Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Encinitas Post-acute during CMS and state inspections, most recent first.
A resident with multiple health conditions experienced a worsening of a right heel pressure injury from stage 2 to unstageable, but the care plan was not updated to reflect this change. The ADON confirmed the care plan should have been revised according to facility policy, which requires updates for acute changes in condition.
Two residents with cognitive impairment and pressure injuries did not receive appropriate pressure ulcer care. One resident's wound care orders were not implemented, the IDT did not meet to address the worsening wound, and the physician was not notified. Another resident's low air loss mattress was not set to the correct weight, contrary to care expectations. These failures resulted in deficiencies in pressure injury management.
Surveyors found that the facility's low-temperature dishwashing machine had visible chalky build-up and lacked proper cleaning documentation, despite facility policy requiring daily cleaning and weekly de-liming. Staff interviews revealed uncertainty about when the machine was last cleaned, and the cleaning schedule did not specifically include the dishwashing machine, resulting in unsanitary conditions and risk for foodborne illness.
Quarterly MDS assessments for several residents with complex medical histories were not completed or signed within the required timeframes, with some assessments left incomplete or finished weeks after the mandated deadlines. Staff interviews confirmed delays and a backlog in the MDS department, with acknowledgment of being behind on required assessments.
Two residents were not properly notified of changes in Medicare coverage when discharged from Part A Skilled Services, as required beneficiary notices were signed only by staff without obtaining resident or representative signatures or documenting refusals. In both cases, staff did not follow procedures for timely delivery or documentation of the SNF ABN and NOMNC forms, and there was no evidence of attempts to contact responsible parties or record refusals.
The facility did not complete and sign comprehensive MDS assessments within 14 days of the ARD for two residents, one with multiple chronic conditions and another with neurological and psychiatric diagnoses. Staff interviews revealed that the MDS department was behind on assessments due to staffing changes and inexperience, resulting in assessments remaining incomplete or being signed late, in violation of federal requirements.
A resident was admitted with an anxiety disorder and later diagnosed with major depressive disorder and schizoaffective disorder. The facility did not complete or submit updated Level I PASARR screenings after these new mental health diagnoses, as confirmed by interviews with nursing leadership and a review of facility policy.
A resident was admitted with a diagnosis of generalized anxiety disorder and was receiving psychotropic medications, but the Level I PASARR completed prior to admission did not document the mental health diagnosis or medication use. Facility staff did not complete a corrected PASARR upon admission, resulting in the omission of the resident's mental illness from required screening.
A resident with severe cognitive impairment and a history of stroke was care planned to have a fall mat beside the bed due to high fall risk, but repeated observations showed the mat was missing while the resident was in bed. Staff interviews revealed confusion over responsibility for ensuring and documenting the intervention, and facility leadership confirmed the mat should have been in place at all times.
Two residents with respiratory conditions had their nebulizer and CPAP masks repeatedly left unbagged on bedside and overbed tables, exposing the face-contact portions to environmental surfaces. Despite facility policy requiring respiratory masks to be stored in labeled bags when not in use, staff failed to consistently follow this protocol, and interviews confirmed that the responsibility for proper storage was not always met.
A resident with a history of wandering and aggressive behavior entered the dining hall unsupervised and hit another resident on the arm. Despite the need for 1:1 supervision, staff were not present during the incident, leading to the altercation. The facility's policy on abuse prevention was not followed, resulting in the incident.
A resident with Alzheimer's and delirium was not provided with an individualized care plan addressing the need for 1:1 supervision while in a wheelchair, leading to unsupervised wandering and altercations. Staff interviews confirmed the necessity of constant supervision, which was not documented in the care plans.
The facility did not report the results of an abuse investigation involving two residents to the CDPH within the required timeframe. Initially, the administrator and DON claimed the results were sent, but later confirmed they were not. The facility's policy requires reporting within five working days, which was not followed.
A facility failed to create a comprehensive care plan for a resident at risk for abuse, leading to staff unawareness of the resident's risk and necessary mitigation measures. The deficiency was noted during an investigation of an altercation between two residents. Despite the IDT's recommendations for specific interventions, these were not included in the care plan. The facility's focus was on protecting others from the resident, rather than considering the resident's potential victimization.
The facility failed to provide privacy for a male resident during bathing, leaving the shower room door wide open and only partially obscuring the shower stall with a curtain. The resident was seen without clothing, and staff admitted to not following the facility's policy requiring the door to be closed during bathing.
A resident did not receive six out of 14 prescribed medications for eight days due to an error in entering physician orders into the computer system. This oversight was discovered when the resident was sent to the hospital for treatment. The missed medications were critical for managing the resident's lung inflammation, heart rhythm, and preventing blood clots.
