Cycle 1
Health 2025-04-24 · Fire 2025-04-24
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
San Diego, CA
Carmel Mountain Rehabilitation & Healthcare Center
3-star overall rating with 2-star inspections with 20 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
11895 Avenue Of Industry, San Diego, CA
(858) 673-0101
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1988-10-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
Hours and turnover
RN hours / resident day
0.97
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.64
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.26
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.61
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.76
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.92
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,183
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9939
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.83
Baseline 21.71% · Performance 19.69% · Measure score 3.83 · Achievement 3.76 · Improvement 3.83
Healthcare-associated infections
6.77
Baseline 8.87% · Performance 6.05% · Measure score 6.77 · Achievement 5.96 · Improvement 6.77
Total nurse turnover
4.13
Baseline 41.35% · Performance 46.79% · Measure score 4.13 · Achievement 4.13 · Improvement 0
Adjusted total nurse staffing
1.68
Baseline 3.28 hours · Performance 3.56 hours · Measure score 1.68 · Achievement 1.68 · Improvement 0.59
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.89% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 306 · Observed rate 6.21% · Lower 95% interval 6.47% |
| Discharge to community | 70.46% |
50.57%
19.9 pts better
|
Better than the National Rate · Eligible stays 293 · Observed rate 69.28% · Lower 95% interval 65.96% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 226 · Denominator 226 |
| Falls with major injury | 0.88% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 226 |
| Discharge self-care score | 58.23% |
53.69%
4.5 pts better
|
Numerator 46 · Denominator 79 |
| Discharge mobility score | 44.3% |
50.94%
6.6 pts worse
|
Numerator 35 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 226 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 179 · Observed rate 4.47% · Lower 95% interval 4.12% |
| Staff COVID-19 vaccination coverage | 0.84% |
8.2%
7.4 pts worse
|
Numerator 2 · Denominator 237 |
| Staff flu vaccination coverage | 48.81% |
42%
6.8 pts better
|
Numerator 143 · Denominator 293 |
| Discharge function score | 49.37% |
56.45%
7.1 pts worse
|
Numerator 39 · Denominator 79 |
| Transfer of health information to provider | 96.75% |
95.95%
0.8 pts better
|
Numerator 119 · Denominator 123 |
| Transfer of health information to patient | 97.62% |
96.28%
1.3 pts better
|
Numerator 82 · Denominator 84 |
| Resident COVID-19 vaccinations up to date | 21.19% |
25.2%
4 pts worse
|
Numerator 25 · Denominator 118 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.3
0.8 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · 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 | 98.6% |
98.2%
0.4 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
1.6%
1.3 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.6% · Q3 1.4% · Q4 2.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
6.8%
3.6 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.2% · Q3 1.8% · Q4 1.9% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
4.1%
0.3 pts worse
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 7.1% · Q3 6.0% · Q4 3.1% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
13.7%
2.3 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 10.3% · Q3 11.9% · Q4 7.7% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
14.2%
5.3 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 5.3% · Q3 8.0% · Q4 10.6% · 4Q avg 8.9% · 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 | 0.0% |
11.0%
11 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.5% |
10.7%
7.2 pts better
|
14.9%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.3% · Q3 2.4% · Q4 2.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.0%
0.3 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.6% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.2%
0.6 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.1% · Q3 2.9% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.5% |
10.9%
11.6 pts worse
|
19.8%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 27.3% · Q3 19.0% · Q4 18.6% · 4Q avg 22.5% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
4.7%
0.5 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 3.7% · Q3 1.2% · Q4 4.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.8% · Q4 99.5% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
11.2%
3.3 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 14.3% · Expected 11.0% · 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 | 99.3% |
93.2%
6.1 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
23.2%
1 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 23.0% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-10 · Fire 2024-05-10
23 health deficiencies
Top issue: Resident Rights (6 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-07-28 · Fire 2023-07-28
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-04-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-04-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-22
D · Potential for more than minimal harm
2025-04-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-23
C · Minimal harm
2025-04-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-05-23
E · Potential for more than minimal harm
2024-05-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-10
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-05-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-21
D · Potential for more than minimal harm
2023-07-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-07-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-07-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
D · Potential for more than minimal harm
2025-09-16
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 2025-10-05
D · Potential for more than minimal harm
2025-09-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-05
E · Potential for more than minimal harm
2025-09-04
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 2025-09-22
D · Potential for more than minimal harm
2025-09-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-05
D · Potential for more than minimal harm
2025-09-04
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-09-22
E · Potential for more than minimal harm
2025-04-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-24
E · Potential for more than minimal harm
2025-04-24
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-05-24
E · Potential for more than minimal harm
2025-04-24
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 2025-05-24
E · Potential for more than minimal harm
2025-04-24
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-05-24
E · Potential for more than minimal harm
2025-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-04-24
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-04-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-04-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-04-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-04-24
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 2025-05-24
D · Potential for more than minimal harm
2025-04-24
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 2025-05-24
D · Potential for more than minimal harm
2025-04-24
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-04-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-04-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-24
E · Potential for more than minimal harm
2024-12-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-03
D · Potential for more than minimal harm
2024-10-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-09-13
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 2024-10-15
D · Potential for more than minimal harm
2024-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-07-30
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 2024-08-22
E · Potential for more than minimal harm
2024-05-10
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 2024-06-21
E · Potential for more than minimal harm
2024-05-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-10
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 2024-06-21
D · Potential for more than minimal harm
2024-05-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-10
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-10
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 2024-06-21
D · Potential for more than minimal harm
2024-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-10
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-10
F693 · Quality of Life and Care Deficiencies
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 2024-06-21
D · Potential for more than minimal harm
2024-05-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-10
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 2024-06-21
D · Potential for more than minimal harm
2024-05-10
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 2024-06-21
D · Potential for more than minimal harm
2024-05-10
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-06-21
D · Potential for more than minimal harm
2023-07-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-28
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-28
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 2023-08-28
D · Potential for more than minimal harm
2023-07-28
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-07-28
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 2023-08-28
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare South LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Cetna Staffing Inc
Operational/Managerial Control · Organization
Kalafer, Michael
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Lincare Inc
Operational/Managerial Control · Organization
Matthews, Glenn
Operational/Managerial Control · Individual
Oh, Katherine
Corporate Officer · Individual
Port, Barry
Corporate Director · Individual
Sato, Ami
Corporate Officer · Individual
Sevenoaks Capital Associates LLC
Operational/Managerial Control · Organization
Willits, Adam
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Villa Rancho Bernardo Care Center
San Diego, CA
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Poway Healthcare Center
Poway, CA
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
The Villas At Poway
Poway, CA
5-star overall rating with 3-star inspections with $57,124 in total fines with 11 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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