Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Villa Rancho Bernardo Care Center during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis after a stroke, and severe dementia was observed with a fading grayish-green discoloration above one eyebrow and could not recall how the injury occurred. Family members reported they believed the resident had fallen from bed during a night shift, but staff had no documented fall and the IDT, ADON, and DON could not determine a definitive cause, considering possibilities such as contact with a side rail or the resident hitting herself. Despite acknowledging the injury was unwitnessed and unexplained, the DON and Administrator, who served as the abuse coordinator, decided not to report the incident to the state agency because they did not consider it reportable or viewed it as light in nature, contrary to facility policies requiring that all injuries of unknown source and alleged abuse/neglect be reported to appropriate agencies within required timeframes.
A resident receiving hospice care was inaccurately coded in the MDS due to a mistake by an LN who discontinued the hospice order. The MDS coordinator did not see the hospice order and coded the resident as not receiving hospice care. The DON confirmed the resident was on hospice, highlighting a failure to adhere to the facility's policy for accurate documentation.
The facility did not include non-pharmacological interventions in the care plans of three residents with depression, despite them receiving multiple antidepressant medications. This omission was confirmed by the LN and ADON, who noted the absence of provider orders and documentation. The facility's policies require such interventions, but they were not followed, potentially affecting the supportive care provided.
A resident with a gastrostomy tube (GT) did not receive proper flushing between medications during administration, contrary to physician orders and facility policy. A nurse confirmed the failure to flush the GT, which is a standard nursing practice, and the Director of Nursing acknowledged the necessity of this procedure.
A facility failed to monitor a resident's use of mirtazapine, a psychotropic medication, as required by its policy. The resident, with diagnoses of depression and hypertension, was receiving the medication without behavior monitoring to assess its effectiveness. Staff interviews revealed a lack of awareness about the medication's necessity, and the facility's policy mandates monitoring and documentation to ensure the medication's benefit.
A resident with Dementia and Heart Failure was found with unattended medications in their room, left by a nurse for post-breakfast consumption. The resident was unaware of the medications' purpose. Interviews with staff confirmed that medications should not be left unattended, aligning with the facility's policy requiring direct observation or secure storage during medication passes.
A resident with muscle weakness and contractures had a physician's order for rolled washcloths to prevent further contractures and maintain skin integrity. However, the facility failed to document the monitoring and application of these washcloths in the resident's medical record. Interviews with staff, including a CNA, LNs, and the DON, confirmed the lack of documentation despite regular application and checks, highlighting a deficiency in maintaining accurate medical records.
A resident with a history of heart failure and severe cognitive deficits was administered amlodipine despite a physician's order to hold the medication if the systolic blood pressure was below 110. The licensed nurse failed to adhere to this parameter, administering the medication when the resident's blood pressure was 104/69, acknowledging the error and potential complications. The DON emphasized the importance of following medication orders and checking parameters.
Failure to Report Unwitnessed Unexplained Injury as Required Under Abuse Policies
Penalty
Summary
A deficiency was cited under F609 for failure to timely report an unwitnessed, unexplained injury as a suspected abuse/neglect incident to the state agency, as required by regulation and the facility’s own policies. The resident involved was admitted with hemiplegia and hemiparesis following a cerebral infarction and had unspecified dementia. The MDS documented a BIMS score of 0, indicating severe cognitive impairment. During observation, the resident was seen in a wheelchair with a fading grayish-green discoloration above the right eyebrow, and the resident could not recall how the injury occurred. Family members reported to facility staff that they believed the resident had fallen out of bed during the night shift, resulting in the discoloration near the right eye, while the facility had no record of a fall. The Social Services Director stated that on learning of the discoloration, the family believed the resident had fallen sometime during the night, but the facility’s investigation could not confirm a fall. The Interdisciplinary Team discussed possible causes, including the resident bumping her head on the side rail or hitting herself while removing hand mittens, and the SSD acknowledged there was still a possibility the resident could have fallen, but the cause remained unknown. The ADON and DON both stated that the cause of the injury could not be definitively determined because it was unwitnessed, and the resident could not verify what happened. The DON acknowledged the injury was unwitnessed and unexplained but stated it was not reported to the California Department of Public Health because she did not think it was reportable. The Administrator, identified as the facility’s abuse coordinator, also stated the injury was not considered reportable because it was “light in nature.” These actions conflicted with the facility’s written policies on Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, Abuse, Neglect, and Exploitation, and Unexplained Injuries, which require that all allegations of abuse, neglect, exploitation, mistreatment, and injuries of unknown source be reported to the Administrator and appropriate agencies within specified timeframes and investigated under abuse procedures.
Inaccurate MDS Coding for Hospice Care
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for a resident receiving hospice care, leading to a deficiency in the assessment process. Resident 212, who was admitted with a diagnosis of dementia, had been receiving hospice care since September 6, 2023. However, during the MDS assessment conducted on August 16, 2024, the resident was not coded as receiving hospice care. This discrepancy arose because Licensed Nurse 1 mistakenly discontinued the hospice order in the physician's order on April 26, 2024, which led to the absence of hospice orders in the November 2024 Order Summary. The MDS coordinator, MDS 1, did not see a physician order for hospice during the assessment and thus coded the resident as not receiving hospice care. The Director of Nursing confirmed that Resident 212 was indeed receiving hospice care and should have been accurately coded in the MDS. The facility's policy requires that documentation in the medical record be accurate, relevant, and complete, which was not adhered to in this case, resulting in the deficiency.
