Home / California / Poway
15632 Pomerado Road, Poway, CA 92064 · San Diego County · (858) 485-5153
99 certified beds, about 96 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1981
CMS Care Compare ratings, data as of September 1, 2026 · CCN 555136 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 8, 2025, inspectors cited 3 health deficiencies (the California average is 15.6, the national average 9.2).
None of its 34 health citations since April 2019 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.97 hours per resident per day, against 4.52 across California and 3.86 nationally. Registered nurses accounted for 0.61 of those hours.
42.5% of nursing staff left within the year CMS measured (California average 36.7%).
CMS links it to PACS Group, an affiliated group of 275 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 34 health citations on file.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) was protected from abuse when Resident 1's wife was allowed to visit Resident 1 without close monitoring. This failure had the potential to affect Resident 1's safety and well-being.
Inspectors wroteBased on interview and record review, the facility failed to provide copies of medical records within two business days of the request for one of two sampled residents (1). As a result, Resident 1's family member was not aware of her medical status.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prescribed medications (meds) were administered as ordered by the physician for two of two sampled residents (Resident 1, Resident 2) As a result, Resident 1 was found unresponsive and life sustaining measures were performed including cardiopulmonary resuscitation (CPR). A. Resident 1 was admitted to the facility on [DATE] at 1:37 P.M., with a diagnosis of atherosclerotic heart disease of native coronary artery and atrial fibrillation (irregular heartbeat that affects blood flow) per the facilities admission record and admission note. A review of Resident 1's physicians orders (PO), dated [DATE], Indicated Resident 1 was a full code The PO's indicated Resident 1 was prescribed the following meds to be administered on [DATE] at 9 P.M. [...]
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to obtain consent for the use of bed rails for 2 (Resident #9 and Resident #24) of 3 sampled residents with bed rails installed; and failed to complete assessments for the continued use of bed rails for 3 (Residents #9, #24, and #54) of 3 sampled residents reviewed for accidents.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to store continuous positive airway pressure (CPAP) masks in a manner that limited the spread of infection for 2 (Resident #22 and Resident #47) of 2 sampled residents reviewed for respiratory care.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) was accurately coded regarding a feeding tube for 1 (Resident #2) of 2 sampled residents reviewed for tube feeding.
Inspectors wroteBased on observation, interview, and record review, the facility failed to keep room temperatures between 71°F and 81°F for four of six sampled residents (1, 2, 3, 4). As a result, residents felt uncomfortably cold.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident records for a resident who left the facility against medical advice (AMA) was accurate and complete for one of two residents (Resident 5) reviewed for complete medical record when: 1. There was no documentation regarding Resident 5 ' s AMA and physician notification. 2. The hospital discharge medication list for Resident 5 was not accurately transcribed. These failures had the potential to cause miscommunication among care providers affecting residents ' treatment and safety, and use of unnecessary medication for the residents.
Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (1) and their responsible party (RP) was informed of charges for Medicare and non-Medicare-covered services, per policy, at admission and did not provide a breakdown of charges at RP request for continued physical and occupational therapy services after benefit exhaustion. This deficient practice placed Resident 1 and the RP at risk of being uniformed of charges and obligations leading to undue hardship.
Inspectors wroteBased on interview and record reviews, the facility failed to consistently document a change of condition assessment for two of three residents reviewed for changes in condition. (Resident 6 and Resident 7) This failure had the potential to promptly identify and delay the necessary treatments for the residents ' declining condition.
Inspectors wroteBased on interview and record review, the facility failed to hold a blood pressure (BP) medication as prescribed by the physician for one resident (Resident 1) with a low BP. As a result, Resident 1's BP had the potential to further decrease below normal and increase the risk of harmful side effects.
