg 4.6% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
4.7%
1.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.0% · Q3 5.1% · Q4 3.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
11.2%
3.1 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 8.1% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.6% |
23.2%
3.6 pts better
|
23.9%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 18.4% · Expected 22.3% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nutrition and Dietary (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-02
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-02
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-02
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-02
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-02
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-02
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-13
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-13
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-12-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-13
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-12-13
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-13
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2022-07-07
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-07-07
Fire Safety
Use approved construction type or materials.
Corrected 2022-07-07
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-07
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-07-07
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-07
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-07-07
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-07-07
Inspection history
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-12
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-12
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2026-01-04
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-01-04
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-04
Health
Implement a program that monitors antibiotic use.
Corrected 2026-01-04
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2026-01-04
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-04
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-04
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2026-01-04
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-01-04
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-01-04
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-18
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-12-18
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-18
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-12-18
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-18
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-18
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-12-18
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-29
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-30
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-06-10
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-06-10
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-06-10
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-10
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-06-10
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-06-10
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2022-06-10
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-06-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-06-10
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-06-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-10
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-10
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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