Cycle 1
Health 2025-02-06 · Fire 2025-02-06
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Carlsbad, CA
Bayshire Carlsbad
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3140 El Camino Real, Carlsbad, CA
(760) 720-9898
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
40
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bayshire Senior Communities
Operator or chain grouping
Approved since
1999-10-04
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.00
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.10
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.28
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.18
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.87
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.91
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.37
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
2.16
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,628
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9922
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.71
Baseline 19.08% · Performance 19.71% · Measure score 3.71 · Achievement 3.71 · Improvement 0
Healthcare-associated infections
9.13
Baseline 5.56% · Performance 5.11% · Measure score 9.13 · Achievement 9.13 · Improvement 7.51
Total nurse turnover
2.83
Baseline 67.86% · Performance 53.52% · Measure score 2.83 · Achievement 2.49 · Improvement 2.83
Adjusted total nurse staffing
0
Baseline 3.53 hours · Performance 3.18 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 692 · Observed rate 9.68% · Lower 95% interval 8.95% |
| Discharge to community | 71.5% |
50.57%
20.9 pts better
|
Better than the National Rate · Eligible stays 677 · Observed rate 68.54% · Lower 95% interval 67.71% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 93.46% |
95.27%
1.8 pts worse
|
Numerator 443 · Denominator 474 |
| Falls with major injury | 0.84% |
0.77%
0.1 pts worse
|
Numerator 4 · Denominator 474 |
| Discharge self-care score | 63.17% |
53.69%
9.5 pts better
|
Numerator 223 · Denominator 353 |
| Discharge mobility score | 65.72% |
50.94%
14.8 pts better
|
Numerator 232 · Denominator 353 |
| Pressure ulcers or injuries, new or worsened | 0.21% |
2.29%
2.1 pts better
|
Numerator 1 · Denominator 474 · Adjusted rate 0.2% |
| Healthcare-associated infections requiring hospitalization | 5.11% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 434 · Observed rate 3.69% · Lower 95% interval 3.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 78 |
| Staff flu vaccination coverage | 90.51% |
42%
48.5 pts better
|
Numerator 124 · Denominator 137 |
| Discharge function score | 63.17% |
56.45%
6.7 pts better
|
Numerator 223 · Denominator 353 |
| Transfer of health information to provider | 96.7% |
95.95%
0.8 pts better
|
Numerator 88 · Denominator 91 |
| Transfer of health information to patient | 98.15% |
96.28%
1.9 pts better
|
Numerator 371 · Denominator 378 |
| Resident COVID-19 vaccinations up to date | 73.28% |
25.2%
48.1 pts better
|
Numerator 192 · Denominator 262 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 11.7% |
11.2%
0.5 pts worse
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 9.8% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.5% · Q4 0.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.7% |
93.2%
6.5 pts better
|
79.7%
20 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
23.2%
0.4 pts worse
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 21.2% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
13 health deficiencies
Top issue: Nutrition and Dietary (6 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-04-28 · Fire 2022-04-28
7 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-19
F · Potential for more than minimal harm
2025-06-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-06-05
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-10
E · Potential for more than minimal harm
2025-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-02-06
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-02-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-12
D · Potential for more than minimal harm
2024-02-29
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-29
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-03-21
E · Potential for more than minimal harm
2022-04-28
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-05-18
E · Potential for more than minimal harm
2022-04-28
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-05-18
E · Potential for more than minimal harm
2022-04-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-28
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-28
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-28
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-28
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-05-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-06
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-06
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-02-28
E · Potential for more than minimal harm
2024-02-29
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-02-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F761 · Pharmacy Service Deficiencies
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 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F803 · Nutrition and Dietary Deficiencies
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 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-03-29
D · Potential for more than minimal harm
2023-12-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-04-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-04-14
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-05-08
D · Potential for more than minimal harm
2023-04-14
F761 · Pharmacy Service Deficiencies
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 2023-05-08
D · Potential for more than minimal harm
2022-04-28
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-05-18
Penalties and ownership
What sits behind the stars
Ownership
Skilled Camino LLC
5% Or Greater Direct Ownership Interest · Organization
Bayshire LLC
5% Or Greater Indirect Ownership Interest · Organization
Coleman, Chad
Corporate Director · Individual
Daynes, Thomas
Operational/Managerial Control · Individual
Golden State Care Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Kirby, Scott
5% Or Greater Indirect Ownership Interest · Individual
Kirby, Scott
Operational/Managerial Control · Individual
Kirby, Scott
Corporate Officer · Individual
Skilled Camino LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Carlsbad, CA
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
La Paloma Healthcare Center
Oceanside, CA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Vista Knoll Specialized Care Facility
Vista, CA
5-star overall rating with 4-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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