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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Poway Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia and severe malnutrition was left unprotected from potential abuse when their spouse, previously alleged to have physically abused the resident, was allowed unsupervised visits in the resident's room. Despite a care plan requiring monitored visits in common areas, staff were unaware of the restrictions and allowed the spouse to visit privately, contrary to policy.
A resident's family member requested copies of the resident's medical records, but the facility did not provide them within the required two business days as outlined in facility policy. The request remained incomplete four business days after submission, leaving the family member unaware of the resident's medical status.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
The facility did not obtain informed consent for bed rail use for two residents and failed to complete required ongoing assessments for three residents with bed rails. Despite policy requiring assessment, risk/benefit review, and consent, documentation was incomplete or missing, and staff confirmed that quarterly assessments and consents were not consistently performed.
Two residents with respiratory conditions had their CPAP masks and tubing left uncovered on dressers instead of being stored in labeled bags as required by facility policy, with staff interviews confirming inconsistent adherence to infection control procedures and confusion over responsibility for proper storage.
A resident with a history of cancer, malnutrition, and dysphagia had their feeding tube removed and was receiving oral nutrition, but the MDS assessment was inaccurately coded to indicate ongoing tube feeding. Multiple staff, including the MDS Coordinator, DON, and dietician, confirmed the error and that the resident's records did not support the MDS entry.
The facility did not keep room temperatures within the required 71°F to 81°F range for several residents, resulting in discomfort due to cold conditions. Multiple rooms were observed to be below policy standards, and both a resident and a responsible party reported concerns about the cold environment.
A resident left the facility against medical advice without proper documentation or physician notification, violating facility policy. Additionally, the hospital discharge medication list was not accurately transcribed, leading to potential medication errors. These deficiencies could have affected the resident's treatment and safety.
A resident and their responsible party were not informed of charges for Medicare and non-Medicare-covered services at admission, leading to potential financial hardship. The facility failed to provide a breakdown of charges for continued therapy services after benefit exhaustion, and the admissions packet was not completed. The business office manager and admissions director acknowledged the oversight, and the director of nursing and administrator recognized the financial unfairness caused by the lack of a cost estimate.
Failure to Monitor Visitation Following Abuse Allegation
Penalty
Summary
The facility failed to protect a resident from abuse by allowing the resident's wife to visit without close monitoring, despite previous allegations of physical abuse. The resident, who had severe protein-calorie malnutrition and dementia, reported to staff that his wife had smacked him on the thighs and slapped him on the cheek. The care plan required that the wife’s visits be limited to common areas and closely monitored, but staff interviews and observations revealed that the wife was allowed to visit the resident in his room unsupervised on multiple occasions. Several staff members, including CNAs and licensed nurses, were unaware of the abuse allegation and the specific visitation restrictions in place for the resident’s wife. The facility’s policies allowed for visitation restrictions in cases of suspected abuse, but staff failed to implement or communicate these restrictions effectively. The Director of Nursing and Administrator confirmed that visits should have been monitored and limited to public areas, but staff assigned to the resident did not receive this information. As a result, the resident’s wife was able to visit and assist the resident in his room without supervision, contrary to the established plan of care and facility policy.
Delay in Providing Medical Records to Resident's Family
Penalty
Summary
The facility failed to provide copies of medical records to a resident's family member within the required two business days after the request was made. The family member submitted a written request for the resident's medical records, as documented on the facility's Authorization Form For the Release of Health Information. Four business days after the request, the Medical Records Director confirmed that the request was still being processed and had not yet been completed, despite the facility's policy stating that records should be provided within forty-eight hours, excluding weekends and holidays. As a result, the family member was not aware of the resident's medical status during this period. The resident involved had a history of falls and had been admitted to the facility prior to the request.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Obtain Informed Consent and Complete Bed Rail Assessments
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails for two residents and did not complete required assessments for the continued use of bed rails for three residents. Facility policy requires that before bed rails are used, staff must assess the resident for safety risk, review risks and benefits with the resident or their representative, obtain informed consent, and document these steps. However, for the residents reviewed, documentation of informed consent was missing, and assessment forms lacked signatures and information regarding the risks and benefits of bed rail use. For one resident with severe cognitive impairment and a history of falls and brain injury, bed rails were used to assist with bed mobility and positioning. Despite multiple assessments recommending bed rails, the sections for risks, benefits, and informed consent were left blank, and there was no evidence that the resident or their representative was informed or had provided consent. The facility was unable to locate the initial consent form, and progress notes did not document any informed consent or additional assessments for bed rail use. Another resident with severe cognitive impairment and physical debility also had bed rails in use for bed mobility and transfers. Although an evaluation noted the need for bed rails and that risks and benefits were discussed, there was no signature to validate informed consent. Similarly, for a third resident with severe cognitive impairment and generalized weakness, the initial consent was documented, but subsequent quarterly assessments lacked documentation of informed consent and did not include signatures. Interviews with facility staff confirmed that required quarterly assessments and consents were not completed, partly due to a change in the electronic medical record system.
