13 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Escondido, CA
5-star overall rating with 4-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1980 Felicita Road, Escondido, CA
(760) 741-6109
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
Beds
120
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David & Frank Johnson
Operator or chain grouping
Approved since
1990-08-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 facilities
Chain averages 3 overall / 3 health / 3 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
RN hours / resident day
0.59
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.76
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
4,279
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9935
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.19
Baseline 21.20% · Performance 18.10% · Measure score 7.19 · Achievement 7.19 · Improvement 6.94
Healthcare-associated infections
0
Baseline 7.53% · Performance 9.28% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.49
Baseline 40.24% · Performance 37.17% · Measure score 6.49 · Achievement 6.49 · Improvement 1.50
Adjusted total nurse staffing
2.57
Baseline 4.04 hours · Performance 3.81 hours · Measure score 2.57 · Achievement 2.57 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.44% |
10.72%
2.3 pts better
|
No Different than the National Rate · Eligible stays 276 · Observed rate 6.52% · Lower 95% interval 6.27% |
| Discharge to community | 56.28% |
50.57%
5.7 pts better
|
Better than the National Rate · Eligible stays 261 · Observed rate 50.19% · Lower 95% interval 51.01% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 297 · Denominator 297 |
| Falls with major injury | 0.67% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 297 |
| Discharge self-care score | 82.11% |
53.69%
28.4 pts better
|
Numerator 156 · Denominator 190 |
| Discharge mobility score | 72.11% |
50.94%
21.2 pts better
|
Numerator 137 · Denominator 190 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 297 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.28% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 219 · Observed rate 10.5% · Lower 95% interval 6.52% |
| Staff COVID-19 vaccination coverage | 1.9% |
8.2%
6.3 pts worse
|
Numerator 4 · Denominator 210 |
| Staff flu vaccination coverage | 36.1% |
42%
5.9 pts worse
|
Numerator 74 · Denominator 205 |
| Discharge function score | 78.42% |
56.45%
22 pts better
|
Numerator 149 · Denominator 190 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 111 · Denominator 111 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 140 · Denominator 140 |
| Resident COVID-19 vaccinations up to date | 61.18% |
25.2%
36 pts better
|
Numerator 93 · Denominator 152 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 1.7 · 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 | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
1.6%
0.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 3.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
6.8%
3.1 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.3% · Q3 3.3% · Q4 1.9% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 0.5% |
4.1%
3.6 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.6% |
13.7%
5.1 pts better
|
19.6%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.0% · Q3 11.3% · Q4 11.8% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
14.2%
1.4 pts better
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 16.7% · Q3 10.8% · Q4 8.6% · 4Q avg 12.8% · 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 | 3.1% |
11.0%
7.9 pts better
|
16.3%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.6% |
10.7%
6.1 pts better
|
14.9%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.0% · Q3 8.5% · Q4 2.2% · 4Q avg 4.6% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.2%
0.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.3% |
10.9%
4.6 pts better
|
19.8%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 1.8% · Q3 9.5% · Q4 9.5% · 4Q avg 6.3% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.7%
0.9 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.6% · Q3 5.3% · Q4 3.0% · 4Q avg 3.8% · Used in QM five-star |
| 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 | 10.2% |
11.2%
1 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 10.6% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.6% · Q3 0.0% · Q4 2.1% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
93.2%
6 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
23.2%
6.2 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 18.1% · Expected 25.4% · Used in QM five-star |
Survey summary
Top issue: Nutrition and Dietary (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-03
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-03
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-03
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-07-03
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 2025-07-03
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2025-07-03
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-03
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-30
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-03-30
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-03-30
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-03-30
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-09-24
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2019-09-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-24
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-09-24
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-09-24
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-09-24
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-04
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-04
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-04
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-07-04
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-04
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-04
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 2025-07-04
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-04
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-07-04
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-04
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-04
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2025-03-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-15
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-06-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-10
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-03-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-18
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-23
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-23
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-09-15
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-09-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-09-15
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-09-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-09-15
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2019-09-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-09-15
Health
Implement a program that monitors antibiotic use.
Corrected 2019-09-15
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 2019-09-15
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-09-15
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2019-09-15
Health
Provide activities to meet all resident's needs.
Corrected 2019-09-15
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 2019-09-15
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 2019-09-15
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-09-15
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 2019-09-15
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-15
Penalties and ownership
Corporate Officer · Individual
5% Or Greater Direct Ownership Interest · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
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