CARMEL MOUNTAIN REHABILITATION & HEALTHCARE CENTER
11895 AVENUE OF INDUSTRY
SAN DIEGO, CA, 92128
8586730101
CCN: 555326
3
Overall2
Health3
Staffing5
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
OIG Federal Exclusion Matches (1)
This facility's name matches one or more entities on the OIG List of Excluded Individuals/Entities (LEIE). Excluded parties are prohibited from participation in Medicare and Medicaid programs.
CENTURION HEALTHCARE, INC
1128a1
Excluded 2013-04-18
OIG Corporate Integrity Agreements (2)
One or more owners of this facility have entered into Corporate Integrity Agreements (CIAs) with the OIG. CIAs are compliance agreements typically resulting from healthcare fraud settlements.
Lincare Inc.
Matched via: LINCARE INC
Closed
2024-01-23
Lincare Inc.
Matched via: LINCARE INC
Effective
2023-08-10
Ownership
| Name | Role | % |
|---|---|---|
| FLAGSTONE HEALTHCARE SOUTH LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| THE ENSIGN GROUP INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% |
| PORT, BARRY | CORPORATE DIRECTOR | NOT APPLICABLE |
| WILLITS, ADAM | CORPORATE OFFICER | NOT APPLICABLE |
| BURNAM, SOON | CORPORATE OFFICER | NOT APPLICABLE |
| KEETCH, CHAD | CORPORATE OFFICER | NOT APPLICABLE |
| OH, KATHERINE | CORPORATE OFFICER | NOT APPLICABLE |
| SATO, AMI | CORPORATE OFFICER | NOT APPLICABLE |
| CETNA STAFFING INC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| SEVENOAKS CAPITAL ASSOCIATES LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| KALAFER, MICHAEL | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| MATTHEWS, GLENN | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| LINCARE INC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
Health Deficiencies (50)
2026-01-22 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2025-09-16 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2025-09-04 · Health
D
F835 · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
E
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2025-04-24 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F865 · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
E
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
D
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
E
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2024-12-26 · Health
E
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2024-10-15 · Health
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
2024-09-13 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F808 · Nutrition and Dietary Deficiencies
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
2024-07-30 · Health
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024-05-10 · Health
D
F921 · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F726 · Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
D
F693 · Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
D
F688 · Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
D
F578 · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
D
F554 · Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2023-07-28 · Health
D
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F699 · Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
5.26
RN Hrs/Resident/Day0.54
0.97
LPN Hrs/Resident/Day0.81
1.64
CNA Hrs/Resident/Day2.33
2.65
PT Hrs/Resident/Day0.12
0.16
Data as of 2026-03-01