Failure to Revise Care Plan After Pressure Injury Worsened
Penalty
Summary
The facility failed to revise the written care plan for a resident after a pressure injury worsened from stage 2 to unstageable. The resident, who was admitted with multiple diagnoses including a left femur fracture, need for assistance with personal care, and cognitive communication deficit, developed a stage 2 pressure injury on the right heel. Documentation showed that the wound progressed to an unstageable pressure injury, but the care plan, which initially noted a right heel blister, was not updated to reflect this change in condition. During a joint interview and record review, the ADON confirmed that the care plan should have been revised when the wound worsened, emphasizing the importance of updating care plans to ensure appropriate care. The facility's policy requires the development of episodic or short-term care plans for acute or temporary changes in a resident's condition, but this was not followed in this case.
Failure to Provide Proper Pressure Ulcer Care and Equipment Settings
Penalty
Summary
Two residents experienced deficiencies in pressure ulcer care and prevention. One resident, admitted with a left femur fracture, cognitive impairment, and no pressure injuries, developed a stage 2 pressure injury (clear fluid-filled blister) on the right heel. The wound worsened to an unstageable pressure injury covered with slough. Despite a wound care recommendation to use medihoney and foam dressing, the treatment administration record showed only skin prep was applied, and the recommended treatment was not implemented. There was no documentation of an Interdisciplinary Team (IDT) meeting to address the worsening wound, nor was the attending physician notified of the change in the wound's status. A second resident, with severe cognitive impairment and a stage 3 pressure injury, was observed using a low air loss mattress intended for wound management. The mattress was set for a person weighing 250 pounds, while the resident's actual weight was 91 pounds. The treatment nurse confirmed the mattress was not set appropriately for the resident's weight, which is necessary for effective pressure redistribution and wound healing. The facility's policy required evidence-based interventions and appropriate support surfaces for residents at risk or with pressure injuries, but did not provide specific guidance on mattress settings. Both cases demonstrated failures to follow established protocols for pressure injury management, including prompt implementation of wound care orders, interdisciplinary assessment, physician notification, and proper use of pressure-relieving equipment. These inactions contributed to the deficiencies identified during the survey.
Failure to Maintain and Document Sanitary Conditions of Dishwashing Equipment
Penalty
Summary
The facility failed to maintain its low-temperature dishwashing machine in a clean and sanitary condition, as observed during multiple kitchen inspections. The dishwashing machine was found with a white and brown chalky build-up around the openings of both the dirty loading and clean exit doors, as well as on the top of the machine. Review of the facility's cleaning schedule and check-off forms revealed that there was no specific documentation indicating when the dishwashing machine was last cleaned, and the last recorded cleaning of the dish area walls/fan was nearly two weeks prior to the observation. The facility's policy required daily cleaning and weekly de-liming of the dishwashing machine, but these actions were not consistently documented or verifiable. Interviews with dietary staff, the Certified Dietary Manager, the Registered Dietitian, the Director of Nursing, and the Administrator confirmed that the expectation was for the dishwashing machine to be cleaned and documented according to the established schedule. However, staff were unable to confirm the last cleaning date, and the cleaning schedule did not specifically include the dishwashing machine. The lack of proper cleaning and documentation placed residents at risk for foodborne illnesses, as the equipment used for cleaning dishes was not maintained in accordance with professional standards and facility policy.
Failure to Complete and Sign Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed at least once every three months and signed as complete within 14 days of the Assessment Reference Dates (ARDs) for multiple residents. According to the CMS Long-Term Care RAI 3.0 User's Manual, quarterly assessments must be completed every 92 days following the previous OBRA assessment, and the MDS must be signed as complete within 14 days of the ARD. The survey found that for seven residents reviewed, these requirements were not met, with assessments either completed late, left incomplete, or not signed within the required timeframe. Specific examples included residents with complex medical histories such as sequelae of cerebral infarction, congestive heart failure, senile degeneration of the brain, hemiplegia, chronic kidney disease, and other significant diagnoses. For these residents, MDS assessments were either not completed within the mandated 92-day interval, not signed as complete within 14 days of the ARD, or left in progress well past the required deadlines. In some cases, sections of the MDS were completed weeks after the ARD, and in others, the assessments remained incomplete with no signature to indicate completion. Interviews with facility staff, including the DON, MDS Manager, and MDS Assistant, revealed that the MDS department was behind on assessments, with staff acknowledging delays and incomplete work. The MDS Assistant was relatively new to the role, and the facility had experienced staffing challenges, leading to a backlog of MDS assessments. The Administrator confirmed awareness of the issue and stated expectations for timely completion in accordance with the RAI manual, but the deficiency persisted at the time of the survey.
