Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Helen Bernardy Center D/p Snf during CMS and state inspections, most recent first.
Failure to Honor Shower Preference: A resident who was dependent on a ventilator and needed total assistance with ADLs did not receive showers for over two years despite the family member’s repeated requests. Staff said the resident was the only one receiving bed baths, while the OT, DON, and ADM acknowledged the need for a shower solution and noted that showers can support hygiene, skin care, and relaxation. The care plan stated the resident would be bathed, showered, and shampooed on a regular schedule.
A resident with cerebral palsy who was nonverbal and dependent for all ADLs was observed during a brief change with the privacy curtain pushed back and the resident’s buttocks, legs, and genitals exposed to view. Two CNAs provided care at the bedside, and the ADM stated the resident’s dignity was not respected during the change. The facility policy reviewed stated privacy curtains may be used during direct patient care when a second staff member is present.
A resident with gastrostomy status had a tube feeding syringe found hanging on the TF pole instead of being stored in its plastic bag. The DON stated the syringe should be placed back in the bag for infection control, and facility policies addressed proper syringe storage and infection-related risk reduction.
The facility failed to consistently implement care plans for residents with cerebral palsy and congenital malformation, leading to potential negative impacts on their health. A resident's tummy time and another's ambulation were not documented, suggesting non-compliance with care plans. Additionally, a resident with a gastrostomy was fed solid foods against medical advice. Staff interviews confirmed the importance of following and documenting care plans.
The facility failed to maintain food safety and sanitation standards, with issues including improper air gaps in floor sinks, unsanitary cutting boards, debris in ice machines, and inconsistent thermometer calibration. These deficiencies were acknowledged by the Director of Food Services and other staff, posing a risk of foodborne illness to residents.
A resident with cerebral palsy and traumatic brain injury had an inaccurate MDS, which failed to document their use of intermittent and Foley catheterization, instead indicating an ostomy. Facility staff confirmed the error, highlighting the importance of accurate MDS for proper care communication.
A facility failed to revise a comprehensive care plan for a resident with cerebral palsy and severe developmental delay, who required specific catheterization and antibiotic flushes. The care plan did not address the resident's urinary retention issues, leading to urinary tract infections. The DON acknowledged the lack of personalization in the care plan, highlighting the need for individualized plans to ensure effective communication among healthcare team members.
The facility failed to upload the MDS for three residents within an appropriate time frame, as required by policy. The MDS, crucial for developing individualized care plans, was delayed by months, contrary to the expectation of uploading within a week. This delay could impact the residents' care, as the MDS is essential for ensuring appropriate care.
A resident with cerebral palsy and chronic lung disease received medication via a gastrostomy tube from an LN who failed to perform hand hygiene before proceeding to tracheostomy care. The LN used the same gloves throughout the procedure, contrary to the facility's infection control policies, which require hand hygiene between tasks to prevent cross-contamination. Both the LN and DON acknowledged the lapse in protocol.
Failure to Honor Resident’s Shower Preference
Penalty
Summary
The facility did not reasonably accommodate a resident’s needs and preferences for bathing when it failed to honor the family member’s request for showers. Resident 32 was admitted with epilepsy, was dependent on a ventilator, required staff assistance for all activities of daily living, and was unable to move voluntarily or sit upright without support. The resident’s family member stated that the resident had been receiving bed baths but had not had a proper shower in over two years, including before admission to the facility, and said a shower would be more relaxing, calming, and better for full cleanliness and skin care. During interviews, a CNA stated this resident was the only one receiving all bed baths while other residents were showered in the shower room, and said the resident would likely enjoy a shower and be more relaxed afterward. An OT stated she became aware in December 2025 that a solution was needed for the resident to shower and described attempts to assess options, including a shower bed that was too large for the shower room and a pediatric shower bed that was too small and unsafe for turning the resident. The DON and Administrator stated they were aware of the family member’s concerns and acknowledged that a shower can be better for mental health, skin, hygiene, and relaxation. The care plan stated the resident would be bathed, showered, and shampooed on a regular schedule and given ample time to enjoy hygiene.