Failure to Implement Non-Pharmacological Interventions in Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans that included non-pharmacological interventions for three residents diagnosed with depression. These residents were receiving multiple antidepressant medications, yet their care plans lacked individualized non-pharmacological strategies. During an interview and record review, the Licensed Nurse and the Assistant Director of Nursing confirmed the absence of such interventions in the care plans and noted the lack of provider orders and documentation in the Medication Administration and Treatment Records. The facility's policies on Comprehensive Care Plans and the Use of Psychotropic Medication, both revised in December 2022, require the inclusion of resident-specific interventions and non-pharmacological strategies to aid in the reduction or discontinuation of psychotropic drugs. However, these policies were not adhered to, as evidenced by the care plans of the three residents, which did not incorporate the necessary non-pharmacological interventions, potentially limiting the supportive care these residents received.
Failure to Flush GT Between Medications
Penalty
Summary
The facility failed to adhere to the standard nursing practice of flushing a gastrostomy tube (GT) between each medication administration for a resident diagnosed with dysphagia and requiring a GT for nutritional support. During an observation of medication administration, a licensed nurse administered multiple medications via the resident's GT without flushing the tube between each medication. This practice was confirmed by the nurse as not aligning with the standard of care. A review of the resident's medication orders revealed a physician's directive to flush the enteral tube with 15-30 mLs of water before and after medication administration and 5 mLs of water between each medication. The Director of Nursing also confirmed the necessity of flushing the GT between medications. The facility's policy on medication administration via enteral tube, dated 12/19/22, supports this requirement, indicating that the tube should be flushed with at least 15 mLs of water prior to and after medication administration.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper behavior monitoring for a psychotropic medication prescribed to Resident 279, which was identified during a survey. Resident 279 was admitted with diagnoses of depression and essential hypertension and was receiving mirtazapine, an antidepressant, via a gastrostomy tube at bedtime for depression. However, there was no behavior monitoring in place to assess the effectiveness or necessity of this medication. Observations conducted on two separate occasions found Resident 279 asleep with no documented behaviors, and a review of the Minimum Data Set indicated moderately impaired cognition. Interviews with facility staff revealed a lack of awareness regarding the necessity of the medication, with a licensed nurse expressing uncertainty about why Resident 279 was receiving mirtazapine, especially given the resident's tube feeding status. The facility's policy on psychotropic medication requires monitoring and documentation to demonstrate the medication's benefit to the resident, which was not adhered to in this case. The Director of Nursing acknowledged the importance of behavior monitoring to evaluate the medication's effectiveness, highlighting the deficiency in the facility's adherence to its own policy.
Unattended Medications in Resident's Room
Penalty
Summary
The facility failed to ensure medications were not left unattended, as observed in the case of a resident diagnosed with Dementia and Heart Failure. During an observation, two medications were found unattended in the resident's room, placed on the bedside table in a small clear cup. The resident mentioned that the nurse left the medications for her to take after breakfast, but she was unaware of what the medications were or their purpose. Interviews with a Licensed Nurse and the Director of Nursing confirmed that medications should not be left unattended for residents' safety. The facility's policy on medication storage mandates that medications must be under direct observation or locked during a medication pass.
Incomplete Documentation of Physician's Order for Resident Care
Penalty
Summary
The facility failed to ensure the completeness of a clinical record for a resident, identified as Resident 153, who was admitted with diagnoses including muscle weakness and contracture of the upper arm. The deficiency was identified when a physician's order for the use of rolled washcloths to manage contractures was not monitored or documented in the resident's medical record. During an observation and interview, it was noted that the resident had rolled washcloths on both hands, which were placed by nursing staff to prevent further contractures and maintain skin integrity. However, there was no documentation of the monitoring or removal of these washcloths, which is crucial for ensuring the effectiveness of the treatment and the resident's skin health. Interviews with facility staff, including a CNA, two licensed nurses, and the Director of Nursing, revealed that while the rolled washcloths were applied and checked regularly, this was not documented in the resident's medical record. The staff acknowledged the importance of documentation to verify that the treatment was being carried out as ordered and to communicate the resident's care needs among healthcare providers. The facility's policy on consulting physician/practitioner's orders emphasized the need for transcribing orders to the medication or treatment administration record, which was not adhered to in this case.
Medication Administration Error Due to Non-Compliance with Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of amlodipine, an antihypertensive medication. The resident, who had a history of systolic heart failure and severe cognitive deficits, was ordered by the physician to receive amlodipine with the instruction to hold the medication if the systolic blood pressure (SBP) was less than 110. On a specific date, a licensed nurse administered the medication despite the resident's SBP being 104/69, which was below the prescribed parameter. The licensed nurse acknowledged the error during an interview, stating that the medication should have been held due to the low blood pressure reading. The nurse recognized the potential complications of administering the medication under these conditions, such as further lowering the blood pressure, dizziness, bradycardia, and more severe outcomes like loss of consciousness. The director of nursing also confirmed that the expectation was for nurses to follow medication orders and check parameters as per the facility's policy and procedure on medication administration.
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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) |
|---|---|---|---|---|
| Carmel Mountain Rehabilitation & Healthcare Center | 1.1 mi | ★★★★★ | 9 | 0 |
| The Villas At Poway | 1.8 mi | ★★★★★ | 0 | 0 |
| Poway Healthcare Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Boulder Creek Post Acute | 2.4 mi | ★★★★★ | 0 | 0 |
| Casa De Las Campanas | 3.3 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.