Federal inspection record · CMS data as of October 1, 2026
Carmel Mountain Rehabilitation & Healthcare Center
11895 Avenue Of Industry, San Diego, CA · (858) 673-0101
- Certified beds
- 120
- Residents per day
- 114
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- October 12, 1988
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in California.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among California homes
Carmel Mountain Rehabilitation & Healthcare Center carries 116 inspection points. That is fewer than 31% of California's 1,154 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in California: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–33 pts
- 4★ 33–66 pts
- 3★ 66–96 pts
- 2★ 96–146 pts
- 1★ over 146 pts
Bars show every rated home in California by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
53 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care13D
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
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.
- D
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.
- D
Provide care or services that was trauma informed and/or culturally competent.
Resident Rights11E
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- E
Reasonably accommodate the needs and preferences of each resident.
- E
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.
- D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
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.
- D
Keep residents' personal and medical records private and confidential.
- D
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.
- D
Reasonably accommodate the needs and preferences of each resident.
Resident Assessment and Care Planning8E
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure each resident receives an accurate assessment.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pharmacy Service7E
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- D
Ensure medication error rates are not 5 percent or greater.
Infection Control5E
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Nutrition and Dietary4E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
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.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration2E
- D
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- E
Have a plan that describes the process for conducting QAPI and QAA activities.
Nursing and Physician Services1D
- D
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.
Environmental1D
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspection history
2025-04-24
18 health deficiencies · 9 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2024-05-10
25 health deficiencies · 6 fire-safety deficiencies
Top issue: Resident Rights (7 deficiencies)
2023-07-28
10 health deficiencies · 3 fire-safety deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 5 h 5 min of nursing staff time a day, 58 min of it from a registered nurse.
This home
5 h 5 min
California average
4 h 33 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 39% of nursing staff and 39% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.1 pts worse | 2.3 | 2.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.6 pts better | 0.9 | 1.5 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.9 pts better | 99.6% | 98.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.1 pts better | 100.0% | 97.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.2 pts better | 1.4% | 1.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms3.5 pts better | 4.1% | 7.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.4 pts better | 3.7% | 4.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication2.8 pts better | 10.9% | 13.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication1.8 pts better | 10.5% | 12.3% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.3 pts better | 0.0% | 0.3% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened2.7 pts better | 6.2% | 8.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased3.6 pts better | 6.6% | 10.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladderAbout the same | 0.7% | 0.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.6 pts worse | 1.8% | 1.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence15.9 pts worse | 25.7% | 9.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.2 pts better | 3.1% | 4.3% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine4.2 pts better | 98.8% | 94.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit3.6 pts worse | 14.7% | 11.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.5 pts better | 0.8% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine5.9 pts better | 99.0% | 93.1% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission2.9 pts worse | 25.5% | 22.6% | 23.4% |
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Who owns and runs it
22 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Burnam, Soon | Managing Control - Governing Body · Individual | 0% | 353 facilities |
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Caretrust Gp LLC | Adp Of The SNF · Organization | 0% | 95 facilities |
| Caretrust Reit Inc | Adp Of The SNF · Organization | 0% | 102 facilities |
| Cetna Staffing Inc | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Cm Health Holdings LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Ctr Partnership LP | Adp Of The SNF · Organization | 0% | 104 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Kalafer, Michael | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Kalafer, Michael | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Kalafer, Michael | Adp Of The SNF · Individual | 0% | 1 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Lincare Inc | Operational/Managerial Control · Organization | 0% | 3 facilities |
| Matthews, Glenn | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Matthews, Glenn | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Matthews, Glenn | Adp Of The SNF · Individual | 0% | 2 facilities |
| Oh, Katherine | Corporate Officer · Individual | 0% | 7 facilities |
| Port, Barry | Corporate Director · Individual | 0% | 203 facilities |
| Sato, Ami | Corporate Officer · Individual | 0% | 151 facilities |
| Sevenoaks Capital Associates LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| The Ensign Group Inc | Adp Of The SNF · Organization | 0% | 135 facilities |
| Willits, Adam | Corporate Officer · Individual | 0% | 77 facilities |
·
Fire safety
18 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke6E
- E
Install corridor and hallway doors that block smoke.
- D
Provide properly protected cooking facilities.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Have approved installation, maintenance and testing program for fire alarm systems.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Inspect, test, and maintain automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems3F
- F
Ensure proper usage of power strips and extension cords.
- D
Have proper medical gas storage and administration areas.
- D
Have generator or other power source capable of supplying service within 10 seconds.
Services2D
- D
Have properly installed electrical wiring and gas equipment.
- D
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Emergency Preparedness2F
- F
Implement emergency and standby power systems.
- D
Provide primary/alternate means for communication.
Egress2D
- D
Install emergency lighting that can last at least 1 1/2 hours.
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Miscellaneous2E
- C
Provide a written emergency evacuation plan.
- E
Provide a written emergency evacuation plan.
Construction1D
- D
Use approved construction type or materials.
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Other homes nearby
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Villa Rancho Bernardo Care Center
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★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 1 min
- Fines
- $0
-
Poway Healthcare Center
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- Nursing / resident / day
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-
The Villas At Poway
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- Nursing / resident / day
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- $48,385