Failure to Properly Store CPAP Masks According to Infection Control Policy
Penalty
Summary
The facility failed to store continuous positive airway pressure (CPAP) masks in accordance with its infection prevention and control policy for two residents who required respiratory care. Observations revealed that both residents' CPAP masks and tubing were left uncovered and placed directly on the surface of their dressers, rather than being stored in labeled bags as specified by facility policy. The policy required that CPAP equipment be stored in a bag labeled with the date and changed weekly to limit the spread of infection. Multiple staff interviews confirmed that the expectation was for CPAP masks to be cleaned and stored in bags after use, but this was not consistently done. Both residents involved had medical histories that included respiratory conditions such as obstructive sleep apnea, lung cancer, asthma, and shortness of breath, and were receiving CPAP therapy as ordered. Staff, including nurses and CNAs, acknowledged during interviews that the proper storage procedure was not followed, and there was confusion among staff regarding responsibility for ensuring the equipment was stored correctly. The Infection Preventionist and Director of Nursing confirmed that the observed storage practices did not align with infection control protocols, and the Administrator noted a lapse in staff adherence to the policy.
Inaccurate MDS Coding for Feeding Tube Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded regarding the use of a feeding tube for one resident. The resident, who had a history of malignant neoplasm of the tongue, oral mucosa hyperplasia, malnutrition, dysphagia, and a gastrostomy, was admitted with a feeding tube. However, the resident's enteral feeding order was discontinued, and the feeding tube was removed several months prior to the quarterly MDS assessment. Despite this, the MDS assessment indicated that the resident was still receiving nutrition via a feeding tube, which was inconsistent with the resident's current care and medical records. Interviews with the resident, nursing staff, the MDS Coordinator, the Registered Dietician, and the Director of Nursing confirmed that the resident no longer had a feeding tube and was receiving nutrition orally. The facility's policy required that MDS assessments be completed by qualified staff and that the information accurately reflect the resident's current status as documented in the medical record and care plans. The inaccurate coding on the MDS was verified by multiple staff members and was acknowledged as an error during the survey.
Failure to Maintain Required Room Temperatures
Penalty
Summary
The facility failed to maintain resident room temperatures within the required range of 71°F to 81°F for four out of six sampled residents. During an observation and interview with the Maintenance Director, room temperatures were recorded as low as 64°F, with several rooms below the facility's policy standard. One resident reported feeling that his room was too cold, and the responsible party for another resident stated that the resident frequently complained about the cold temperature. The facility's policy, revised in February 2021, specifies that staff and management are to ensure comfortable and safe temperatures within the stated range to provide a homelike environment.
Incomplete Documentation and Medication Transcription Errors
Penalty
Summary
The facility failed to ensure that the medical records for a resident who left against medical advice (AMA) were accurate and complete. Specifically, there was no documentation regarding the resident's decision to leave AMA or any notification to the physician. The resident, who had been admitted with hepatic encephalopathy, left the facility without proper documentation of the events leading to the AMA decision. Interviews with the social service director, licensed nurse, and registered nurse supervisor revealed that none of them documented the conversations with the resident or notified the physician, which was against the facility's policy. Additionally, the facility did not accurately transcribe the hospital discharge medication list for the resident. The discharge summary from the hospital indicated that the medication spironolactone had been discontinued, but the facility's physician orders still listed it as an active medication. The registered nurse supervisor and director of staff development were unable to verify the admission orders or recognize the discontinued medication list, leading to potential medication errors. The facility's policies and procedures required prompt physician notification for AMA discharges and accurate medication reconciliation upon admission. However, these procedures were not followed, resulting in incomplete documentation and potential miscommunication among care providers. This lack of adherence to policies could have affected the resident's treatment and safety, as well as led to the use of unnecessary medication.
Failure to Inform Resident of Financial Obligations
Penalty
Summary
The facility failed to inform a resident and their responsible party (RP) of charges for Medicare and non-Medicare-covered services at the time of admission, as per policy. The resident was admitted with a diagnosis of fractures to the right fibula and patella. Despite receiving Medicare benefits through a Medicare Advantage plan, the facility did not provide a breakdown of charges for continued physical and occupational therapy services after the exhaustion of benefits. This oversight placed the resident and RP at risk of being uninformed about charges and obligations, potentially leading to undue hardship. Interviews and record reviews revealed that the facility's business office manager (BOM) stated that residents and their RPs are typically provided with written financial information about Medicare-covered services upon admission. However, the admissions director (AD) confirmed that the admissions packet, which should have included a financial breakdown, was not provided to or signed by the resident and/or RP. The AD acknowledged that the resident and RP were not informed of their rights and financial obligations at the time of admission, which should have been completed as part of the admissions process. Further investigation showed that the facility began charging the resident for physical and occupational therapy services after the exhaustion of Medicare benefits without providing a written estimate of costs beforehand. The BOM admitted that the resident and RP were not given written information regarding payment and charges for these services until after they had already been charged. The director of nursing (DON) and the administrator (ADMIN) both acknowledged the failure to provide necessary financial information and the potential financial unfairness to the resident and RP due to the lack of a cost estimate for uncovered services.
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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 Poway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villas At Poway | 0 mi | ★★★★★ | 0 | 0 |
| Boulder Creek Post Acute | 0.6 mi | ★★★★★ | 0 | 0 |
| Carmel Mountain Rehabilitation & Healthcare Center | 1.2 mi | ★★★★★ | 9 | 0 |
| Villa Rancho Bernardo Care Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Casa De Las Campanas | 3.7 mi | ★★★★★ | 0 | 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.