Failure to Provide and Document Required Medicare/Medicaid Coverage Notices
Penalty
Summary
The facility failed to provide appropriate and timely notices of payor source changes to residents when they were discharged from Medicare Part A Skilled Services, despite days of eligibility remaining. Specifically, staff did not ensure that required beneficiary notifications, such as the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC), were properly completed, signed by the resident or their representative, or documented when signatures were refused or not possible. In both reviewed cases, staff members signed the forms themselves without obtaining the required resident or representative signatures, and there was no documentation of attempts to contact responsible parties or to record refusals to sign. One resident, who had a history of hypertensive heart disease and stage 3 chronic kidney disease, was admitted with a responsible party and was assessed as independent in cognitive skills but with memory problems. The resident experienced a payor change, and the SNF ABN and NOMNC forms were signed by staff after the resident was discharged from Part A Skilled Services. The forms did not specify which care was not covered, and there was no evidence that the resident or their representative received or signed the forms. The case manager confirmed that she was unsure of the correct procedures, did not document any verbal consent, and had checked an option on the form without understanding its meaning. Another resident, with diagnoses including depression, cognitive communication deficit, and chronic kidney disease, was also subject to a payor change. The SNF ABN form for this resident was signed by two staff members, with no signature from the resident, who was cognitively intact and listed as their own responsible party. The resident stated they did not know who signed the form, and the case manager confirmed that the resident refused to sign but that this was not documented. Interviews with facility leadership confirmed that staff were expected to provide these notices timely and to document when they were given and whether the resident or responsible party signed or refused, but this was not done in these cases.
Failure to Complete MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed and signed as required within 14 days of the Assessment Reference Date (ARD) for two residents. According to facility policy and the CMS RAI 3.0 User's Manual, comprehensive assessments must be completed and signed within the specified timeframe. However, for one resident with a history of chronic obstructive pulmonary disease, adult failure to thrive, dementia, and disorientation, the annual MDS assessment with an ARD of 03/26/2025 was still marked as 'In Progress' at the time of the survey, with several sections incomplete and the assessment not signed as complete. Another resident, who had diagnoses including Parkinson's disease, restless leg syndrome, and schizoaffective disorder, had an annual MDS assessment with an ARD of 02/27/2025 that was not signed as complete until 04/25/2025, which exceeded the 14-day requirement. Interviews with the MDS Manager, MDS Assistant, and DON revealed that the MDS department was behind on assessments, with staff acknowledging delays and ongoing efforts to catch up. The MDS Assistant reported using a spreadsheet to track due dates, but assessments from previous months remained incomplete at the time of the survey. The Administrator confirmed that timely completion of MDS assessments was expected and acknowledged challenges within the MDS department. The DON and MDS staff indicated that staffing changes and inexperience contributed to the delays, and that part-time staff were being utilized to assist with the backlog. Despite these efforts, the required MDS assessments for the two residents were not completed within the mandated timeframe, resulting in noncompliance with federal requirements.
Failure to Update PASARR After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that a new Level I Preadmission Screening and Resident Review (PASARR) was submitted after a resident was diagnosed with additional mental disorders during their stay. The resident was initially admitted with a diagnosis of generalized anxiety disorder, and later received diagnoses of major depressive disorder, recurrent, moderate, and schizoaffective disorder, depressive type. Despite these new psychiatric diagnoses, there was no documented evidence that the facility completed or submitted updated Level I PASARR screenings as required by their policy. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that the facility was not updating Level I PASARRs when new psychiatric diagnoses were added to a resident's record. The facility's policy required prompt referral for a Level II review when a resident exhibited a newly evident possible serious mental disorder, but this process was not followed for the resident in question.