Failure to Protect Resident Privacy During Brief Change
Penalty
Summary
The facility failed to ensure a resident’s privacy and dignity were protected during personal care for one of 13 residents. Resident 4 was admitted with diagnoses including cerebral palsy and repeated UTI, did not speak, and was dependent on staff for all ADLs. The resident could not control bladder and bowels and was changed by staff. During observation, two CNAs were seen providing a brief change while standing on either side of the bed, with the privacy curtain pushed back to the head of the bed and looped closed. The resident was rolled to face the window, and bare buttocks were visible from the doorway. The resident’s legs and genitals were exposed while being turned, cleaned, and fitted with a new brief. The Administrator stated she observed the resident being exposed during care and stated brief changes are private and the resident’s dignity was not respected when changed without privacy. The CNA stated the facility policy was to provide privacy by blocking with staff bodies and said curtains were not pulled. The facility policy reviewed stated that privacy curtains may be used to protect privacy and dignity during direct patient care when a second staff member is present.
Tube Feeding Syringe Left Hanging on Pole
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when a tube feeding syringe for Resident 22 was found hanging on the tube feeding pole and not stored in its plastic bag. Resident 22 was admitted with gastrostomy status, and on observation of the resident's room, the syringe used for administering medications, fluids, and nutrition was seen hanging on the pole instead of being placed back in the plastic bag. During interview, the DON stated it was her expectation that the tube feeding syringe be placed back into the plastic bag for infection control. Facility policies titled Gastrostomy Tube Feeding, Preparation, Storage, and Administration of Medications, and Infection Prevention and Control Management Plan all addressed storage of syringes and reducing infection-related risk related to medical instruments.
Inconsistent Implementation of Care Plans
Penalty
Summary
The facility failed to consistently implement appropriate services for four residents, leading to potential negative impacts on their overall care and health. For Resident 1, who was diagnosed with cerebral palsy, the care plan included daily tummy time to improve mobility and range of motion. However, there was no consistent documentation that this activity was performed, as confirmed by interviews with the Administrator, Clinical Activities Assistants, and the Activities Program Manager. The lack of documentation suggested that the care plan was not followed, which could lead to stiffness or decline in the resident's condition. Resident 3, diagnosed with congenital malformation, had a care plan that included ambulation with a gait trainer. Despite the Physical Therapy notes indicating specific goals for standing and ambulation, there was no consistent documentation of these activities being implemented. Interviews with staff, including Clinical Activities Assistants and Licensed Nurses, highlighted the importance of following care plans to maximize residents' potential and the necessity of documenting care activities to confirm their completion. Resident 4, also diagnosed with cerebral palsy, was on a standing program as per the care plan. However, the standing program was not consistently documented as being implemented. Additionally, Resident 4 had a gastrostomy and was not supposed to eat by mouth due to aspiration risks, yet was observed being fed solid foods by a family member. This was against the recommendations of Occupational Therapy and the care plan, which called for pureed foods. The facility's failure to update and follow care plans, as well as to communicate and document care activities, contributed to these deficiencies.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation standards in several areas of the kitchen, as observed during a survey. Two floor sinks had pipes without the required air gap, which could lead to contamination from backflow. Cutting boards with deep cuts and food stains were stored in the clean area, making them difficult to sanitize and potentially allowing pathogenic microorganisms to accumulate. Additionally, two ice machines were found with debris inside the storage parts, indicating a lack of regular cleaning and maintenance. The Director of Food Services and other staff acknowledged these issues during interviews. Furthermore, the facility did not consistently calibrate food thermometers according to its policy, which requires daily calibration. The Head Chef admitted to calibrating thermometers only twice a week, and records showed calibration was performed on only a few days in October and November. This inconsistency in thermometer calibration could lead to inaccurate temperature readings, posing a risk of foodborne illness to residents. The Head Food Service Worker emphasized the importance of accurate thermometer calibration to ensure food safety.