Inspectors wroteBased on interview and record review, the facility failed to employ a qualified full time Infection Preventionist (IP, the person(s) designated by the facility to be responsible for the infection prevention and control program) with primary professional training, education, and experience as a Licensed Nurse. This failure had the potential to compromise the facility's ability to maintain a safe and effective infection prevention and control program (IPCP) for all residents residing in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide non-English communication boards (a board in a specific language use to communicate) to non- English speaking residents for one of one sampled resident (Resident 53) and three non-sampled residents (Resident 141, 140, 46) reviewed for communication. This failure had the potential for Residents' 46, 53, 140, and 141, to not have their needs known or met, and for decreased socialization. 1. Resident 141 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), per the facility's admission Record. On 3/14/22 at 9 A.M., an observation was conducted inside Resident 141's room. Resident 141 was lying flat in bed with his eyes open, with the lights off, curtain pulled, and no TV or radio on. Resident 141 did not communicate when questions were asked. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing standards of practice were followed when: 1a. A peripherally inserted central catheter (PICC-a main intravenous line) was not consistently monitored or documented for one of two residents (Resident 11), reviewed for Professional Standards of Practice; 1b. Intravenous (IV) antibiotic medication was not documented as administered via the PICC line for one of two residents (Resident 11), reviewed for Professional Standards of Practice; and 2. Medication injection sites were not consistently rotated for two of two residents (Residents 4 and 22), reviewed for medication administration of insulin (a hormone normally produced by the body, which regulates sugar in the blood). [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices when: 1. A glucometer (a device used for measuring sugar levels in the blood) was not disinfected between the use of two of two residents (Resident 4 and 22), observed for medication administration. 2. A urinary Foley (brand name) catheter bag was touching the floor for one of one resident, (Resident 79), reviewed for urinary catheter care. As a result, there was the potential for Residents 4, 22, and 79 to be at risk for a facility acquired infection, which would negatively impact their quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity for one of one sampled resident (79) reviewed for dignity. This failure had the potential to affect Resident 79's dignity, causing a negative effect on his quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care to a resident who was dependent on staff for activities of daily living (ADL-basic hygiene) for one of one resident, (Resident 27) reviewed for ADL care. This failure had the potential to result in Resident 27 to experience psychosocial distress, infection and compromised hygiene.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide one to one (1:1) feeding assistance (staff sit and assist resident with eating) and supervision in the dining room during a lunch meal for one of one resident, (Resident 24), reviewed for Supervision. As a result, Resident 24 was unsupervised and grabbed another resident's food bowl and spilled the food content onto herself, while attempting to ingest the food contents.
Inspectors wroteBased on observation, interview and policy review the facility failed to ensure: 1. Licensed nursing staff demonstrated sufficient knowledge with monitoring and documenting continuous tube feeding (a flexible tube surgically inserted into the body to provide nourishment) for one of one residents (Resident 6), reviewed for tube feeding; and 2. The facility did not have or use a standardized pain assessment tool with parameters to determine the amount of pain medication to be administered for one of one resident, (Resident 69), reviewed for pain. This failure had the potential to adversely impact Resident's 6 and Resident's 69's care.
Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 6.25 percent. Two (2) medications were omitted for one of six residents (Resident 47), randomly selected for medication administration. As a result, Resident 47 did not receive two anti-depressant medications (to prevent and treat depression) which had the potential for mood alternations.
Inspectors wroteBased on observation, interview and facility policy review, the facility failed to implement their policy and procedure related to storing of food items for one of one resident reviewed for Resident Food Storage. The food stored inside the refrigerator were not labeled, dated, and expired food were not discarded. This failure had the potential to expose the facility's residents to unsafe food storage practices which could lead to foodborne-illnesses.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document fluid intake and output (I&0), for one of two residents (Resident 43), reviewed for hydration. This failure had the potential to inaccurately portray Resident 43's current hydration status.
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and implement a routine monitoring of the disinfecting system within the laundry area. This failure had a potential to put residents' linens and personal laundry at risk for contamination of pathogens (organisms causing disease).
Inspectors wroteBased on interview and record review, the facility failed to ensure staff answered residents' call lights in a timely manner for one of one residents reviewed for dignity (55), two confidential residents (CR 1, CR 3) interviewed during a confidential group, and an unsampled resident (86). These failures resulted in residents dignity and needs to not be met in a timely manner, which had the potential to result in physical and psychosocial harm.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a language line for personal interpretation via telephone was available or utilized to communicate with two of two residents (40, 60) reviewed for language/communication who did not speak English. As a result, Resident's 40 and 60 may not have had their need mets.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments according to the physician's order when surgical wound dressing changes were not done as ordered, for one of one resident (34) reviewed for dressing changes. This failure had the potential to cause infection and delayed healing of the surgical wound.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standards of practice were followed for one of one residents (48) reviewed for dialysis (blood is cleaned by a machine then returned to the body) when the pressure dressing (a gauze and tape dressing which stops a dialysis site from bleeding) was not removed in a timely manner. As a result, there was a potential for Resident 48 to have complications that may not have been identified.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication order for Ativan (lorazepam - an anxiety reducing medication) was processed in a timely manner for one of one residents (45) reviewed for discharge. This failure had the potential to have caused Resident 45 to experience anxiety unnecessarily in the final days of his life (Resident 45 expired on [DATE]).
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide: 1. Documentation of clinical justification for not performing a gradual dose reduction (GDR) on a psychotropic (drugs that affect mental state) medication for one of three residents (16) reviewed for psychotropic medications, and 2. Non-pharmacological interventions (methods, programs or services that aim to prevent, care, or cure health problems) for one of three residents (58) reviewed for the use of psychotropic medications. These failures created the potential for Resident's 16 and 58 to receive unnecessary medications.
Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide a breakfast which followed the physician's orders for one resident reviewed for dialysis care (48), and 2. Obtain input from residents and resident groups regarding a new menu implementation. These failures had the potential to place Resident 48 at risk for complications related to his kidney failure, and placed all residents at risk for poor nutrition intake and weight loss.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a physician ordered therapeutic diet was provided to one sampled resident (48). As a result, Resident 48 did not receive an appropriate meal to take with him during his dialysis (a treatment using a machine to clean and filter a person blood) treatment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the proper air gap between the dishwasher drain pipe and the flood level rim (kitchen floor level) of the floor drain apparatus (a drain that is set approximately six inches below the level of a kitchen floor). This failure created the potential for contaminated water to go back up into the dishwasher potentially causing the dishwasher to operate with unclean water and cause residents to be eating from unsanitized dishes.
Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive facility assessment was completed. The facility assessment failed to include the care and resources required for the resident population it serves. This deficient practice had the potential to place residents at risk of the inability to identify their needs, and evaluating the resources needed to provide the care and services necessary.
Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurate for one sampled resident (16) when: 1. A consent was not completed related to an increased dose of a psychotropic (drugs that affect mental state) medication, and; 2. Multiple medication administrations were not charted at the time the medications were given. These failures had the potential for incorrect information to be shared between staff in regards to whether Resident 16 received knowledge of the risk and benefits related to the increased dose in medication or if the medication was administered on time.
13 fire safety citations on file: 4 on May 8, 2025, 4 on March 17, 2022, 5 on April 11, 2019.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | California | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.97 | 4.52 | 3.86 |
| Registered nurses | 0.61 | 0.67 | 0.69 |
| All nursing staff on weekends | 3.67 | 4.09 | 3.42 |
| Nurse aides | 2.32 | ||
| Licensed practical nurses | 1.05 | ||
| Nursing staff turnover (share who left in a year) | 42.5% | 36.7% | 45.8% |
| Registered nurse turnover | 43.8% | 38.1% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.65 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.09 on weekdays and 3.67 on weekends, 10% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 16.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.14 in April to June 2025 to 3.97 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.97 | 0.61 | 4.09 | 3.67 | 16.8% | 0 of 90 | 96 |
| Oct to Dec 2025 | 4.08 | 0.59 | 4.21 | 3.77 | 15.9% | 0 of 92 | 96 |
| Jul to Sep 2025 | 4.18 | 0.62 | 4.32 | 3.83 | 15.6% | 0 of 92 | 97 |
| Apr to Jun 2025 | 4.14 | 0.58 | 4.28 | 3.78 | 15.0% | 0 of 91 | 96 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| California, Jan to Mar 2026 | 4.36 | 0.59 | 4.52 | 3.97 | 2.3% | 0.5% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| California, all employers | |||
| CNAs (nursing assistants) | $22.90 | $22.04 to $26.35 | 110,060 |
| LPNs and LVNs | $38.34 | $35.98 to $45.06 | 82,850 |
| Registered nurses | $67.44 | $58.87 to $83.25 | 338,940 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | California | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 5.5 | 10.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.4 | 0.8 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.8 | 1.2 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.6 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.2 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 3.7 | 9.8 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.8 | 4.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 0.7 | 12.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 25.1 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 15.9 | 11.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.4 | 2.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 1.6 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Poway Healthcare Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (65.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
65.4% this home
Better than the national rate
US median of homes 51.5% · California: 301 better, 190 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 221 eligible stays.
10.0% this home
No different from the national rate
US median of homes 10.7% · California: 10 better, 22 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 228 eligible stays.
7.1% this home
No different from the national rate
US median of homes 7.1% · California: 8 better, 48 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 140 eligible stays.
61.2% this home
Median of homes: California59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 67 residents counted.
0.0% this home
Median of homes: California0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 224 residents counted.
0.8% this home
Median of homes: California0.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 224 residents counted.
97.4% this home
Median of homes: California96.2% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 38 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: POPLAR HOLDINGS LLC. CMS links this home to PACS Group, a group of 275 nursing homes averaging 2.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Hudson River Opco LLC | 5% or greater direct ownership interest | Organization | 100% | 11/05/2021 |
| Bay Bridge Capital Partners, LLC | 5% or greater indirect ownership interest | Organization | 11/05/2021 | |
| Providence Group, Inc. | 5% or greater indirect ownership interest | Organization | 11/05/2021 | |
| Thaper, Mohinderpal | Contracted managing employee | Individual | 11/01/2023 | |
| Pepin, Austin | W-2 managing employee | Individual | 02/12/2024 | |
| Apt, Frederick | Corporate officer | Individual | 01/01/2024 | |
| Jergensen, Joshua | Corporate officer | Individual | 01/01/2024 | |
| Mitchell, John | Corporate officer | Individual | 01/01/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living homes in the same town or within 5 miles, each with its California inspection record.
These are the official offices in California. NursingHomeClear cannot take or act on complaints.