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
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
0.65
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
2.51
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
4.35
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
7.52
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
3.16
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
7.28
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.83
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
7.22
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
27%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,012
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.32
Composite VBP score used to determine payment impact.
Payment multiplier
1.0068
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.38
Baseline 21.76% · Performance 19.92% · Measure score 3.38 · Achievement 3.25 · Improvement 3.38
Healthcare-associated infections
6.67
Baseline 7.90% · Performance 5.84% · Measure score 6.67 · Achievement 6.67 · Improvement 6.59
Total nurse turnover
5.64
Baseline 58.97% · Performance 40.62% · Measure score 5.64 · Achievement 5.64 · Improvement 4.88
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 7.78% · Lower 95% interval 6.34% |
| Discharge to community | 65.94% |
50.57%
15.4 pts better
|
Better than the National Rate · Eligible stays 81 · Observed rate 67.9% · Lower 95% interval 57.47% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.11% |
95.27%
2.8 pts better
|
Numerator 52 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 45.45% |
53.69%
8.2 pts worse
|
Numerator 20 · Denominator 44 |
| Discharge mobility score | 56.82% |
50.94%
5.9 pts better
|
Numerator 25 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 7.55% |
2.29%
5.3 pts worse
|
Numerator 4 · Denominator 53 · Adjusted rate 7.48% |
| Healthcare-associated infections requiring hospitalization | 5.84% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 0% · Lower 95% interval 2.92% |
| Staff COVID-19 vaccination coverage | 1.11% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 90 |
| Staff flu vaccination coverage | 38.67% |
42%
3.3 pts worse
|
Numerator 29 · Denominator 75 |
| Discharge function score | 72.73% |
56.45%
16.3 pts better
|
Numerator 32 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 41 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 3.7% |
25.2%
21.5 pts worse
|
Numerator 1 · Denominator 27 |
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 · 4Q avg 100.0% |
| 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 · 4Q avg 10.0% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 23.8% · 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 3.4% · Used in QM five-star |
| 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 · 4Q avg 6.7% |
| 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 · 4Q avg 10.2% · Used in QM five-star |
| 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 · Q1 96.6% · Q2 97.4% · Q3 97.9% · Q4 96.9% · 4Q avg 97.3% |
| 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 · Adjusted 20.4% · Observed 17.0% · Expected 9.3% · Used in QM five-star |
| 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 · Q2 0.0% · Q3 5.6% · Q4 12.5% · 4Q avg 4.8% · 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 | 23.3% |
23.2%
0.1 pts worse
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 17.0% · Expected 17.4% · Used in QM five-star |
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
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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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