Cycle 1
Health 2024-10-31 · Fire 2024-10-31
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Escondido, CA
Meadowbrook Village Christian Retirement Community
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
100 Holland Glen, Escondido, CA
(760) 746-2500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
19
Certified beds
Average residents
14
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-11-01
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing
LPN hours / resident day
2.51
Licensed practical nurse staffing
Aide hours / resident day
4.35
Nurse aide staffing
Weekend hours
7.28
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
27%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.0% |
1.6%
8.4 pts worse
|
3.3%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
4.1%
4.1 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.0% |
13.7%
13.7 pts better
|
19.6%
19.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.8% |
10.7%
13.1 pts worse
|
14.9%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.2%
2.2 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.7% |
10.9%
4.2 pts better
|
19.8%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 10.2% |
4.7%
5.5 pts worse
|
5.1%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
94.0%
3.3 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.4% |
11.2%
9.2 pts worse
|
12.0%
8.4 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.8% |
1.5%
3.3 pts worse
|
1.6%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
23.2%
0.1 pts worse
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-09-15 · Fire 2022-09-15
2 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-27
F · Potential for more than minimal harm
2024-10-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-27
C · Minimal harm
2024-10-31
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-11-15
C · Minimal harm
2024-10-31
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-15
F · Potential for more than minimal harm
2023-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-30
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-12-15
F · Potential for more than minimal harm
2022-09-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-15
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 2022-10-17
E · Potential for more than minimal harm
2022-09-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-17
E · Potential for more than minimal harm
2022-09-15
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-15
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2022-10-17
C · Minimal harm
2022-09-15
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-10-17
C · Minimal harm
2022-09-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-10-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-31
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 2024-11-18
E · Potential for more than minimal harm
2024-10-31
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-31
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 2024-11-18
F · Potential for more than minimal harm
2023-11-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-11-30
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-11-30
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 2024-01-04
D · Potential for more than minimal harm
2023-11-30
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 2024-01-04
D · Potential for more than minimal harm
2023-11-30
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 2024-01-04
B · Minimal harm
2023-11-30
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 2024-01-04
E · Potential for more than minimal harm
2022-09-15
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 2022-10-17
E · Potential for more than minimal harm
2022-09-15
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 2022-10-17
Penalties and ownership
What sits behind the stars
Ownership
Brouwer, Jacob
Operational/Managerial Control · Individual
Brouwer, Jacob
Corporate Officer · Individual
Cooper, Joanne
Operational/Managerial Control · Individual
Cooper, Joanne
Corporate Officer · Individual
Denboer, Derkina
Operational/Managerial Control · Individual
Denboer, Derkina
Corporate Officer · Individual
Francis, Lisa
Operational/Managerial Control · Individual
Francis, Lisa
Corporate Director · Individual
Hoeksema, Larry
Operational/Managerial Control · Individual
Hoeksema, Larry
Corporate Officer · Individual
Jansma, James
Operational/Managerial Control · Individual
Jansma, James
Corporate Officer · Individual
Meadowbrook Village Christian Retirement Community
5% Or Greater Direct Ownership Interest · Organization
Memmelaar, Mark
Operational/Managerial Control · Individual
Memmelaar, Mark
Corporate Director · Individual
Prins, Ron
Operational/Managerial Control · Individual
Prins, Ron
Corporate Officer · Individual
Veldkamp, Arnold
Operational/Managerial Control · Individual
Veldkamp, Arnold
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Escondido Post Acute
Escondido, CA
4-star overall rating with 4-star inspections with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Palomar Vista Healthcare Center
Escondido, CA
2-star overall rating with 2-star inspections with 22 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Palomar Heights Post Acute
Escondido, CA
3-star overall rating with 2-star inspections with $11,622 in total fines with 20 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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