Failure to Accurately Reflect Mental Health Diagnosis in PASARR Screening
Penalty
Summary
The facility failed to ensure that a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a diagnosed mental illness for one resident. The resident was admitted with a diagnosis of generalized anxiety disorder, which was documented in the admission record as an active diagnosis and classified as an admission diagnosis. The resident's Minimum Data Set (MDS) assessment confirmed the presence of an active anxiety diagnosis and indicated the use of antipsychotic and antidepressant medications. However, the Level I PASARR completed at the hospital prior to admission did not reflect the resident's diagnosis of generalized anxiety disorder or the use of psychotropic medications, resulting in a negative PASARR and no Level II evaluation being required. Interviews with facility staff revealed that hospital staff typically completed the Level I PASARRs, and facility staff were expected to review them for accuracy upon admission. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the facility had recently started checking PASARRs for accuracy due to previous omissions by hospitals, but had not reviewed all prior admissions. In this case, no corrected Level I PASARR was completed upon the resident's admission, despite the presence of a qualifying mental health diagnosis.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident identified as high risk for falls. The resident, who had a history of hemiplegia and hemiparesis due to a previous stroke, severe cognitive impairment, and was dependent on staff for transfers, was care planned to have a fall mat placed beside the bed whenever in bed. Despite this, multiple observations over two days revealed that the fall mat was not present at the bedside while the resident was in bed. Interviews with staff, including LVNs and CNAs, confirmed that the expectation was for a fall mat to be in place for the resident, and that both nursing and CNA staff were responsible for ensuring interventions were implemented. However, there was confusion among staff regarding who was responsible for placing and documenting the presence of the fall mat. Some staff believed it was the nurses' responsibility, while others thought CNAs should handle it, and documentation practices did not consistently include the fall mat intervention. Further interviews with facility leadership, including the ADON, DON, and Administrator, confirmed that the fall mat should have remained in the resident's room and been in use whenever the resident was in bed. The absence of the fall mat was noted by staff, but no one could account for its removal or ensure its replacement, resulting in the resident being left without a key fall prevention intervention as required by the care plan and facility policy.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically nebulizer masks and CPAP masks, were stored in accordance with facility policy and standard precautions. Observations revealed that for two residents with significant respiratory conditions, their respiratory masks were repeatedly left unbagged on bedside tables, oxygen concentrators, or overbed tables, with the portions of the masks that made contact with the residents' faces exposed to environmental surfaces. The facility's policy required that oxygen masks be placed in labeled bags when not in use, but did not specifically address nebulizer masks. Despite this, staff interviews confirmed that the expectation was for all types of respiratory masks to be stored in bags to prevent contamination. For one resident with a history of pneumonia, COPD, and hypoxemia, the nebulizer mask was observed multiple times over several days to be unbagged and in direct contact with various surfaces in the resident's room. The resident reported using the mask twice daily and expressed concern about the mask being left out and not cleaned. Staff interviews revealed inconsistent practices regarding the replacement and storage of the mask, with some staff unsure if clean masks were provided or if used masks were properly bagged. The Director of Nursing and other staff acknowledged that masks should be stored in bags and that the responsibility for this task fell primarily to the nursing staff, with CNAs able to assist if they noticed improper storage. A second resident with acute hypoxic respiratory failure, pneumonitis, and obstructive sleep apnea also had both a CPAP mask and a nebulizer mask left unbagged on the overbed table. Multiple observations confirmed that the masks were not stored in bags as required. Staff interviews indicated that nurses were responsible for placing and removing the masks and that the expectation was for masks to be stored in labeled bags when not in use. However, staff were observed not following this protocol, and the Director of Nursing confirmed that all respiratory masks should be bagged to prevent contamination.
Failure to Protect Resident from Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had a history of wandering and aggressive behavior, entered the dining hall unsupervised and hit the resident on the arm. The incident occurred when the resident was having a private conversation with another resident, and the aggressive resident intruded, taking food from their trays. Despite being told not to touch the food, the aggressive resident yelled and hit the resident, causing distress. Staff were not present during the incident, and the resident had to call for assistance using a cell phone. The aggressive resident had a documented history of wandering, entering other residents' rooms, and taking personal items, which was known to staff. Multiple staff members, including CNAs and the director of nursing, acknowledged the resident's behavior and the need for increased supervision. The resident's care plan indicated a need for 1:1 supervision when in a wheelchair to prevent such incidents, but this was not implemented, leading to the altercation. Interviews with other residents and staff revealed that the aggressive resident's behavior was a known issue, causing discomfort and fear among other residents. The facility's policy on abuse prevention emphasized the need for sufficient staff to meet residents' needs and prevent abuse, but this was not adhered to, resulting in the incident. The director of nursing admitted that the resident's care plan should have included increased supervision to prevent further incidents.
Failure to Individualize Care Plan for Resident with Wandering Behavior
Penalty
Summary
The facility failed to ensure that the care plans for a resident with Alzheimer's Disease and delirium were individualized to address the need for increased supervision while in a wheelchair. The resident was admitted with a history of wandering and entering other residents' rooms, which led to altercations and an incident of physical abuse. Despite these behaviors being documented in the resident's care plans for elopement and mood, the necessary intervention of 1:1 supervision was not included. Interviews with staff, including CNAs and LNs, revealed that the resident required constant supervision to prevent unsafe wandering and potential altercations. The staff acknowledged that the resident's behavior of wandering and rummaging could lead to abuse, and the need for 1:1 supervision was recognized but not documented in the care plans. The Director of Nursing confirmed that the resident's care plan should have included increased supervision to prevent further incidents.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of an abuse investigation to the California Department of Public Health (CDPH) within the required five working days. The incident involved two residents, where one resident hit another. The facility's administrator and director of nursing initially stated that the investigation results had been sent to CDPH, but upon further verification, it was revealed that the results were not reported. The director of nursing acknowledged that the results should have been sent by a specific date, which was not met. The facility's policy mandates that investigative findings be reported to the appropriate state agency within five working days, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plan for Resident at Risk for Abuse
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident at risk for abuse, which resulted in staff being unaware of the resident's risk and the necessary measures to mitigate these risks. The deficiency was identified during an investigation of a physical and verbal altercation between two residents. Resident 1, who has a history of aggressive behaviors and is cognitively intact, was involved in the incident. The interdisciplinary team (IDT) had previously noted Resident 1's behaviors and recommended specific interventions, such as encouraging the resident to notify staff when others are aggressive and to remove themselves from situations. However, these recommendations were not included in the resident's care plan. The facility's policy on abuse prevention requires the identification, assessment, and care planning for residents with behaviors that might lead to conflict. Despite this, the care plan for Resident 1 did not include personalized interventions to keep the resident safe from altercations. Interviews with the Administrator and Director of Nursing revealed that the facility focused on protecting others from Resident 1, rather than considering the resident's potential victimization due to their behaviors. This oversight meant that the care plan lacked specific strategies to address the resident's behavior problems and ensure their safety.
Failure to Provide Privacy During Bathing
Penalty
Summary
The facility failed to provide privacy for a male resident during bathing. On the specified date, the shower room door was observed to be held wide open with a large magnet, and a curtain only partially obscured the shower stall. The resident was seen seated in a shower chair, facing the door, and rinsing himself with a hand-held shower head without any clothing. A staff member was present, giving verbal cues to the resident. Interviews with the Licensed Nurse (LN) and Certified Nursing Assistant (CNA) revealed that the facility's policy requires the shower room door to be closed and a sign indicating occupancy to be displayed when a resident is bathing. However, CNA 1 admitted to usually leaving the door open due to frequent staff movement in and out of the room to gather supplies. Further interviews with the resident confirmed that privacy is of utmost importance to him, and he would feel embarrassed if someone unknown saw him bathing or changing clothes. The Director of Nursing (DON) reiterated that privacy should be provided for all personal care to avoid discomfort and embarrassment. The facility's policies and procedures for bathing and resident rights, dated 2006 and 2022 respectively, also emphasize the importance of covering the resident with an appropriate drape and treating residents with respect and dignity.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer six out of 14 medications ordered by the physician for a total of eight days for one resident. This deficiency occurred because the licensed nurse responsible for processing the resident's admission paperwork did not enter all of the physician's orders into the computer system. As a result, the medications were not included in the Medication Administration Record (MAR), and the medication nurses were unaware that these medications needed to be administered. The resident was admitted with diagnoses including cancer in the right lung and pneumonia in the left lung, and was supposed to receive medications for these conditions, as well as for atrial fibrillation and depression. The error was discovered eight days later when the resident was sent to the hospital for radiation treatment. During this period, the resident missed critical medications such as Prednisone, Amiodarone, and Apixaban, which were essential for managing her lung inflammation, heart rhythm, and preventing blood clots. The resident's vital signs were monitored during this period, showing fluctuations in blood pressure, heart rate, and respiratory rate, but the omission of these medications posed significant health risks. The resident was eventually admitted to the hospital with pneumonia, sepsis, and rapid atrial fibrillation. Interviews with the Assistant Director of Nursing, licensed nurses, the facility's pharmacist, and the resident's medical doctor confirmed the oversight and the potential health risks associated with the missed medications. The licensed nurse responsible for the admission paperwork admitted to missing a page of the medication orders, which led to the medications not being entered into the system. The facility's policy on the admission of residents was reviewed, highlighting the requirement for designated staff to obtain information and perform assessments as per facility protocol, which was not fully adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Encinitas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviara Healthcare Center | 0.6 mi | ★★★★★ | 27 | 0 |
| The Dorothy & Joseph Goldberg Healthcare Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Glenbrook | 2.6 mi | ★★★★★ | 18 | 0 |
| Bayshire Torrey Pines Post-acute | 6 mi | ★★★★★ | 1 | 0 |
| Village Square Healthcare Center | 7.7 mi | ★★★★★ | 2 | 0 |
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