Carmel Mountain Rehabilitation & Healthcare Center

Nursing Home · San Diego, CA

CMS overall rating 3/5 For profit - Limited Liability company

CMS certification number555326

Contact & location

11895 Avenue of Industry
San Diego, CA 92128
San Diego County
Phone
(858) 673-0101
ZIP code
92128 – all care providers

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Facility details

Certified beds
120
Residents per day
114.9 (96% occupied)
Ownership
For profit - Limited Liability company
Legal name
Bernardo Heights Healthcare, INC.
Chain
The Ensign Group (342 facilities, avg 3.2★)
Medicare certified since
October 12, 1988
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 3/5
State avg 3.2
Health inspections★★★★★ 2/5
State avg 2.8
Staffing★★★★★ 3/5
State avg 3.3
Quality measures★★★★★ 5/5
State avg 4.1
Long-stay quality★★★★★ 5/5
Short-stay quality★★★★★ 5/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
5.02 (state 4.52 · U.S. 3.86)
Registered nurses (RN)
0.96 (state 0.67 · U.S. 0.69)
Licensed practical nurses
1.57 (state 1.20 · U.S. 0.86)
Nurse aides
2.49 (state 2.65 · U.S. 2.32)
Weekend total
4.61 (state 4.09 · U.S. 3.42)
Nursing staff turnover
40.0 (state 36.7 · U.S. 45.8)%
RN turnover
37.9 (state 38.1 · U.S. 42.9)%
Administrators who left
1 in the last year

Inspections

Last standard inspection
April 24, 2025
Health deficiencies (last cycle)
23.0 (state 15.7 · U.S. 9.3)
From complaints
11
Citations on record (3 years)
53 health · 17 fire safety · includes actual harm
DateCitationSeverityStatus
2026-04-15 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2026-05-04
2026-04-15 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F0657 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-04
2026-04-15 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-04
2026-01-22 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-12
2025-09-16 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-10-05
2025-09-16 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-10-05
2025-09-04 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-09-22
2025-09-04 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-10-05
2025-09-04 Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F0835 · Administration Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-09-22
2025-04-24 Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 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.
F0584 · Resident Rights Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 Have a plan that describes the process for conducting QAPI and QAA activities.
F0865 · Administration Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F0561 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 Provide safe, appropriate dialysis care/services for a resident who requires such services.
F0698 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 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.
F0758 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2025-04-24 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-24
2024-12-26 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-02-03
2024-10-15 Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-11-15
2024-10-15 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F0655 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-11-15
2024-09-13 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.
F0808 · Nutrition and Dietary Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-10-15
2024-09-13 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-10-15
2024-07-30 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-08-22
2024-05-10 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 Allow residents to self-administer drugs if determined clinically appropriate.
F0554 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 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.
F0578 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 Keep residents' personal and medical records private and confidential.
F0583 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 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.
F0584 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 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.
F0688 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 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.
F0693 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 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.
F0726 · Nursing and Physician Services Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 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.
F0761 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2024-05-10 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F0921 · Environmental Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-21
2023-07-28 Reasonably accommodate the needs and preferences of each resident.
F0558 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-08-28
2023-07-28 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-08-28
2023-07-28 Provide care or services that was trauma informed and/or culturally competent.
F0699 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-08-28
2023-07-28 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2023-08-28

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

No federal fines or payment denials in the last three years.

Ownership & management

NameRoleSince
Caretrust GP LLC (organization)Administrator · NOT APPLICABLE
Caretrust Reit INC (organization)Administrator · NOT APPLICABLE
CM Health Holdings LLC (organization)Administrator · NOT APPLICABLE
CTR Partnership LP (organization)Administrator · NOT APPLICABLE
Ensign Services INC (organization)Administrator · NOT APPLICABLE
Kalafer, Michael (individual)Administrator · NOT APPLICABLE
Matthews, Glenn (individual)Administrator · NOT APPLICABLE
The Ensign Group INC (organization)Administrator · NOT APPLICABLE
Port, Barry (individual)Corporate Director · NOT APPLICABLE
Burnam, Soon (individual)Corporate Officer · NOT APPLICABLE
Keetch, Chad (individual)Corporate Officer · NOT APPLICABLE
Oh, Katherine (individual)Corporate Officer · NOT APPLICABLE
Sato, Ami (individual)Corporate Officer · NOT APPLICABLE
Willits, Adam (individual)Corporate Officer · NOT APPLICABLE
Burnam, Soon (individual)Managing Control - Governing Body · NOT APPLICABLE
Kalafer, Michael (individual)Managing Control - Governing Body · NOT APPLICABLE
Matthews, Glenn (individual)Managing Control - Governing Body · NOT APPLICABLE
Cetna Staffing INC (organization)Operational/managerial Control · NOT APPLICABLE
Kalafer, Michael (individual)Operational/managerial Control · NOT APPLICABLE
Lincare INC (organization)Operational/managerial Control · NOT APPLICABLE
Matthews, Glenn (individual)Operational/managerial Control · NOT APPLICABLE
Sevenoaks Capital Associates LLC (organization)Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Carmel Mountain Rehabilitation & Healthcare Center?

Carmel Mountain Rehabilitation & Healthcare Center has a 3-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.2-star average in California.

How many beds does Carmel Mountain Rehabilitation & Healthcare Center have?

It has 120 certified beds and cares for about 115 residents per day.

Has Carmel Mountain Rehabilitation & Healthcare Center been fined?

CMS lists no federal fines or payment denials in the last three years.

Who owns Carmel Mountain Rehabilitation & Healthcare Center?

It is part of The Ensign Group and is classified as for profit - limited liability company. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Carmel Mountain Rehabilitation & Healthcare Center?

(858) 673-0101. The facility is located at 11895 Avenue of Industry, San Diego, CA 92128.

Other nursing homes in San Diego

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Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.