Barton Hospital D/P SNF
2170 South Avenue, South Lake Tahoe, CA 96150 · El Dorado County · 48 certified beds · avg 44 residents/day · certified since Apr 4, 1997
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 4, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 2, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 29, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 12, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (18)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 16, 2026 | B · Minimal risk, repeated | The facility was not properly licensed, or did not operate in compliance with federal, state, and local laws, regulations, and accepted professional standards. · from a complaint |
| Apr 10, 2026 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 10, 2026 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 10, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 10, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 10, 2026 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Apr 10, 2026 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Apr 10, 2026 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Apr 10, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 10, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 10, 2026 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Feb 4, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 22, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 3, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 29, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 22, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 5, 2023 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 2 | 0 | E |
| 2025 | 4 | 1 | G ▲ |
| 2026 | 12 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $9,252, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Feb 4, 2026 | Fine | $9,252 |
| Feb 4, 2026 | Payment Denial | 3 days from Feb 27, 2026 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.31 | 4.31 | 3.95 | top 10% in California; top 9% in the U.S. |
| Registered Nurse hours | 1.64 | 0.61 | 0.69 | top 3% in California; top 3% in the U.S. |
| Weekend total nurse staffing | 4.75 | 3.90 | 3.50 | top 9% in California; top 9% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.98 | 0.51 | 0.48 | top 8% in California; top 6% in the U.S. |
| Total nursing staff turnover (%) | 32.0 | 36.7 | 45.8 | top 37% in California; top 18% in the U.S. |
| RN turnover (%) | 21.4 | 38.1 | 42.9 | top 22% in California; top 16% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.34, RN 1.34, weekend 3.88. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Barton Healthcare System | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/07/1997 |
| Adams, Carla | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2023 |
| Adams, Carla | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2023 |
| Anderson, Shawn | Individual | Corporate Director | NOT APPLICABLE | 04/01/2021 |
| Barton Healthcare System | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/04/1997 |
| Barton Healthcare System | Organization | ADP of the SNF | NOT APPLICABLE | 03/07/1997 |
| Biasotti, Kathryn | Individual | Corporate Director | NOT APPLICABLE | 09/01/2019 |
| Cefalu, Jonathon | Individual | Corporate Director | NOT APPLICABLE | 05/01/2024 |
| Digrande, Peter | Individual | Corporate Director | NOT APPLICABLE | 05/01/2024 |
| Fry, Patrick | Individual | Corporate Director | NOT APPLICABLE | 05/01/2020 |
| Killebrew, Abby | Individual | Corporate Director | NOT APPLICABLE | 05/22/2014 |
| Ledbetter, Kirk | Individual | Corporate Director | NOT APPLICABLE | 01/01/2008 |
| Mlynsky, Sherry | Individual | Corporate Director | NOT APPLICABLE | 05/01/2022 |
| Neiger, Kelly | Individual | Corporate Officer | NOT APPLICABLE | 11/11/2018 |
| Purvance, Clinton | Individual | Corporate Officer | NOT APPLICABLE | 11/01/2015 |
| Rahbeck, Jeffrey | Individual | Corporate Director | NOT APPLICABLE | 05/01/2017 |
| Schunk, Stefan | Individual | Corporate Director | NOT APPLICABLE | 05/01/2018 |
| Weavil, Scott | Individual | Corporate Director | NOT APPLICABLE | 05/01/2023 |
| Wonnacott, Matthew | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2023 |
| Wonnacott, Matthew | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you tell me about this citation and confirm your license and compliance status today?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you inspect and maintain essential equipment, and how quickly are repairs made?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Gardnerville Health & Rehabilitation Center | 13.1 mi | Gardnerville, NV | ★☆☆☆☆ | 1/5 | abuse |
| Mountain View Health and Rehabilitation | 19.7 mi | Carson City, NV | ★★☆☆☆ | 2/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 555698.