Inaccurate MDS Completion for a Resident
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for a resident, which is a critical health status screening and assessment tool. This deficiency was identified for one of the six sampled residents, who was admitted with diagnoses including cerebral palsy and traumatic brain injury. The resident's care plan indicated the use of intermittent catheterization during the day and a Foley catheter for continuous drainage at night. However, the MDS inaccurately documented that the resident did not receive intermittent or Foley catheterization, instead indicating the presence of an ostomy, which the resident did not have. Interviews with facility staff, including a Licensed Nurse, the Program Manager, and the Director of Nursing, confirmed the inaccuracy of the MDS. The Program Manager acknowledged the error in the MDS dated September 4, 2024, and emphasized the importance of accurate MDS completion to ensure proper care communication to nursing staff. The Director of Nursing reiterated that the MDS is essential for driving care and reporting accurate data to the government. The facility's policy requires an RN to certify the accuracy of the assessment, which was not adhered to in this instance.
Failure to Revise Comprehensive Care Plan for Catheterization
Penalty
Summary
The facility failed to revise a comprehensive care plan for a resident requiring intermittent and indwelling catheterization. The resident, who was admitted with diagnoses including cerebral palsy and severe developmental delay, had specific medical orders for catheterization and antibiotic flushes. However, the care plan for urinary incontinence was not personalized to address the resident's urinary retention issues, which had led to urinary tract infections. The Director of Nursing (DON) acknowledged the care plan's lack of personalization and emphasized the importance of individualized care plans to ensure effective communication among healthcare team members, especially with the presence of temporary staff. The facility's policy on care plans requires them to be based on comprehensive assessments and reviewed by the nursing team, with updates as needed due to changes in a resident's health condition. Despite this policy, the care plan for the resident in question did not reflect the specific needs and medical orders, potentially leading to negative clinical outcomes. The DON recognized the need for more detailed care plans to guide staff, particularly those who are new or temporary, in providing appropriate care.
Delayed Upload of MDS Assessments
Penalty
Summary
The facility failed to upload the Minimum Data Set (MDS) for three residents within an appropriate time frame, which is crucial for developing individualized care plans. The Program Manager emphasized the importance of the MDS in ensuring residents receive appropriate care, while the Director of Nursing stated that documentation should be completed within the same shift and uploaded into the electronic health record within a week. However, the MDS assessments for Residents 59, 63, and 66 were uploaded months after their completion, which is not acceptable according to the facility's policy. The facility's policy, revised in September 2024, requires that once the MDS is complete, it should be scanned into the resident's electronic health record within a reasonable time frame. Despite this policy, the MDS assessments for the three residents were significantly delayed, with some assessments taking several months to be uploaded. This delay in uploading the MDS assessments could potentially impact the residents' care, as the MDS is used to create accurate and individualized care plans.
Infection Control Breach During Medication and Tracheostomy Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during a medication administration and tracheostomy care procedure for a resident. The resident, who was admitted with cerebral palsy, gastrostomy tube dependency, and chronic lung disease, was observed receiving medications via a gastrostomy tube by a licensed nurse. After administering the medications, the nurse proceeded to perform tracheostomy site care without changing gloves or performing hand hygiene, which is against the facility's infection control policy. The nurse used the same gloves to clean the tracheostomy site, apply a topical medication, and place sterile sponge dressings, which could lead to cross-contamination. During interviews, both the nurse and the Director of Nursing acknowledged the importance of hand hygiene between procedures to prevent contamination. The facility's policies on hand hygiene and tracheostomy care clearly state the need for hand hygiene before and after contact with body fluids and before performing tracheostomy care, which were not followed in this instance.
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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 San Diego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Shores Post-acute | 0.4 mi | ★★★★★ | 6 | 0 |
| Kearny Mesa Convalescent And Nursing Home | 1.2 mi | ★★★★★ | 1 | 0 |
| Hillcrest Heights Healthcare Center | 3.7 mi | ★★★★★ | 1 | 0 |
| Mission Hills Post Acute Care | 4 mi | ★★★★★ | 0 | 0 |
| Balboa Nursing & Rehabilitation Center | 4.1 mi | ★★★★★ | 7 | 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.