Nursing homeActive
Carmel Mountain Rehabilitation & Healthcare Center
11895 Avenue Of Industry, San Diego, CA 921288586730101120 certified beds · 115 residentsFor profit - Limited Liability companyMedicare and Medicaid
Surveys on file
11
since 2023
Deficiencies
53
● 0● 52● 1
Penalties · 3 yrs
—
none on file
Last survey
2026-04-15
Complaint
CMS overall
3 / 5
stars as published by CMS
CMS overall 3/5
Health 2
Staffing 3
Quality 5
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · California Department of Public Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-04-15 | Complaint | 021 | CMS-2567 (Care Compare) | — |
| 2026-01-22 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-09-16 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2025-09-04 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2025-04-24 | Standard | 0140 | CMS-2567 (Care Compare) | — |
| 2024-12-26 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-10-15 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-09-13 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-07-30 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-05-10 | Standard | 0170 | CMS-2567 (Care Compare) | — |
| 2023-07-28 | Standard | 070 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · California Department of Public Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2026-05-04Record 555326-20260415-F689
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-04Record 555326-20260415-F657
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-05-04Record 555326-20260415-F684
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-12Record 555326-20260122-F880
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-05Record 555326-20250916-F550
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-05Record 555326-20250916-F880
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-05Record 555326-20250904-F684
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-09-22Record 555326-20250904-F755
F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-22Record 555326-20250904-F835
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F558
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F561
F584Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F584
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F656
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F690
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F698
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F758
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F842
F865Have a plan that describes the process for conducting QAPI and QAA activities.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F865
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-24Record 555326-20250424-F880
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-02-03Record 555326-20241226-F656
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-15Record 555326-20241015-F641
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-15Record 555326-20241015-F655
F808Ensure 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.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-15Record 555326-20240913-F808
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-15Record 555326-20240913-F880
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-22Record 555326-20240730-F689
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F550
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F554
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F558
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F578
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F583
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F584
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F656
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F684
F688Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F688
F693Ensure 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F693
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F726
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F755
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F880
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555326-20240510-F921
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-28Record 555326-20230728-F558
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-28Record 555326-20230728-F656
F699Provide care or services that was trauma informed and/or culturally competent.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-28Record 555326-20230728-F699
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-28Record 555326-20230728-F755
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-28Record 555326-20230728-F758
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-28Record 555326-20230728-F759
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-28Record 555326-20230728-F812
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.96
Facility
California
National
California 0.67 · National 0.69
Total nurse hours per resident day5.02
Facility
California
National
California 4.52 · National 3.86
Weekend total nurse hours4.61
Facility
California
National
California 4.09 · National 3.42
Total nursing staff turnover40%
Facility
California
National
California 37% · National 46%
Registered nurse turnover38%
Facility
California
National
California 38% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | California | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 2.8% | 4.3% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 1.4% | 1.6% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 10.4% | 12.0% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 2.2% | 1.2% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.4% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 3.9% | 10.2% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 3.7% | 4.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 10.3% | 13.7% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Cetna Staffing Inc Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Kalafer, Michael Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Lincare Inc Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Matthews, Glenn Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Sevenoaks Capital Associates LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Burnam, Soon Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Burnam, Soon Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Caretrust Gp LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Caretrust Reit Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Cm Health Holdings LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Ctr Partnership LP Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Ensign Services Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Kalafer, Michael Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Kalafer, Michael Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Keetch, Chad Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Matthews, Glenn Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Matthews, Glenn Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Oh, Katherine Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Port, Barry Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Sato, Ami Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| The Ensign Group Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Willits, Adam Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
Part of a chain
The Ensign Group — 342 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or California.
No county cost figures on file for San Diego.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Villa Rancho Bernardo Care Center San Diego | 1.1 mi | 2026-03-04 | 0210 |
| Poway Healthcare Center Poway | 1.2 mi | 2025-08-28 | 0120 |
| The Villas At Poway Poway | 1.3 mi | 2025-05-22 | 0161 |
| Boulder Creek Post Acute Poway | 1.8 mi | 2025-02-14 | 0180 |
| Casa De Las Campanas San Diego | 4.1 mi | 2026-07-01 | 0310 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |