Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glenbrook during CMS and state inspections, most recent first.
The facility failed to document nonpharmacological or behavioral interventions before starting antipsychotic medications for two residents. One resident with Alzheimer’s disease, dementia, and paranoia received olanzapine, and another resident with Parkinson’s disease, dementia, and hallucinations received quetiapine; in both cases, the DON confirmed no prior behavioral interventions were done and behavior monitoring showed no documented behaviors.
Survey Results Binder Not Readily Identified: Three of four residents polled at a resident council meeting did not know where the survey results binder was located. The ADM verified the binder locations and confirmed there was no sign at one site indicating where to find it. The ADM also stated the facility had no policy and procedure for posting or making survey results accessible.
Failure to Notify Ombudsman of Resident Discharges: The facility did not document sending required written notice to the State LTC Ombudsman for two residents who were discharged or transferred. One resident was sent to the hospital and later returned, and another resident with a left femur fracture was discharged home after meeting functional goals. Staff stated Medical Records was responsible for the notifications, but no written ombudsman notice was found in either record.
Failure to provide assistive device for repositioning: A resident with a recent fall and right femur fracture, who needed substantial/maximal assistance for bed mobility, was observed using the bedside drawer to help turn in bed and stated difficulty repositioning. A CNA said this was not safe practice, an LVN confirmed the resident did not have an assistive device for positioning, and the DON confirmed the issue was not reported or addressed.
A resident with dementia and diabetic neuropathy fell and fractured her wrist due to the facility's failure to consistently implement her care plan. Despite requiring assistance and reminders for safe transfers, the resident attempted to sit without adequate supervision, resulting in a fall. The care plan had been revised to include assistance and standby support, but these measures were not consistently followed, leading to the incident.
Failure to Use Nonpharmacological Interventions Before Antipsychotic Use
Penalty
Summary
The facility failed to initiate nonpharmacological or behavioral interventions before starting antipsychotic medications for two residents. One resident had diagnoses including Alzheimer’s disease, dementia, delusional disorders, depression, mild cognitive impairment, and disorientation, and was documented as alert to person but not to place or time. That resident was receiving olanzapine 2.5 mg in the evening for psychosis manifested by paranoia that staff had a conspiracy against her. The record showed psychiatry notes continuing the medication, but the DON stated there was no non-pharmacological or behavior intervention done before the olanzapine was given, and behavior monitoring from the documented period showed no behaviors recorded. The second resident had diagnoses including Parkinson’s disease, dementia, and psychosis, and was alert and oriented to name only with no capacity to make his own decisions. That resident was ordered quetiapine fumarate 25 mg at bedtime for hallucinations, later changed to quetiapine fumarate 0.5 mg daily for hallucinations. The DON stated there was no non-pharmacological or behavior intervention done before the quetiapine was given, and the behavior monitoring sheet showed no documented behaviors during the reviewed period. The DON was also unable to find documentation of non-pharmacological or behavioral intervention prior to initiating the quetiapine on readmission.
Survey Results Binder Not Readily Identified
Penalty
Summary
The facility failed to ensure that three of four sampled residents, Residents 2, 44, and 11, knew the location of the survey results binder. During an interview on 9/17/25 at 2:30 PM, three of four residents polled at the resident council meeting did not know where the survey results binder was located. During a concurrent observation of the facility and interview with the Administrator on 9/17/25 at 4:37 PM, the Administrator verified the three locations of the survey results binders and confirmed there was no sign at one of the sites in the facility indicating where to find it. The Administrator stated that the facility did not have a policy and procedure regarding posting and accessibility of survey results. A review of the State of California-Health and Human Services Agency, Attachment F Resident [NAME] of Rights, Section 72527 Skilled Nursing Facilities indicated that a resident has the right to examine the results of the most recent survey and any plan of correction, and that the facility must make the results available in a place readily accessible to residents and post notice of their availability.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman before discharge for two sampled residents, Resident 5 and Resident 7. For Resident 7, the history and physical dated 9/2/25 indicated the resident was sent to the hospital on 8/24/25 and returned to the facility on 8/30/25. During interview and record review, the Social Services Director stated the facility must send written notification to the ombudsman when a resident is discharged or transferred, and Medical Records staff must send the notification. The Medical Records Director confirmed there was no written notification of transfer sent to the ombudsman. For Resident 5, the admission record indicated the resident was admitted due to a fall resulting in a left femur fracture, and the history and physical stated the resident had the capacity to make his own healthcare decisions. The interdisciplinary discharge summary indicated Resident 5 was discharged home with a discharge reason of met functional goals, but there was no documented evidence in the clinical record of notification to the ombudsman. The facility policy titled Record Content. Transfer and Discharge Notice stated that a written discharge notice must be provided to the resident and resident representative with a copy to the State LTC Ombudsman at least 30 days prior to discharge or as soon as possible, and that the copy to the ombudsman must be sent at the same time notice is provided to the resident and resident representative.
Failure to Provide Assistive Device for Repositioning
Penalty
Summary
The facility failed to properly identify and provide necessary assistive devices for repositioning for one sampled resident. During a concurrent observation and interview on 9/16/25 at 9:28 AM, the resident was observed holding on to the bedside drawer while turning to their side and stated difficulty repositioning in bed. The resident had been using the bedside table drawer to assist in turning to their side. Record review showed the resident was admitted on [DATE], had a history and physical dated 9/5/25 noting a chief complaint of a fall resulting in a right femur fracture, and had the capacity to make their own healthcare decisions. The MDS dated 9/5/25 indicated the resident needed substantial/maximal assistance for bed mobility. A CNA stated the resident was assisted with repositioning every 3 to 4 hours and would grab the bedside table drawer when turning, and stated this was not safe practice and could cause injury. An LVN stated on 9/18/25 that the resident did not have an assistive device for positioning. The DON stated staff were expected to monitor safety and report incidents to nursing leadership to address residents' needs, and confirmed the resident's use of the bedside drawer when turning was not reported and the resident's need was not addressed.
Failure to Implement Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to consistently implement a written care plan for a resident, leading to an unwitnessed fall and a fractured wrist. The resident, who was admitted with diagnoses including unspecified dementia and diabetic neuropathy, required assistance for transfers and reminders for safety during activities of daily living. Despite these needs, the resident attempted to transfer into a chair without adequate supervision, resulting in a fall. Interviews with staff revealed that the resident was known to require assistance and reminders to safely transfer, yet these measures were not consistently applied. The care plan for the resident had been revised to include partial to maximum assistance with activities of daily living and standby assistance to prevent falls. However, the staff did not adhere to these guidelines, as evidenced by the resident's fall in the sunroom. The incident occurred when the resident attempted to sit down and slipped, with the activities assistant noting the lack of proper supervision. The care plan also noted previous falls, indicating a pattern of insufficient implementation of safety measures.
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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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Nursing homes near Carlsbad
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Dorothy & Joseph Goldberg Healthcare Center | 2.3 mi | ★★★★★ | 1 | 0 |
| Aviara Healthcare Center | 2.5 mi | ★★★★★ | 27 | 0 |
| Encinitas Post-acute | 2.6 mi | ★★★★★ | 0 | 0 |
| Village Square Healthcare Center | 5.3 mi | ★★★★★ | 2 | 0 |
| Bayshire Carlsbad | 7.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.